Common misconceptions of safety code compliance
Common misconceptions of safety code compliance
Complying with all of the vast details of the Life Safety Code is one of the more challenging aspects of outpatient surgery management.
One common misconception is that once you've gone through an accreditation survey and you're approved, you're "grandfathered" in for any noncompliance found in the future, says William Lindeman, founder and president of Tucson, AZ-based WEL Designs, which is a health care facility planning firm. Lindeman spoke on the LSC at the recent annual meeting of the Ambulatory Surgery Center Association. However, an approval made in error, even if it's innocent, is never grandfathered, he explains. "If you have a facility that's been surveyed eight times, and the fire marshal all eight times has missed something, the next time someone sees it, you're not allowed to maintain [your certification]," Lindeman says. Your building never met the requirements, he says. "You have a lot of liability for fixing it if it's ever found wrong," he adds.
Even if your facility is in compliance, be warned that you might improve your facility right out of compliance, he says. A facility might need some storage space and add a small wing in a corner. "Well now, the dimensions of the building are bigger, and the exits aren't far apart enough any more, and they no longer comply with fire codes because they added a storage closet in the corner," Lindeman says. Even something as seemingly minor as propping open a door or running a wire to a computer station can cause violations, he warns. "The most common problem is IT guys will run holes through your file walls with a hammer instead of a fine-drill bit, and they will not seal the holes on both sides of the walls," Lindeman says. Other programs decide to add one more recovery position, but they block a second exit from the building. "I've seen it," he says.
If you do any modifications to your facility, you must make certain that you don't compromise your compliance with the Life Safety Code, Lindeman says.
For hospital-based programs, the biggest problem seems to be not consistently keeping their Electronic Statement of Conditions current, says George Mills, MBA, FASHE, CEM, CHSP, senior engineer in the Department of Standards Interpretation at The Joint Commission. In the first six months of 2008, 46% of hospitals were not in compliance with the Life Safety Code.
Facilities use the Electronic Statement of Conditions to tracks deficiencies in their buildings and create plans for improvement. However, a hospital might have a same-day surgery center, and managers forget to create a basic building information (BBI) form for that facility, Mills says. Or they might identify deficiencies, but forget to identify them on their plan for improvement (PFI), he says. A surveyor subsequently could uncover deficiencies, such as holes in a wall (penetrations), during a survey. "If they self-identified it and are managing it through a Statement of Conditions, the PFI, we would consider them compliant because they're managing those deficiencies," Mills says.
What Medicare requires, and what managers think the program requires, can be very different, Lindeman says. One example is a nurse call station. Medicare only requires those stations in the emergency department, although states can be more restrictive, he says.
"Consultatively, I would encourage you to have a nurse call at any position a patient can be overwhelmed or away from care, like pre-op, recovery, toilets," he says. "I certainly haven't designed an ASC without them."
Mills says hospital-based units should perform a risk assessment to determine if nurse call stations are needed in areas such as patient restrooms and waiting areas.
For freestanding facilities, step one is to determine if it's legal to have an ambulatory surgery center (ASC) in the building you're located in, Lindeman says. "Believe it or not, it's true, not every building in this country is allowed to have an ASC in it in the first place," he says.
Determine how many stories your building is, based on definitions from the National Fire Protection Association (NFPA). NFPA's definition is that more than half of the story is above ground on its perimeter wall. A basement that's fully buried will not count as a story, Lindeman says. "One of the shocks I've had in the last 10 years was on a survey where I saw a facility that's been approved for 20 years, and it's in a two-story unsprinklered unprotected building, and that's really scary," he recalls. "The organization really has a problem, now that it's been brought to light that they have issues there."
One-story buildings don't require any other special protection, Lindeman says. In fact, "you could build it out of tissue paper and balsam wood and meet fire codes," he jokingly says. If it is more than one story, it has to be protected either by a full sprinkler system, or there has to be fireproofing in all of the structural members. "So, if you're in a building that is more than one story, and it does not have a fire sprinkler system, you need to know what the construction type of the building is," Lindeman says. Obtain that information from your architect or builder, he says. "From that construction type, you can then discern if you meet the requirements for the code," Lindeman says.
If your surgery center makes up one-tenth of a building, regardless of the number of stories, it has to meet the construction requirements for a surgery center, he says. "If you're in a city looking at office buildings, you need to be very careful, because you'll find some buildings don't provide the protection required here," Lindeman says.
Resource
For more information on facility compliance, go to www.weldesigns.com/publications_links.htm.
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Meet your new employee: Dr. Smith, surgeon By Stephen W. Earnhart, MS How many times have you sat around the lounge, sipping coffee and complaining about some new policy from your employer? It goes on every day in every city. Now imagine those complaints coming from the newest employee, who happens to be a surgeon. Whoa! Can this be? An increasing number of surgeons are becoming employees of health care providers. Many of the primary care physicians in your area probably already are employees of one of the hospitals. The concept of surgeons being employed by the local hospital or specialty hospital is relatively new, but it is growing in popularity for several reasons. If you are not experiencing it at your facility, hang on. It is coming! In fact, 62% of U.S. hospitals employ specialist physicians, according to the American Medical Association, and that number has been rising. We have several hospital clients that, rather than joint venture a surgery center with the local surgeons, choose to simply employ them and remove the threat of an ambulatory surgery center (ASC). In addition to that benefit, the provider also enjoys the higher reimbursement of hospital revenue. The surgeons, after reviewing the employment package offered by the hospital, often will realize that they will make out better than if they did their own surgery center. While they might have an equity position in the potential center, the employment might be a better option for them. After negotiating for several surgeons, the concessions that many hospitals will make to a surgeon employee are significant. There is a likelihood of some changes from the Obama administration. Bundling of fees paid to health care providers is certainly going to be one. That is (potentially) the good news. The bad news is who gets what from the bundled payment. If the provider receives, for example, $2,200 for a hernia operation, what percent goes to the hospital, what percent goes to the surgeon, and what percent goes to anesthesia? There are ways to make it equitable, but not without some blood, sweat, and tears. You can imagine the chaos this is going to produce. Egos, out of the way! Clearly, a benefit to the now-employed surgeon is reduced liability, more financial stability — which certainly is becoming more attractive to surgeons — and more personal freedom. Of course, the hospital has just the opposite of those benefits, but they maintain and grow market share, eliminate threat, and have a greater recruitment arm for specialists in areas that might not be attractive to solo practitioners. Some of you already may have surgeon employees. For the rest of you, it is probably just a matter of when. As a company, we have worked with socialized medicine programs (gasp!) around the world. Do the surgeons like it? Well, most, if not all of them, have never experienced the alternative; but yes, they do. They are content to work on a production schedule that is completely different from what we work under. The downside is that much of the entrepreneurialism is removed, but overall they enjoy the freedom of going home at 5 p.m. and letting their employer worry about the details. So, with everything that I see happening, it is coming, and it is going to hit hard and fast. Many readers are going to ask, "How will this affect my ASC? What we have seen over the past year is for-profit ASCs being purchased by hospitals and either being assimilated into the organization or being shut down. For many ASC staff, neither is an attractive option, but for the hospital, it typically are their only options. The end result will be a gradual decline in ASC development, with most surgeons unwilling to front the capital to establish their own competing centers, and the selling of many existing centers to hospitals. Hospitals, for the most part, have learned a valuable lesson from the for-profit centers, namely that efficiency works as an incentive and strong marketing tool. A major downside to all of this is the risk of a return to the days when surgeons had very little input into the management of their surgical environment. Perhaps that is the price of admission to employment. Let's hope not. |
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