PATIENT SAFETY FIRST A Successful Life Safety Survey in an Ambulatory Surgery Center LEE ANNE BLACKWELL, EMBA, BSN, RN, CNOR
A
patient-centered environment of care is not just the care provided at the patient’s side. It is seen throughout the facilityd inside the walls and ceilings, within securely locked storage areas, in the emergency generators equipped with emergency battery backup lighting, and in the heating ventilation and air conditioning units that promote optimum air quality and support infection prevention measures. A safe environment of care also is evident in the fire alarm systems that provide alerts to people to evacuate to safe areas and the fire extinguishers and sprinkler systems that help extinguish potentially life-threatening surgical fires. An environment of safety encompasses all of this and ensures that patients can count on health care personnel to protect them from harm and to keep them safe during their surgical experiences. THE SETTING The ambulatory surgery center (ASC) staff members worked hard to open a state-of-the-art facility that provides a comfortable surgical setting for our patients, physicians, employees, and guests. The four-OR facility is located in Colorado and employs a skilled staff of physicians and clinicians to provide outpatient surgical and nonsurgical pain management services. Before the surveyors arrived, we completed our first quality and patient safety
committee and governing body meetings to review and approve policies, procedures, and protocols established by ASC physicians and team members. All of these policies, procedures, and protocols focused on providing a safe environment of patient care. After completing these policies and procedures, we were ready for our first survey. THE SURVEY On day one of our first survey, staff members had successfully and safely completed 38 patient procedures by the time the surveyors arrived. A telephone call from the front desk receptionist announced that surveyors had arrived at our new ASC for its 2013 unannounced Medicare status accreditation survey. Initially, two surveyors arrived and spent a day and a half focusing on whether we had met Accreditation Association for Ambulatory Health Care accreditation standards1 and Centers for Medicare & Medicaid Services (CMS) conditions for coverage.2 On day two of the survey, a life safety surveyor arrived to conduct a full fire and life safety inspection based on National Fire Protection Association codes and standards,3 compliance with which is mandated by CMS for ASCs seeking accreditation. This surveyor spent another entire day with the ASC team concentrating on the physical environment of the ASC. This
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.01.001
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 431
March 2014 Vol 99 No 3
PATIENT SAFETY FIRST
one of the areas where the surveyor lifted ceiling included how we met the 2000 Life Safety CodeÒ 3 tiles near the fire walls to inspect the openings requirements ; CMS conditions for coverage stanaround the pipes and wires that extended through dards, characteristics, and requirements for ASCs 2 the fire-rated walls to ensure that appropriate fireregarding spatial requirements and construction ; rated caulking material was used to create a comand other specifics related to signage, laboratory plete seal. facilities, hazardous material storage, personal protective equipment, medical gases, the ASC’s Electrical electrical system and emergency power resources, Team members escorted the surveyor to the elecinterior finishes, fire alarms systems and fire regu1 trical room, where he examined the electrical lations, and emergency plans and drills. panels and breakers to ensure that they were all Upon arrival to the center, the life safety labeled appropriately to clearly identify the life surveyor provided a structured, detailed plan safety branch circuit, for completing this the critical branch assessment related to the standards and reg- The surveyor examined the hazardous storage circuit, and the equipment branch circuit. ulations that applied to areas to ensure that appropriate protective equipment and processes were in place to He examined the our center. This was protect the patient, environment, and personnel testing and maintethe first time the from potentially hazardous and biohazardous nance schedules for ASC’s team expericonditions. exit lights, backup enced such an inemergency lights, and depth survey, with an critical electrical outentire day dedicated to lets to ensure that they were operational and assessing life safety and physical building safety appropriately connected to the correct branch cirprovisions. cuits for utility power, and he also checked connections for a second, alternate power source (ie, a Layout, Mechanical, and Gases generator) to be used in the event of a power The surveyor began the life safety survey by taking interruption. This dual branch circuitry meets the a facility tour and examining the ASC’s architecASC’s need for an electrical system that must tural floor plans, blue prints, and electrical drawsustain designated emergency equipment during ings that identified the layout of the exit routes with power interruptions. appropriate signage; fire-rated walls with thorough Facilities in which procedures that are limited sealing of all penetrations; fire-rated windows; fire to local or moderate sedation are equipped with alarm system plan; sprinkler system; smoke alarms an essential electrical system (EES) type 2 or EES and dampers; and the heating ventilation and air type 3. These systems allow only for uninterrupted conditioning duct pathways, air handler, and filter operation of a limited type of identified equipment, maintenance. Next, the nurse manager showed the such as freezers and laboratory equipment. In fasurveyor the ASC mechanical room and the medicilities that provide deeper levels of sedation and cal gas room where the surveyor examined the anesthesia (eg, ASCs), classified as Class C provacuum system, boiler, and gas cylinders, making cedures, the electrical system must be classified as a notes regarding the appropriate labeling of pipes, EES type 1, and these facilities must obtain power boiler, pumps, and valves, and examined the gas under normal operating conditions from a utility cylinders to ensure that they were appropriately company and obtain power from an alternate source maintained by a certified gas contractor and sewhen the normal source of power is interrupted.2 cured to prevent them from falling over. This was 432 j AORN Journal
PATIENT SAFETY FIRST The surveyor confirmed that the ASC had an established and fully functioning EES type 1 system. Other areas the surveyor then identified and tested included the automatic electric transfer switches that transfer power automatically to the alternate power source during power interruption and transfer service back to utility power when service is restored. The surveyor told the team that the ASC’s main circuit breakers should be inspected annually and must only be accessible to authorized individuals. He observed that no extension cords were used in the ORs and recommended that if extension cords needed to be used in other locations of the ASC (eg, in the business office), the cords must be of health care grade and have the correct electrical characteristic for the situation in which they are being used. Storage and Hazards The surveyor examined the hazardous storage areas to ensure that appropriate protective equipment and processes (eg, personal protective equipment, policies, and procedures), were in place to protect the patient, environment, and personnel from potentially hazardous and biohazardous conditions. He reviewed the ASC’s safety plans and bloodborne pathogens plan to ensure the presence of regulatorybased guidelines, policies, and procedures. Maintenance Logs, Schedules, and Assessments The team escorted the surveyor to the equipment storage room that contained patient medical equipment that must be examined, monitored, and tested according to a definitive schedule. The team provided various checklists, logs, and reports for the surveyor to examine, including the equipment preventive maintenance record, which a certified biomedical engineer is contracted to maintain during scheduled service visits to the ASC. The surveyor requested further clarification from the team regarding which safety assessments we perform, who is responsible for completing them, and when they are to be completed. The surveyor also
www.aornjournal.org
requested that the team have an established schedule in place for the various safety assessments to help ensure that scheduled testing does not lapse. The team provided the following checklists and logs for the surveyor to review: n
n
n n
n n
n n
A facility environmental safety assessment schedule, providing a weekly, monthly, quarterly, and annual checklist with descriptions of what to examine and test for each item or area listed. A visual inspection of the generator and a testing log for daily, weekly, monthly, and annual generator testing. An exit light and emergency light testing log. A fire alarm system inspection report completed by a designated fire prevention and alarm system vendor. A sprinkler system inspection report completed by a designated sprinkler system testing expert. A certification report and monthly assessment log for all fire extinguishers completed by facility team members and also by a designated vendor on a quarterly and annual basis. A temperature and humidity log for the ORs, sterile storage areas, and clean prep areas. An equipment preventive maintenance schedule.
The surveyor recommended that the team include contact information for contractors and service vendors on our center-based logs and checklists for quick identification of service and repair vendors as needed. Adding the service vendor contact information to each type of report and log can save valuable time when identified resources must be contacted quickly. LESSONS LEARNED The team received valuable information from the survey experience, including details of the life safety electrical requirements, construction and fire-rated wall requirements, and elements of the emergency management plan and its relation to the local emergency management authority who must review and approve the plan before providing patient care services to the ASC. The team gained AORN Journal j 433
PATIENT SAFETY FIRST
March 2014 Vol 99 No 3
a new level of understanding regarding the critical elements of the Life Safety Code requirements expressed in this article, and they learned of additional safety measures that must be in place to provide a safe environment of care for patients, employees, medical staff, and others. A safe environment extends beyond the patient’s bedside, and maintaining it requires dedication from team members to ensure that regularly scheduled testing and assessments are completed accurately and on time. The entire ASC team celebrated a successful survey experience, and we have a new appreciation and awareness of how to ensure a safe environment of care for patients, members of the staff, and visitors. A dedicated ASC team focused on maintaining a safe environment and working together to complete the various scheduled safety assessments and tests can support a culture of safety in the ASC. The continued maintenance of a safe, patientcentered environment presents opportunities for ASC team members to further their knowledge and understanding regarding changes in environment of care and safety regulation and best practice standards. Ambulatory surgery center team members can accomplish this by establishing important relationships with key industry partners and experts, such as the local and national health care
434 j AORN Journal
engineers associations, local emergency management authorities, accreditation organizations, and professional societies that provide education and training for ambulatory care settings. Editor’s note: Life Safety Code is a registered trademark of the National Fire Protection Association, Inc, Quincy, MA. References 1. 2013 Accreditation Handbook for Ambulatory Health Care. Skokie, IL: Accreditation Association for Ambulatory Health Care, Inc; 2013. http://www.aaahc.org/accredi tation/policies/standards. Accessed December 10, 2013. 2. Centers for Medicare & Medicaid Services. State Operations Manual Appendix L: Guidance for Surveyors: Ambulatory Surgical Centers. Rev. 89; 2013. http:// www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/som107ap_l_ambulatory.pdf. Published August 30, 2013. Accessed November 13, 2013. 3. NFPA 101: Life Safety CodeÒ. Quincy, MA: National Fire Protection Association; 2000.
Lee Anne Blackwell, EMBA, BSN, RN, CNOR, is vice president of clinical services at Practice Partners in Healthcare, Inc, Birmingham, AL. Ms Blackwell has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
A
patient-centered environment of care is not just the care provided at the patient’s side. It is seen throughout the facilityd inside the walls and ceilings, within securely locked storage areas, in the emergency generators equipped with emergency battery backup lighting, and in the heating ventilation and air conditioning units that promote optimum air quality and support infection prevention measures. A safe environment of care also is evident in the fire alarm systems that provide alerts to people to evacuate to safe areas and the fire extinguishers and sprinkler systems that help extinguish potentially life-threatening surgical fires. An environment of safety encompasses all of this and ensures that patients can count on health care personnel to protect them from harm and to keep them safe during their surgical experiences. THE SETTING The ambulatory surgery center (ASC) staff members worked hard to open a state-of-the-art facility that provides a comfortable surgical setting for our patients, physicians, employees, and guests. The four-OR facility is located in Colorado and employs a skilled staff of physicians and clinicians to provide outpatient surgical and nonsurgical pain management services. Before the surveyors arrived, we completed our first quality and patient safety
committee and governing body meetings to review and approve policies, procedures, and protocols established by ASC physicians and team members. All of these policies, procedures, and protocols focused on providing a safe environment of patient care. After completing these policies and procedures, we were ready for our first survey. THE SURVEY On day one of our first survey, staff members had successfully and safely completed 38 patient procedures by the time the surveyors arrived. A telephone call from the front desk receptionist announced that surveyors had arrived at our new ASC for its 2013 unannounced Medicare status accreditation survey. Initially, two surveyors arrived and spent a day and a half focusing on whether we had met Accreditation Association for Ambulatory Health Care accreditation standards1 and Centers for Medicare & Medicaid Services (CMS) conditions for coverage.2 On day two of the survey, a life safety surveyor arrived to conduct a full fire and life safety inspection based on National Fire Protection Association codes and standards,3 compliance with which is mandated by CMS for ASCs seeking accreditation. This surveyor spent another entire day with the ASC team concentrating on the physical environment of the ASC. This
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.01.001
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 431
March 2014 Vol 99 No 3
PATIENT SAFETY FIRST
one of the areas where the surveyor lifted ceiling included how we met the 2000 Life Safety CodeÒ 3 tiles near the fire walls to inspect the openings requirements ; CMS conditions for coverage stanaround the pipes and wires that extended through dards, characteristics, and requirements for ASCs 2 the fire-rated walls to ensure that appropriate fireregarding spatial requirements and construction ; rated caulking material was used to create a comand other specifics related to signage, laboratory plete seal. facilities, hazardous material storage, personal protective equipment, medical gases, the ASC’s Electrical electrical system and emergency power resources, Team members escorted the surveyor to the elecinterior finishes, fire alarms systems and fire regu1 trical room, where he examined the electrical lations, and emergency plans and drills. panels and breakers to ensure that they were all Upon arrival to the center, the life safety labeled appropriately to clearly identify the life surveyor provided a structured, detailed plan safety branch circuit, for completing this the critical branch assessment related to the standards and reg- The surveyor examined the hazardous storage circuit, and the equipment branch circuit. ulations that applied to areas to ensure that appropriate protective equipment and processes were in place to He examined the our center. This was protect the patient, environment, and personnel testing and maintethe first time the from potentially hazardous and biohazardous nance schedules for ASC’s team expericonditions. exit lights, backup enced such an inemergency lights, and depth survey, with an critical electrical outentire day dedicated to lets to ensure that they were operational and assessing life safety and physical building safety appropriately connected to the correct branch cirprovisions. cuits for utility power, and he also checked connections for a second, alternate power source (ie, a Layout, Mechanical, and Gases generator) to be used in the event of a power The surveyor began the life safety survey by taking interruption. This dual branch circuitry meets the a facility tour and examining the ASC’s architecASC’s need for an electrical system that must tural floor plans, blue prints, and electrical drawsustain designated emergency equipment during ings that identified the layout of the exit routes with power interruptions. appropriate signage; fire-rated walls with thorough Facilities in which procedures that are limited sealing of all penetrations; fire-rated windows; fire to local or moderate sedation are equipped with alarm system plan; sprinkler system; smoke alarms an essential electrical system (EES) type 2 or EES and dampers; and the heating ventilation and air type 3. These systems allow only for uninterrupted conditioning duct pathways, air handler, and filter operation of a limited type of identified equipment, maintenance. Next, the nurse manager showed the such as freezers and laboratory equipment. In fasurveyor the ASC mechanical room and the medicilities that provide deeper levels of sedation and cal gas room where the surveyor examined the anesthesia (eg, ASCs), classified as Class C provacuum system, boiler, and gas cylinders, making cedures, the electrical system must be classified as a notes regarding the appropriate labeling of pipes, EES type 1, and these facilities must obtain power boiler, pumps, and valves, and examined the gas under normal operating conditions from a utility cylinders to ensure that they were appropriately company and obtain power from an alternate source maintained by a certified gas contractor and sewhen the normal source of power is interrupted.2 cured to prevent them from falling over. This was 432 j AORN Journal
PATIENT SAFETY FIRST The surveyor confirmed that the ASC had an established and fully functioning EES type 1 system. Other areas the surveyor then identified and tested included the automatic electric transfer switches that transfer power automatically to the alternate power source during power interruption and transfer service back to utility power when service is restored. The surveyor told the team that the ASC’s main circuit breakers should be inspected annually and must only be accessible to authorized individuals. He observed that no extension cords were used in the ORs and recommended that if extension cords needed to be used in other locations of the ASC (eg, in the business office), the cords must be of health care grade and have the correct electrical characteristic for the situation in which they are being used. Storage and Hazards The surveyor examined the hazardous storage areas to ensure that appropriate protective equipment and processes (eg, personal protective equipment, policies, and procedures), were in place to protect the patient, environment, and personnel from potentially hazardous and biohazardous conditions. He reviewed the ASC’s safety plans and bloodborne pathogens plan to ensure the presence of regulatorybased guidelines, policies, and procedures. Maintenance Logs, Schedules, and Assessments The team escorted the surveyor to the equipment storage room that contained patient medical equipment that must be examined, monitored, and tested according to a definitive schedule. The team provided various checklists, logs, and reports for the surveyor to examine, including the equipment preventive maintenance record, which a certified biomedical engineer is contracted to maintain during scheduled service visits to the ASC. The surveyor requested further clarification from the team regarding which safety assessments we perform, who is responsible for completing them, and when they are to be completed. The surveyor also
www.aornjournal.org
requested that the team have an established schedule in place for the various safety assessments to help ensure that scheduled testing does not lapse. The team provided the following checklists and logs for the surveyor to review: n
n
n n
n n
n n
A facility environmental safety assessment schedule, providing a weekly, monthly, quarterly, and annual checklist with descriptions of what to examine and test for each item or area listed. A visual inspection of the generator and a testing log for daily, weekly, monthly, and annual generator testing. An exit light and emergency light testing log. A fire alarm system inspection report completed by a designated fire prevention and alarm system vendor. A sprinkler system inspection report completed by a designated sprinkler system testing expert. A certification report and monthly assessment log for all fire extinguishers completed by facility team members and also by a designated vendor on a quarterly and annual basis. A temperature and humidity log for the ORs, sterile storage areas, and clean prep areas. An equipment preventive maintenance schedule.
The surveyor recommended that the team include contact information for contractors and service vendors on our center-based logs and checklists for quick identification of service and repair vendors as needed. Adding the service vendor contact information to each type of report and log can save valuable time when identified resources must be contacted quickly. LESSONS LEARNED The team received valuable information from the survey experience, including details of the life safety electrical requirements, construction and fire-rated wall requirements, and elements of the emergency management plan and its relation to the local emergency management authority who must review and approve the plan before providing patient care services to the ASC. The team gained AORN Journal j 433
PATIENT SAFETY FIRST
March 2014 Vol 99 No 3
a new level of understanding regarding the critical elements of the Life Safety Code requirements expressed in this article, and they learned of additional safety measures that must be in place to provide a safe environment of care for patients, employees, medical staff, and others. A safe environment extends beyond the patient’s bedside, and maintaining it requires dedication from team members to ensure that regularly scheduled testing and assessments are completed accurately and on time. The entire ASC team celebrated a successful survey experience, and we have a new appreciation and awareness of how to ensure a safe environment of care for patients, members of the staff, and visitors. A dedicated ASC team focused on maintaining a safe environment and working together to complete the various scheduled safety assessments and tests can support a culture of safety in the ASC. The continued maintenance of a safe, patientcentered environment presents opportunities for ASC team members to further their knowledge and understanding regarding changes in environment of care and safety regulation and best practice standards. Ambulatory surgery center team members can accomplish this by establishing important relationships with key industry partners and experts, such as the local and national health care
434 j AORN Journal
engineers associations, local emergency management authorities, accreditation organizations, and professional societies that provide education and training for ambulatory care settings. Editor’s note: Life Safety Code is a registered trademark of the National Fire Protection Association, Inc, Quincy, MA. References 1. 2013 Accreditation Handbook for Ambulatory Health Care. Skokie, IL: Accreditation Association for Ambulatory Health Care, Inc; 2013. http://www.aaahc.org/accredi tation/policies/standards. Accessed December 10, 2013. 2. Centers for Medicare & Medicaid Services. State Operations Manual Appendix L: Guidance for Surveyors: Ambulatory Surgical Centers. Rev. 89; 2013. http:// www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/som107ap_l_ambulatory.pdf. Published August 30, 2013. Accessed November 13, 2013. 3. NFPA 101: Life Safety CodeÒ. Quincy, MA: National Fire Protection Association; 2000.
Lee Anne Blackwell, EMBA, BSN, RN, CNOR, is vice president of clinical services at Practice Partners in Healthcare, Inc, Birmingham, AL. Ms Blackwell has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
