Communication is key to achieving compliance

The Howlett File

CV

• Standards adviser, EM/PE/LS, Healthcare Facilities Accreditation Program.
• Chair, Zoning Board of Appeals, Loves Park, Ill.

Accomplishments

• Certified Healthcare Facility Manager.
• Certified Fire Plans Examiner.
• Certified Plans Examiner.
• Training consultant for multiple health care education groups nationwide.

Education

• Bachelor of science in architectural studies, University of Illinois, Urbana-Champaign.

Alise Howlett, Assoc. AIA, CHFM, CFPE, stepped into her role as adviser for life-safety, physical environment and emergency management standards with the Healthcare Facilities Accreditation Program (HFAP) at the beginning of the year. This month, she shares her experiences in this new position.

What was your background in health care prior to joining HFAP?

I worked at SwedishAmerican health system, a division of UW Health, in
Rockford, Ill., for eight years. Before that, I was employed in architectural offices to provide project design and compliance services for hospital projects.

What is your HFAP role today?

Early in my career, when working on the architectural side, I discovered that I had an affinity for code compliance. I worked on many Americans with Disabilities Act-compliance evaluations and projects for the state of Illinois and other public entities.

I also was privileged to work on many hospital projects from a design and construction aspect. While working for a hospital system in Rockford, I started with HFAP as part of the first wave of Life Safety Code surveyors hired in 2014 to review life-safety compliance for accreditation.

Brad Keyes, the previous HFAP standards adviser, retired at the end of 2017, which gave me an opportunity to apply for adviser for life-safety, physical environment and emergency management standards.

In this role, I review all related survey documents, orchestrate compliance tools and author standards updates, and guide surveyors and survey activities for quality control and accuracy. I also take pride in being a ready resource for our HFAP facilities when anyone has questions.

What are some defining characteristics of HFAP’s approach to accreditation and surveying?

One of the distinguishing characteristics of HFAP’s approach is the emphasis on providing an educational environment when performing accreditation surveys. The Centers for Medicare & Medicaid Services (CMS) requires all witnessed noncompliance during surveys to be included as citations in our final report.

With HFAP, we strive to verify that the hospital knows and understands each element of noncompliance that will be noted on the final deficiency report. Facility personnel have an opportunity to interact with our surveyors on a personal level and are encouraged to ask questions about the requirements and current-practice interpretations. In the end, the goal is to provide a safer and healthier environment for patients and staff. HFAP states that the best way to do this is by including education to encourage continued improvement.

We want to apply the same quality initiatives to our own work as the hospitals we survey. To help gauge and improve, we make a focused effort to educate our surveyors to be consistent from survey to survey with regard to interpretations.

Because I review all life-safety, physical environment and emergency management findings, I identify incorrect interpretations and inconsistencies in our process and provide immediate feedback to surveyors. We also follow up on all comments and feedback from hospitals regarding their survey experiences so we can improve our core fundamentals.

Why is communication between clinical and nonclinical staff an important aspect to achieving compliance?

I am often asked what one thing any facility can do that will have the largest impact on compliance. The answer, simply stated, is communicate.

Clinical staff and facility staff are often operating in silos that do not allow for free-flowing communication. Clinical staff and technical facility staff come from different backgrounds and use different, sometimes very esoteric, terminology.

Without giving time and attention to using a good recursive communication model, misunderstanding or a disconnect happens. In these gaps, compliance issues can occur.

What are some of the current physical environment challenges health care facilities are facing?

When it comes to the Life Safety Code, the element most affecting facilities now is the fourth dimension of time. The change in survey expectations brought on by the addition of life-safety surveyors has elevated review intensity for physical environment compliance, occupant egress and also fire-safety system testing documents that are required to be presented for review.

Many hospitals are not up to date on the current requirements if their survey experiences have not mandated that they do so.

Emergency management is another challenge. Those entities that have had a real-world event and put their emergency operations plan (EOP) to work are better equipped to meet the standards. Unfortunately, I have seen a lot of staff turnover in this arena, so the responsible individual cannot locate required elements in their EOP; and there is a lack of document preparation as staff assume all has been vetted and any situation will “just get dealt with.”

I usually recommend a side-by-side review of standards versus EOP and survey prep sessions, so staff have practice time locating processes included or referenced by the EOP. A big hint: Ask for help. The emergency preparedness committee chair should not have to do all the work alone.

There also is the emphasis on patient safety, which is such an important directive from CMS, and specifically the attention that is mandated to ligature risks in patient care environments.

As each hospital serves different patient populations and has different levels of clinical need, HFAP expects each facility to determine its own areas of risk regarding patients with high levels of potential for self-harm or harm to others. It is expected that risk assessments be made for behavioral health units and emergency departments, but other patient populations warrant consideration, too — for example, those with constant or chronic pain.

Again, this is a communication issue. Clinical staff who determine patient-
assessment criteria and facility staff who review the built environment need to work closely together on this topic and share assessment and compliance resources.

Maintenance and testing of building systems also plays a crucial role in reducing the spread of germs and bacteria. Water management plans with consideration of Legionella as well as required temperature, humidity and positive/negative room pressure can affect patient care.

How is HFAP helping health care facility professionals to deal with these and other challenges?

HFAP is known for the accessibility of staff and the quality of its customer service on an individual basis. We also offer regular webinars for standards updates and other compliance-related issues to help hospitals identify areas to review and verify compliance, or simply to address common questions.

For face-to-face training, HFAP hosts a two-day conference event called Academy Live. This year, it was held Oct. 11-12 in Chicago. It offers targeted training with focused tracks for hospital leaders — clinical, administrative and facility — as well as a separate track for ambulatory surgery centers.

HFAP also offers tools and checklists for standard processes. Guides for life-safety waivers and equivalencies, required testing, emergency management checklists and more are available.

Many of these are the same forms that surveyors are required to use for survey purposes, so there are no differences in what the hospital prepares for proof of compliance and what is requested on the survey. It is intended to be a transparent process.

Jamie Morgan is associate editor of Health Facilities Management.

Photo by David Olson Photography