Please read the press release below. HealthCare Source is excited about this new strategic merger and will keep you up to date as we see improvements and expansion associated with the changes.
************************************************************
FOR IMMEDIATE RELEASE Contacts: Kevin Mortesen
800-437-6633, ext. 2877
Todd Ross
800-848-6462
CAPSA SOLUTIONS ANNOUNCES ACQUISITION OF ARTROMICK MOBILE SOLUTIONS GROUP
Company Adds Additional Strength in the Long-Term and Acute Healthcare Markets
WOODINVILLE, WA and COLUMBUS, OH (December 1, 2009) – Capsa Solutions, a leading provider of storage, processing and transport products, has announced the acquisition of Artromick Mobile Solutions Group and their comprehensive line of medical and mobile computing carts for the extended and acute healthcare sectors.
Capsa Solutions currently services the needs for their healthcare, retail, and light manufacturing customers with MMI Med Carts and IRSG product lines. The addition of Artromick further widens a broad product offering for the healthcare market and offers Capsa Solutions’ customers more options.
“Artromick has a history of integrating superior design with the latest technology features to improve the efficiency of caregivers at the point of care,” said Capsa Solutions CEO Dave Burns. “The addition of Artromick to the Capsa Solutions family is an absolute win for our healthcare partners. Our spectrum of cart, storage, and mobility solutions fill needs for most any healthcare application. Artromick is a strong and healthy brand that will continue to grow as part of Capsa Solutions.”
The combined product lines of Artromick, MMI Med Carts and IRSG cover virtually every room of an acute or long-term healthcare facility. Included in the product portfolio are carts for point of care computing, medication control, anesthesia, malignant hyperthermia, transport and more. Additionally, the company’s high-density mobile storage and fixed shelving are key components for central supply and materials management and a host of additional specialty care carts serve varied roles in a facility.
“The acquisition of Artromick Mobile Solutions Group by Capsa Solutions creates a significantly stronger healthcare firm for our domestic and international core markets,” said Artromick CEO Paul Guth. “This alliance of products and professionals with extensive healthcare experience will drive new innovation that facilitates accuracy in the delivery of patient care.”
-more-
2-2-2-2/Capsa Solutions Acquires Artromick Mobile Solutions Group
The addition of Artromick to Capsa Solutions will provide clients with a strong sales and service force that works as a cohesive team, with broader capabilities and the ability to deliver customers a wider array of services and more product options, for healthcare, retail and light manufacturing markets.
About Capsa Solutions
Capsa Solutions includes the MMI Med Cart, IRSG and Artromick Mobile Solutions lines of product. The company has over 100 years of combined experience providing solutions for multiple applications to the healthcare, retail and light manufacturing markets. Headquartered in Woodinville, Washington, the company has additional manufacturing, distribution and management facilities in Los Angeles, the Chicago area and Columbus, Ohio. To learn more, visit www.capsasolutions.com or call 800-437-6633.
Long Term Healthcare Industry news and editorial from Dennis Boren - a 40+ year veteran.
Monday, December 7, 2009
Wednesday, September 2, 2009
Value Analysis
VALUE ANALYSIS IN HEALTHCARE PURCHASING
We have another article request from a client. I promise I will get to my own scheduled series of articles someday, but I want to always give priority to customer inquiries. This most recent one piqued my attention because I was caught making a mistake, about which I have constantly lectured my HCS staff. I tell them they should, “Never speak to a client about products using industry jargon! Explain yourself clearly!”
And, as most of you know I spent the first 23 years of my career in health care purchasing for two different multi-billion dollar health care corporations (back when a billion dollars was serious money). And now my customers and staff are telling me that the things I say about purchasing (that I take for granted) sometimes come off as “jargon” to the rest of the world.
So, here is my oops and apologies to all! And this criticism really hit home just last week when another client asked me to expand on what I mean when I refer to the application of “Value Analysis” when making a purchasing decision. … so, as my penance, here goes my answer to your request in an overview of the purchasing process …
CATEGORIZING THE PURCHASE DECISION
My first advice to someone making a health care purchasing decision is that they should put that project into one of two categories. The first category is CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES (a good place to start might be to consider unit prices below 250-500), and the second category is CAPITAL PURCHASING (products with a depreciable useful life).
Next, the buyer must get comfortable with the idea that the process of purchasing items for one category is COMPLETELY DIFFERENT from the process of purchasing items for the other.
And Dennis’ false assumption #1 is that everyone understood this basic premise.
CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES
Consumables, disposables, expensables and services are an easy category for purchasers. It is just like shopping for yourself! Everyone seems to be comfortable with this category and in fact my greatest criticism is that far too often the purchasing criteria for this category are used when purchasing capital equipment. Using a “consumables” approach to “capital purchasing” can be a huge and costly mistake.
AXIOM: WHEN ALL ELSE IS EQUAL, PURCHASE CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES AT THE LOWEST DELIVERED COST OF ACQUISITION!
CAPITAL PURCHASING
When it comes to capital purchasing the buyer should be ready to do some serious analytical work, especially when the TOTAL purchase is for a significant amount of money.
AXIOM: WHEN ALL ELSE IS EQUAL, PURCHASE CAPITAL EQUIPMENT AT THE LOWEST COST OF OWNERSHIP!
ESTABLISHING COST OF OWNERSHIP
Dennis’ false assumption #2; everyone understands the “value analysis” process which determines “the lowest cost of ownership”.
Let’s keep the example simple and generic. Let’s say the buyer has been told to purchase 100 new beds for their facility. The beds vary in price from 600 - 1600. Which one has the lowest cost of ownership?
It may come as a surprise to some, but the higher priced beds MIGHT have the lowest cost of ownership. Let’s examine that possibility.
DISCLAIMER: This example is not meant to represent a “value analysis” checklist. It is only an example of a few of the issues that might be considered when making a “value analysis” purchase. A good bed analysis will probably have at least 50 or more “value consideration” columns to review.
WHERE TO START?
An error that the inexperienced buyer might make is to START the purchasing process using the specifications from a known product. What the buyer should do is to look at what their facility is using now and try to determine what works and what doesn’t work for the staff … how much are the repair and maintenance costs? Have there been any injuries related to the product…to clients or employees? What bed features are on the employee’s wish list? Interview patients/residents, employees, your management team, the finance department, doctors and therapists regarding their needs for these beds. Speak to anyone who will talk to you about their ideas for the new beds. Be sure to discuss the “amortized” useful life and the “expected” useful life with management.
And after gathering this information, determine what features you NEED and what feature you WANT and then write your own specs to submit to the manufacturers!
AXIOM: WRITE YOUR OWN SPECS. USING SOMEONE ELSE’S SPEC GUARANTEES YOU WON’T GET THE BEST VALUE FOR YOUR COMPANY.
QUALIFY YOUR VENDORS
Make a list of all the POTENTIAL bed vendors and begin the process of qualifying (or disqualifying) them for your project. How long have they been in business? Are they financially stable (very important in today’s economy)? Are they a certified regulatory compliant manufacturer? Are they actually the manufacturer or just a distributor? When negotiating, you want to be sure you are speaking to the “organ grinder” and not to the “monkey”.
Make your selected list of vendors based on their qualifications and ONLY offer the chance to participate further to those vendors you have qualified. You do not need to include EVERY vendor. Once you have qualified a number of vendors for the project and shown them your specs to confirm that they are interested and capable, you only need enough vendors to make sure that the bid will be competitive.
EVALUATE THE MANUFACTURER’S RESPONSES And just as your business needs change, so does the manufacturing environment. An example of that would be that one of your qualified manufacturers may decide to go “off shore” for production. That manufacturer’s decision could/should dramatically change your weighted points of evaluation for the analysis and potentially alter the final purchasing decision.
A few, very large manufacturers have done very well with off shore production but most average size companies experience quality assurance challenges and you don’t want to be the guy caught in the middle of such a transition. Those are the kinds of things you are probing for when interviewing manufacturers.
MAKE FORWARD LOOKING DECISIONS
When you purchase consumables, disposables, expensables and services, those products are purchased for IMMEDIATE CONSUMPTION and are USED UP promptly. If you made an error, it is an easy one to correct and has very short-term financial impact.
When you make a capital equipment purchase you will own that equipment for a long time. The potential for significant financial impact due to a bad selection can be huge. In the case of our example, most beds are warranted for 15 years or more. Over the 15 years, those beds need TLC (parts, maintenance, repairs, touch-ups). The prudent buyer takes the knowledge of that need into account.
So, What if you purchased from a manufacturer who goes out of business? Or discontinues the product? Where will you get parts? Will you throw those beds away? What does that do to the expected useful life of your beds?
So, What if you purchased from a manufacturer who has regulatory problems? Are you going to throw those beds away? Risk Management will want you to do that? What does that do to the amortized value of the product? Is your company going to take a huge write-off?
So, what is your customer going to look like in 15 years? And will the bed you are buying today service that population? Are you going to replace the beds sooner if they don’t?
So, What if the bed that you purchased saved 200 per unit at the time of purchase but that bed requires 15 minutes a day of extra attention by staff? No big deal you say?
15 minutes per day times 100 beds = 25 hours per day
25 hours per day times 365 days per year = 9125 hours per year
9125 hours per year times 15 years (useful life) = 136,875 hours over the life of the beds
136,875 hours at ? per hour = ? .
If you use something conservative like 25 per hour the total is 3.5 million in wasted labor to save 20,000 in acquisition costs. I sure am glad I am not the person that made that buying decision!
AXIOM: AT THE VERY LEAST, HOLD THE PRODUCT AND THE MANUFACTURER ACCOUNTABLE TO PERFORM “AS EXPECTED” FOR THE AMORTIZED LIFE OF THE PRODUCT. MORE IS BETTER.
SUMMARY
I can only begin to “teach” about value analysis in 10 paragraphs, but let me conclude that “any effort” on the buyer’s part to make thoughtful capital purchasing decisions is better than “no effort at all”. Is it intimidating to do this the first time? Yes! But the goal is not to make a “perfect decision”. The goal is to make the “best decision possible” and document how you arrived at the decision … and so that is what I mean by citing the term “value analysis” when we talk about purchasing capital equipment.
Then, once you have made your decision, don’t be looking “over your shoulder” or second guessing yourself. Make the informed decision and embrace it. Execute your buying program in the most conscientious way. You will have the opportunity and the documentation to go back and see how well you did in two or three years (unless it was a REALLY bad decision and someone else like “the boss” beats you to it… just kidding…).
Purchasing decisions are often delegated by management to financial or operations people who do not have a great deal of purchasing experience. We hope that this outline will help those people move forward with their purchasing project with a new found confidence.
We have another article request from a client. I promise I will get to my own scheduled series of articles someday, but I want to always give priority to customer inquiries. This most recent one piqued my attention because I was caught making a mistake, about which I have constantly lectured my HCS staff. I tell them they should, “Never speak to a client about products using industry jargon! Explain yourself clearly!”
And, as most of you know I spent the first 23 years of my career in health care purchasing for two different multi-billion dollar health care corporations (back when a billion dollars was serious money). And now my customers and staff are telling me that the things I say about purchasing (that I take for granted) sometimes come off as “jargon” to the rest of the world.
So, here is my oops and apologies to all! And this criticism really hit home just last week when another client asked me to expand on what I mean when I refer to the application of “Value Analysis” when making a purchasing decision. … so, as my penance, here goes my answer to your request in an overview of the purchasing process …
CATEGORIZING THE PURCHASE DECISION
My first advice to someone making a health care purchasing decision is that they should put that project into one of two categories. The first category is CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES (a good place to start might be to consider unit prices below 250-500), and the second category is CAPITAL PURCHASING (products with a depreciable useful life).
Next, the buyer must get comfortable with the idea that the process of purchasing items for one category is COMPLETELY DIFFERENT from the process of purchasing items for the other.
And Dennis’ false assumption #1 is that everyone understood this basic premise.
CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES
Consumables, disposables, expensables and services are an easy category for purchasers. It is just like shopping for yourself! Everyone seems to be comfortable with this category and in fact my greatest criticism is that far too often the purchasing criteria for this category are used when purchasing capital equipment. Using a “consumables” approach to “capital purchasing” can be a huge and costly mistake.
AXIOM: WHEN ALL ELSE IS EQUAL, PURCHASE CONSUMABLES, DISPOSABLES, EXPENSABLES AND SERVICES AT THE LOWEST DELIVERED COST OF ACQUISITION!
CAPITAL PURCHASING
When it comes to capital purchasing the buyer should be ready to do some serious analytical work, especially when the TOTAL purchase is for a significant amount of money.
AXIOM: WHEN ALL ELSE IS EQUAL, PURCHASE CAPITAL EQUIPMENT AT THE LOWEST COST OF OWNERSHIP!
ESTABLISHING COST OF OWNERSHIP
Dennis’ false assumption #2; everyone understands the “value analysis” process which determines “the lowest cost of ownership”.
Let’s keep the example simple and generic. Let’s say the buyer has been told to purchase 100 new beds for their facility. The beds vary in price from 600 - 1600. Which one has the lowest cost of ownership?
It may come as a surprise to some, but the higher priced beds MIGHT have the lowest cost of ownership. Let’s examine that possibility.
DISCLAIMER: This example is not meant to represent a “value analysis” checklist. It is only an example of a few of the issues that might be considered when making a “value analysis” purchase. A good bed analysis will probably have at least 50 or more “value consideration” columns to review.
WHERE TO START?
An error that the inexperienced buyer might make is to START the purchasing process using the specifications from a known product. What the buyer should do is to look at what their facility is using now and try to determine what works and what doesn’t work for the staff … how much are the repair and maintenance costs? Have there been any injuries related to the product…to clients or employees? What bed features are on the employee’s wish list? Interview patients/residents, employees, your management team, the finance department, doctors and therapists regarding their needs for these beds. Speak to anyone who will talk to you about their ideas for the new beds. Be sure to discuss the “amortized” useful life and the “expected” useful life with management.
And after gathering this information, determine what features you NEED and what feature you WANT and then write your own specs to submit to the manufacturers!
AXIOM: WRITE YOUR OWN SPECS. USING SOMEONE ELSE’S SPEC GUARANTEES YOU WON’T GET THE BEST VALUE FOR YOUR COMPANY.
QUALIFY YOUR VENDORS
Make a list of all the POTENTIAL bed vendors and begin the process of qualifying (or disqualifying) them for your project. How long have they been in business? Are they financially stable (very important in today’s economy)? Are they a certified regulatory compliant manufacturer? Are they actually the manufacturer or just a distributor? When negotiating, you want to be sure you are speaking to the “organ grinder” and not to the “monkey”.
Make your selected list of vendors based on their qualifications and ONLY offer the chance to participate further to those vendors you have qualified. You do not need to include EVERY vendor. Once you have qualified a number of vendors for the project and shown them your specs to confirm that they are interested and capable, you only need enough vendors to make sure that the bid will be competitive.
EVALUATE THE MANUFACTURER’S RESPONSES And just as your business needs change, so does the manufacturing environment. An example of that would be that one of your qualified manufacturers may decide to go “off shore” for production. That manufacturer’s decision could/should dramatically change your weighted points of evaluation for the analysis and potentially alter the final purchasing decision.
A few, very large manufacturers have done very well with off shore production but most average size companies experience quality assurance challenges and you don’t want to be the guy caught in the middle of such a transition. Those are the kinds of things you are probing for when interviewing manufacturers.
MAKE FORWARD LOOKING DECISIONS
When you purchase consumables, disposables, expensables and services, those products are purchased for IMMEDIATE CONSUMPTION and are USED UP promptly. If you made an error, it is an easy one to correct and has very short-term financial impact.
When you make a capital equipment purchase you will own that equipment for a long time. The potential for significant financial impact due to a bad selection can be huge. In the case of our example, most beds are warranted for 15 years or more. Over the 15 years, those beds need TLC (parts, maintenance, repairs, touch-ups). The prudent buyer takes the knowledge of that need into account.
So, What if you purchased from a manufacturer who goes out of business? Or discontinues the product? Where will you get parts? Will you throw those beds away? What does that do to the expected useful life of your beds?
So, What if you purchased from a manufacturer who has regulatory problems? Are you going to throw those beds away? Risk Management will want you to do that? What does that do to the amortized value of the product? Is your company going to take a huge write-off?
So, what is your customer going to look like in 15 years? And will the bed you are buying today service that population? Are you going to replace the beds sooner if they don’t?
So, What if the bed that you purchased saved 200 per unit at the time of purchase but that bed requires 15 minutes a day of extra attention by staff? No big deal you say?
15 minutes per day times 100 beds = 25 hours per day
25 hours per day times 365 days per year = 9125 hours per year
9125 hours per year times 15 years (useful life) = 136,875 hours over the life of the beds
136,875 hours at ? per hour = ? .
If you use something conservative like 25 per hour the total is 3.5 million in wasted labor to save 20,000 in acquisition costs. I sure am glad I am not the person that made that buying decision!
AXIOM: AT THE VERY LEAST, HOLD THE PRODUCT AND THE MANUFACTURER ACCOUNTABLE TO PERFORM “AS EXPECTED” FOR THE AMORTIZED LIFE OF THE PRODUCT. MORE IS BETTER.
SUMMARY
I can only begin to “teach” about value analysis in 10 paragraphs, but let me conclude that “any effort” on the buyer’s part to make thoughtful capital purchasing decisions is better than “no effort at all”. Is it intimidating to do this the first time? Yes! But the goal is not to make a “perfect decision”. The goal is to make the “best decision possible” and document how you arrived at the decision … and so that is what I mean by citing the term “value analysis” when we talk about purchasing capital equipment.
Then, once you have made your decision, don’t be looking “over your shoulder” or second guessing yourself. Make the informed decision and embrace it. Execute your buying program in the most conscientious way. You will have the opportunity and the documentation to go back and see how well you did in two or three years (unless it was a REALLY bad decision and someone else like “the boss” beats you to it… just kidding…).
Purchasing decisions are often delegated by management to financial or operations people who do not have a great deal of purchasing experience. We hope that this outline will help those people move forward with their purchasing project with a new found confidence.
Friday, August 21, 2009
Health Care Televisions
SELECTING TELEVISIONS FOR A HEALTHCARE FACILITY
This article is prompted by another client request. It is one that I have been putting off writing so that I could do additional “research”. In fact, I have been struggling to complete this article because I was looking for exactly the right answers. After working with another client yesterday, and helping that client make TV selections, I had a revelation! THERE IS NO “RIGHT” WAY TO DO THIS! No matter what decision you make, some aspects of the decision are likely to be compromised.
OK, now that I have gotten that out of the way, let’s get productive and talk about making the “BEST” decision.
CATEGORIES OF TELEVISIONS
TV’s are manufactured for specific applications. All of us have gone to Best Buy or Costco and gazed at the array of BIG screen, flat panel TV’s that are offered in plasma, LCD and now LED … All of those TV’s were made specifically for the RETAIL market. Retail TV’s are designed with features you and I want so we can use them in our homes. What is generally not understood is that there are also special televisions made with certain features for other applications; for the hospitality market, the long term care market and for use in hospitals.
I’m not going into a lot of detail here, but I do want to address some of the differentiating features.
Let’s start with “commercial” TVs. The commercial TV evolved from the demands of an industry that has been buying and using TV’s for more than 50 years, the HOSPITALITY industry (hotels and motels). Hospitality buyers have forgotten more details about buying and owning TV’s than the health care industry (a relatively new participant in this market) has had the opportunity to absorb. We can take some hints from the hospitality industry’s experience though and cobble onto some of the features on which they will not compromise … and by the way, the hospitality industry has NEVER been know for “wasting a dollar” so it is safe to assume that their standards are steeped in value.
Features of commercial TV’s are:
The” Long Term Care TV” is a relatively new addition to the line-up of TV choices (as is the LTC industry in providing TV’s for residents). Two features have been added to the commercial television to create the LTC TV:
The” Acute Care” TV (hospital grade) has all of the above features and adds a PILLOW SPEAKER option and better INFECTION CONTROL by utilizing a “sealed” cleanable case for the monitor. There are also some higher end features available (read higher priced) that also allow for DC powered systems and eventual conversion to touch screen and interactive applications.
SCREEN SIZE
So, putting all the “this is a guy thing” jokes aside, screen size is a function of the distance of the patient/resident to the television screen. There are formulae on the internet to readily help you calculate correct size screen. There is one additional important twist that everyone needs to understand about screen size and that is that when television went “digital”, the aspect ratio changed from 4:3 to 16:9 (we went widescreen). Almost all NEW flat panel televisions have been sized to optimize the 16:9 ratio. Some older flat panel television such as the 20”, now render a much smaller picture (for the 20” TV, about the equivalent of a 16-17” monitor) because the 20” TV was designed to optimize the 4:3 ratio.
MOUNTING THE TV
So now we have selected our TV … what else is there left to do besides setting it up?
Oops! Did I forget to tell you that we don’t recommend that you select the TV first? We need to figure out HOW and WHERE to mount the TV, and AFTER THAT pick the best TV option. My analogy for the commercial TV selection process (and to a lesser degree, buying a TV for your home) is taken from the early days of personal computing (and yes, I was there…). Often, people would rush out to buy a computer only to learn later that the software they wanted to run was not compatible with the computer they had just purchased. The same problem now arises with commercial TV’s … If you buy 22” TVs and then find out that the only practical place to mount them is clear across the room, you will be disappointed with the result because no one can see the picture that far away.
There are lots of TV mounting options to consider and then, once you select the option you want, there are then multiple styles of mounts; wall mounts, ceiling mounts, fixed mounts, articulating mounts, adjustable mounts, you name it mounts, to consider. Space available and construction of your building dictate the best choices for mounts. And even though almost all TV’s come with a table base included, we do not recommend using the table base in a commercial application. The table base is not secure from theft and is prone to being knocked over. WARNING: Some TV mounting systems can cost more than the television. Much more!
NOISE POLLUTION
The hospital grade unit has the only “built in” solution to noise pollution by providing the pillow speaker option and commercial and Long Term Care Grade TV’s can be programmed to “cap the volume”. There are a number of third party products that look like they have some promise to provide” personal sound” alternatives while working with other than just the hospital grade TVs. It is a little too soon to name any one of these the “panacea” for the industry. Keep in touch with Health Care Source and we will let you know as soon as we have a remote speaker product to endorse.
OTHER COOL STUFF
Don’t forget to ask us about single patient use hand controls.
AND LEST WE FORGET! THE REGULATIONS
In California we must take OSHPD regulations into account. If you are adding televisions as part of an OSHPD approved remodel, they will want details about the TV and the TV mounting device you have selected. As a point of reference, most 26” or smaller commercial TV’s weigh less than 20 lbs.
More important to regulatory considerations in the long term care use of televisions are the new CMS “Home Like Environment” guidelines. The long term care industry was beginning to trend toward an “acute care” approach to mounting their televisions on “swing away” mounting arms attached to the wall or the ceiling.
Unfortunately, the swing away arm mount is not anything that you would ever see in a home like environment. They are, oh how can I be kind here?…. quite ugly, invasive and very institutional in nature. I do not see now how this mechanism could be disguised, and so, given the new CMS guidelines, I don’t think the “articulating arm” is a practical mounting application for a Skilled Nursing facility’s televisions.
CONCLUSION
So now do you see why I said; “THERE IS NO RIGHT WAY TO DO THIS”?
We think the “BEST” way for our client to make a good decision regarding TV selection is to establish values and then measure the choices against those values.
Why are you purchasing the TV’s for the facility? Is it for competitive marketing reasons? Is it for patient/resident satisfaction (an amenity)? Is it to offer diversion to the patient/resident? Is it some other reason/reasons?
If the client has weighed their values to determine what is most important to them and then shares that decision with one of our HealthCare Source staff, then with our expertise and experience, we can together quickly identify the “best solution” and opt for the “best value” in televisions, mounts and accessories.
This article is prompted by another client request. It is one that I have been putting off writing so that I could do additional “research”. In fact, I have been struggling to complete this article because I was looking for exactly the right answers. After working with another client yesterday, and helping that client make TV selections, I had a revelation! THERE IS NO “RIGHT” WAY TO DO THIS! No matter what decision you make, some aspects of the decision are likely to be compromised.
OK, now that I have gotten that out of the way, let’s get productive and talk about making the “BEST” decision.
CATEGORIES OF TELEVISIONS
TV’s are manufactured for specific applications. All of us have gone to Best Buy or Costco and gazed at the array of BIG screen, flat panel TV’s that are offered in plasma, LCD and now LED … All of those TV’s were made specifically for the RETAIL market. Retail TV’s are designed with features you and I want so we can use them in our homes. What is generally not understood is that there are also special televisions made with certain features for other applications; for the hospitality market, the long term care market and for use in hospitals.
I’m not going into a lot of detail here, but I do want to address some of the differentiating features.
Let’s start with “commercial” TVs. The commercial TV evolved from the demands of an industry that has been buying and using TV’s for more than 50 years, the HOSPITALITY industry (hotels and motels). Hospitality buyers have forgotten more details about buying and owning TV’s than the health care industry (a relatively new participant in this market) has had the opportunity to absorb. We can take some hints from the hospitality industry’s experience though and cobble onto some of the features on which they will not compromise … and by the way, the hospitality industry has NEVER been know for “wasting a dollar” so it is safe to assume that their standards are steeped in value.
Features of commercial TV’s are:
- Special software that allows you to program one TV and then “one touch program” all the other TV’s with that same remote. Think about this feature in the health care context of having “pre-tuned” a control for a foreign language preference, one for sports and one for programs of medical interest. When a new patient/resident moves in to the facility, you can “one touch” the TV to be specific to that patient/resident’s preferences.
- Warranty. Some commercial TV manufacturers who “toughen” their commercial product also offer special extended warranties in the commercial environment. In almost all cases, delivering a retail grade TV for use in a commercial environment VOIDS the manufacturer’s warranty. BEWARE!
- Limits on sound adjustments to avoid noise pollution.
- The TV always turns “on” to a specific channel. This is a great feature if the facility has invested in a personalized channel receiver and uses the channel for daily announcements and other information. Individual patient/resident schedules can even be displayed on a specific TV screen only. This is similar to the ability to check your hotel bill from the TV in your room.
The” Long Term Care TV” is a relatively new addition to the line-up of TV choices (as is the LTC industry in providing TV’s for residents). Two features have been added to the commercial television to create the LTC TV:
- A simplified hand control for a less “sophisticated” user.
- Discrete IR which eliminates “cross talk” between two television remotes in the same room.
The” Acute Care” TV (hospital grade) has all of the above features and adds a PILLOW SPEAKER option and better INFECTION CONTROL by utilizing a “sealed” cleanable case for the monitor. There are also some higher end features available (read higher priced) that also allow for DC powered systems and eventual conversion to touch screen and interactive applications.
SCREEN SIZE
So, putting all the “this is a guy thing” jokes aside, screen size is a function of the distance of the patient/resident to the television screen. There are formulae on the internet to readily help you calculate correct size screen. There is one additional important twist that everyone needs to understand about screen size and that is that when television went “digital”, the aspect ratio changed from 4:3 to 16:9 (we went widescreen). Almost all NEW flat panel televisions have been sized to optimize the 16:9 ratio. Some older flat panel television such as the 20”, now render a much smaller picture (for the 20” TV, about the equivalent of a 16-17” monitor) because the 20” TV was designed to optimize the 4:3 ratio.
MOUNTING THE TV
So now we have selected our TV … what else is there left to do besides setting it up?
Oops! Did I forget to tell you that we don’t recommend that you select the TV first? We need to figure out HOW and WHERE to mount the TV, and AFTER THAT pick the best TV option. My analogy for the commercial TV selection process (and to a lesser degree, buying a TV for your home) is taken from the early days of personal computing (and yes, I was there…). Often, people would rush out to buy a computer only to learn later that the software they wanted to run was not compatible with the computer they had just purchased. The same problem now arises with commercial TV’s … If you buy 22” TVs and then find out that the only practical place to mount them is clear across the room, you will be disappointed with the result because no one can see the picture that far away.
There are lots of TV mounting options to consider and then, once you select the option you want, there are then multiple styles of mounts; wall mounts, ceiling mounts, fixed mounts, articulating mounts, adjustable mounts, you name it mounts, to consider. Space available and construction of your building dictate the best choices for mounts. And even though almost all TV’s come with a table base included, we do not recommend using the table base in a commercial application. The table base is not secure from theft and is prone to being knocked over. WARNING: Some TV mounting systems can cost more than the television. Much more!
NOISE POLLUTION
The hospital grade unit has the only “built in” solution to noise pollution by providing the pillow speaker option and commercial and Long Term Care Grade TV’s can be programmed to “cap the volume”. There are a number of third party products that look like they have some promise to provide” personal sound” alternatives while working with other than just the hospital grade TVs. It is a little too soon to name any one of these the “panacea” for the industry. Keep in touch with Health Care Source and we will let you know as soon as we have a remote speaker product to endorse.
OTHER COOL STUFF
Don’t forget to ask us about single patient use hand controls.
AND LEST WE FORGET! THE REGULATIONS
In California we must take OSHPD regulations into account. If you are adding televisions as part of an OSHPD approved remodel, they will want details about the TV and the TV mounting device you have selected. As a point of reference, most 26” or smaller commercial TV’s weigh less than 20 lbs.
More important to regulatory considerations in the long term care use of televisions are the new CMS “Home Like Environment” guidelines. The long term care industry was beginning to trend toward an “acute care” approach to mounting their televisions on “swing away” mounting arms attached to the wall or the ceiling.
Unfortunately, the swing away arm mount is not anything that you would ever see in a home like environment. They are, oh how can I be kind here?…. quite ugly, invasive and very institutional in nature. I do not see now how this mechanism could be disguised, and so, given the new CMS guidelines, I don’t think the “articulating arm” is a practical mounting application for a Skilled Nursing facility’s televisions.
CONCLUSION
So now do you see why I said; “THERE IS NO RIGHT WAY TO DO THIS”?
We think the “BEST” way for our client to make a good decision regarding TV selection is to establish values and then measure the choices against those values.
Why are you purchasing the TV’s for the facility? Is it for competitive marketing reasons? Is it for patient/resident satisfaction (an amenity)? Is it to offer diversion to the patient/resident? Is it some other reason/reasons?
If the client has weighed their values to determine what is most important to them and then shares that decision with one of our HealthCare Source staff, then with our expertise and experience, we can together quickly identify the “best solution” and opt for the “best value” in televisions, mounts and accessories.
Thursday, August 13, 2009
Dealer Services
WHAT SERVICES SHOULD I EXPECT FROM A HEALTH CARE DEALER?
This article was written at the request of one of our clients. The e-mail inquiry, which was sent to “The Boren Report”, pointed out that there is a lot of confusion as to who is and who is not a dealer. Also, in the e-mail message the client asked about what they were paying for when they purchased from a dealer instead of purchasing factory direct.
Nobody said writing my “blog” would be easy, and this is indeed a challenging question to answer. Given that there are entire books written about how “distribution channels” function, I am going to try and answer the question in a concise and somewhat generic manner. My goal is to provide the buyer with enough information to help determine whether or not they are getting their money’s worth when they employ a dealer.
A BASIC DEFINITION:
A DEALER: A dealer is an individual or a company who purchases product from a manufacturer and then re-sells it to the end user. The dealer’s selling price to the end user includes a “mark up” on his cost to pay for any additional “value added” services that the dealer could provide to an end user. Some dealers will unbundle their services and allow the buyer to “shop” for only those services they need. Other dealers will only offer a fixed package of services. And then, there are those dealers that charge a mark up and offer the end user very little in return. Hopefully this article will help protect you from the latter.
You may ask me, what is confusing about this definition of a dealer? I think people are finding the dealer relationship confusing because, in practice, some companies who operate in the health care “distribution channel” WANT it to be confusing. On opposite ends of the distribution scale, we see well known manufacturers who are acting as dealers and well known dealers who like to appear as though they are a “factory direct” source. No wonder there is confusion.
To get closer to a working definition of a dealer, let’s examine and define a list of “value added” dealer services that the buyer might get with the products they buy.
PRODUCT SPECIFICATION:
Product specification, especially in health care equipment is CRITICAL. Health Care is one of the most highly regulated industries in the world and answers to a matrix of Federal, State, regional and private regulators. Errors and omissions in product specifications can lead to a host of problems. A knowledgeable dealer should have a good grasp of these issues and help you make the right selections. We recently worked with a facility which was making a purchase of new furniture. The dealer (a national supplier) that they were planning to use was not aware of the California Air Resources Board standards for toxic emissions from furniture (this is a VERY real health issue) and had specified non-compliant products for this facility. The CARB regulation went into effect in California on January 1, 2009, eight months ago. The dealer in question was clearly out of touch with State and regional requirements. Had the facility made the planned purchase, they would have had significant liability exposure in case of resident illness.
Some dealers will also help the buyer with color recommendations and fabric selection or they will refer the buyer to a qualified health care designer to assist in this process. When you think about the fact that you want your capital equipment purchases to last for seven to fifteen years, and that you will be looking at them for that long, GOOD design is a GOOD investment.
FINANCING:
Out of the specification frying pan and into the financing fire! Financing is one of the benchmark services of dealers. Manufacturers do not finance … dealers finance! If you think you are getting financing from a factory, then one or more of three things is probably happening: 1. The factory is using a third party financier 2. The factory is actually a dealer and passing themselves off as a manufacturer 3. You are paying a financing fee which is pocketed by the manufacturer. When you finance through a dealer, especially a local dealer, the terms are generally more transparent and negotiable. Always consider obtaining your financing independent of ANY third party.
ORDERING:
There is lots of paperwork and legal mumbo jumbo involved in placing an order, especially for capital equipment. A knowledgeable dealer should handle this process for you and make sure you get the product you intended to buy.
EXPEDITING:
Expediting is the “are we there yet?” of dealer services. Keeping track of when product is shipping, if it is shipping on schedule, checking with the factory regularly regarding the order status, and alerting the end user ahead of time that their shipment will be arriving on a given day is the expeditors’ job. This is another valuable dealer service.
RECEIVING:
What do you mean you are in the “middle of survey” and you have no place to park a 75’ long truck, much less receive the shipment? A full service dealer will receive the merchandise for you at his dock until YOU are ready to take delivery. Also, when you take “direct shipment” you are technically responsible for freight damage once product leaves the factory (that what FOB means). When you purchase through a dealer, the dealer assumes that responsibility for you. Look closely at this issue anytime a dealer wants to “drop ship” product into your facility.
INVENTORY:
A full service dealer will immediately un-package and inspect your shipment. The buyer has a VERY limited window to report errors, omissions and damage. Too often the staff at a facility do not have the time to “get around to doing this inspection”, and by the time they do, it is too late. Plus, if there is a problem with the product, that “problem” is not sitting in the middle of your facility, waiting to be resolved.
STORAGE:
Is your re-modeling project running behind schedule and you are not ready to take delivery? A full service dealer will store and protect you product until you are ready to take delivery.
ASSEMBLY:
Does that product that arrived in the box look like an “erector set” when you opened it? A full service dealer will have qualified staff toassemble your product for you.
DELIVERY:
A full service dealer will deliver your purchase to your door with trained staff and an appropriately sized vehicle.
INSTALLATION:
A full service dealer will install the products you have purchased using “bonded” employees who may safely enter your facility.
REMOVAL:
A full service dealer will have an empty truck when the installation is complete. Most will haul away cartons and packing materials and often any old product you want to dispose of.
CONCLUSION:
So, how about it? Using this article and the inclusive list of dealer services as your scale: 1. Was your most recent purchase transaction made with a manufacturer or with a manufacturer acting as a dealer or with a dealer 2. If it was a dealer, were they a full service dealer, and 3. If you are paying for dealer services, are you getting the dealer services you are paying for??????
And for our client who asked this question, please let me know if I have answered to your satisfaction.
This article was written at the request of one of our clients. The e-mail inquiry, which was sent to “The Boren Report”, pointed out that there is a lot of confusion as to who is and who is not a dealer. Also, in the e-mail message the client asked about what they were paying for when they purchased from a dealer instead of purchasing factory direct.
Nobody said writing my “blog” would be easy, and this is indeed a challenging question to answer. Given that there are entire books written about how “distribution channels” function, I am going to try and answer the question in a concise and somewhat generic manner. My goal is to provide the buyer with enough information to help determine whether or not they are getting their money’s worth when they employ a dealer.
A BASIC DEFINITION:
A DEALER: A dealer is an individual or a company who purchases product from a manufacturer and then re-sells it to the end user. The dealer’s selling price to the end user includes a “mark up” on his cost to pay for any additional “value added” services that the dealer could provide to an end user. Some dealers will unbundle their services and allow the buyer to “shop” for only those services they need. Other dealers will only offer a fixed package of services. And then, there are those dealers that charge a mark up and offer the end user very little in return. Hopefully this article will help protect you from the latter.
You may ask me, what is confusing about this definition of a dealer? I think people are finding the dealer relationship confusing because, in practice, some companies who operate in the health care “distribution channel” WANT it to be confusing. On opposite ends of the distribution scale, we see well known manufacturers who are acting as dealers and well known dealers who like to appear as though they are a “factory direct” source. No wonder there is confusion.
To get closer to a working definition of a dealer, let’s examine and define a list of “value added” dealer services that the buyer might get with the products they buy.
PRODUCT SPECIFICATION:
Product specification, especially in health care equipment is CRITICAL. Health Care is one of the most highly regulated industries in the world and answers to a matrix of Federal, State, regional and private regulators. Errors and omissions in product specifications can lead to a host of problems. A knowledgeable dealer should have a good grasp of these issues and help you make the right selections. We recently worked with a facility which was making a purchase of new furniture. The dealer (a national supplier) that they were planning to use was not aware of the California Air Resources Board standards for toxic emissions from furniture (this is a VERY real health issue) and had specified non-compliant products for this facility. The CARB regulation went into effect in California on January 1, 2009, eight months ago. The dealer in question was clearly out of touch with State and regional requirements. Had the facility made the planned purchase, they would have had significant liability exposure in case of resident illness.
Some dealers will also help the buyer with color recommendations and fabric selection or they will refer the buyer to a qualified health care designer to assist in this process. When you think about the fact that you want your capital equipment purchases to last for seven to fifteen years, and that you will be looking at them for that long, GOOD design is a GOOD investment.
FINANCING:
Out of the specification frying pan and into the financing fire! Financing is one of the benchmark services of dealers. Manufacturers do not finance … dealers finance! If you think you are getting financing from a factory, then one or more of three things is probably happening: 1. The factory is using a third party financier 2. The factory is actually a dealer and passing themselves off as a manufacturer 3. You are paying a financing fee which is pocketed by the manufacturer. When you finance through a dealer, especially a local dealer, the terms are generally more transparent and negotiable. Always consider obtaining your financing independent of ANY third party.
ORDERING:
There is lots of paperwork and legal mumbo jumbo involved in placing an order, especially for capital equipment. A knowledgeable dealer should handle this process for you and make sure you get the product you intended to buy.
EXPEDITING:
Expediting is the “are we there yet?” of dealer services. Keeping track of when product is shipping, if it is shipping on schedule, checking with the factory regularly regarding the order status, and alerting the end user ahead of time that their shipment will be arriving on a given day is the expeditors’ job. This is another valuable dealer service.
RECEIVING:
What do you mean you are in the “middle of survey” and you have no place to park a 75’ long truck, much less receive the shipment? A full service dealer will receive the merchandise for you at his dock until YOU are ready to take delivery. Also, when you take “direct shipment” you are technically responsible for freight damage once product leaves the factory (that what FOB means). When you purchase through a dealer, the dealer assumes that responsibility for you. Look closely at this issue anytime a dealer wants to “drop ship” product into your facility.
INVENTORY:
A full service dealer will immediately un-package and inspect your shipment. The buyer has a VERY limited window to report errors, omissions and damage. Too often the staff at a facility do not have the time to “get around to doing this inspection”, and by the time they do, it is too late. Plus, if there is a problem with the product, that “problem” is not sitting in the middle of your facility, waiting to be resolved.
STORAGE:
Is your re-modeling project running behind schedule and you are not ready to take delivery? A full service dealer will store and protect you product until you are ready to take delivery.
ASSEMBLY:
Does that product that arrived in the box look like an “erector set” when you opened it? A full service dealer will have qualified staff toassemble your product for you.
DELIVERY:
A full service dealer will deliver your purchase to your door with trained staff and an appropriately sized vehicle.
INSTALLATION:
A full service dealer will install the products you have purchased using “bonded” employees who may safely enter your facility.
REMOVAL:
A full service dealer will have an empty truck when the installation is complete. Most will haul away cartons and packing materials and often any old product you want to dispose of.
CONCLUSION:
So, how about it? Using this article and the inclusive list of dealer services as your scale: 1. Was your most recent purchase transaction made with a manufacturer or with a manufacturer acting as a dealer or with a dealer 2. If it was a dealer, were they a full service dealer, and 3. If you are paying for dealer services, are you getting the dealer services you are paying for??????
And for our client who asked this question, please let me know if I have answered to your satisfaction.
Friday, August 7, 2009
The new CMS “homelike environment survey guidelines” F252
What can I say? These changes will significantly alter how a facility looks and operates! I am still thinking through the implications of these changes and how they will impact the care providers, the manufacturers who service the industry and the products that HealthCare Source represents.
One customer has already commented that they felt mitigated by the length of time that it will take for these guidelines to take hold. I explained that, operationally this is true, but HealthCare Source looks at the guidelines from a “capital equipment perspective” with purchases having a useful life of 10 years or more. If you are spending capital dollars TODAY then you need to at least take these guidelines into account, even if you say NO to implementing them.
My initial reaction is that some of the guideline changes have real merit. Some of the guideline changes are going to be difficult for the industry to address. And at least one of the guideline changes MUST have been written by some Senator’s “idiot love child”, because no one with intimate knowledge the industry would initiate a guideline like this. This one guideline, if interpreted and implemented as written, with no further thought, has the potential to return a disaster on the scale of New York’s 1911 Triangle Factory debacle.
I “betcha” you want to know which I think it is!
Before we go there, I can’t just let the industry “off the hook” in this matter. These guidelines are printed for comment in advance of adoption. Why are we dealing with these issues after they have already been implemented and why are they such a surprise to everyone I talk to about them? The most common response I have gotten from industry professionals is; “They can’t do that!”.
Back to the business at hand! Let’s start with the short list of what items the guideline RECOMMENDS be “banned” from the long term care environment.
Here is the guideline … Chapter and Verse:
F252
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.15(h) - Environment
The facility must provide--
§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;
Interpretive Guidelines: §483.15(h)(1)
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment.
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of:
Overhead paging and piped-in music throughout the building;
Meal service in the dining room using trays (some residents may wish to eat certain meals in their rooms on trays);
Institutional signage labeling work rooms/closets in areas visible to residents and the public;
Medication carts (some innovative facilities store medications in locked areas in resident rooms);
The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network;
Mass purchased furniture, drapes and bedspreads that all look alike throughout the building (some innovators invite the placement of some residents’ furniture in common areas); and
Large, centrally located nursing/care team stations.
Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them.
One customer has already commented that they felt mitigated by the length of time that it will take for these guidelines to take hold. I explained that, operationally this is true, but HealthCare Source looks at the guidelines from a “capital equipment perspective” with purchases having a useful life of 10 years or more. If you are spending capital dollars TODAY then you need to at least take these guidelines into account, even if you say NO to implementing them.
My initial reaction is that some of the guideline changes have real merit. Some of the guideline changes are going to be difficult for the industry to address. And at least one of the guideline changes MUST have been written by some Senator’s “idiot love child”, because no one with intimate knowledge the industry would initiate a guideline like this. This one guideline, if interpreted and implemented as written, with no further thought, has the potential to return a disaster on the scale of New York’s 1911 Triangle Factory debacle.
I “betcha” you want to know which I think it is!
Before we go there, I can’t just let the industry “off the hook” in this matter. These guidelines are printed for comment in advance of adoption. Why are we dealing with these issues after they have already been implemented and why are they such a surprise to everyone I talk to about them? The most common response I have gotten from industry professionals is; “They can’t do that!”.
Back to the business at hand! Let’s start with the short list of what items the guideline RECOMMENDS be “banned” from the long term care environment.
- Banned - Overhead paging and piped in music.
- Good call! No one cares to know that the Administrator has a phone call and no one “lives” in an elevator.
- Besides that, the person who is assigned to pick the playlist generally has terrible taste in music.
- Banned - Meal service on trays in the dining room.
- Good call! It’s tough enough for some residents to maintain an “interest in food” without making the servings look like “fast food”.
- Banned – Institutional signage labeling workrooms and closets.
- Hmmm. There are areas that need signs, either to keep people out or to get people in. One good example is a public restroom.
- Banned - Medication Carts.
- Another Hmmm. I can clearly see the objection to the “monster” medication carts that serve 50 residents, weigh hundreds of pounds and block the hallways … but facilities are not required to use those carts except for the fact that this may be the type of cart that is provided to facilities by their pharmacy at no charge.
- Is this a really a legitimate regulatory change or is it an obtuse way for CMS to address what some consider an ongoing “Safe Harbors” violation? The guidelines recommend that “medications could be stored in the resident room” instead of in carts, but they do not address how the facility should deal with narcotics or refrigerated medications in this situation.
- If this guideline is implemented, a facility will need to completely alter how they address med storage and med delivery. Double hmmm.
- Banned – Audible Alarms and Call Systems.
- A double good call. See my previous posting addressing wireless call systems.
- Banned – Mass purchased furniture.
- Are you kidding me??? On the surface this looks …. OK. And then you start thinking about the ramifications, and I am not talking about the design issues, those points can be addressed by a professional designer! I am talking about both Residents and Operators bringing toxic, flammable junk furniture into the health care environment.
- Has no one read about off shore furniture that contains dangerous levels of formaldehyde gasses? … this guideline could place that dangerous furniture right under resident’s noses!
- And this same guideline is asking that we use “home like” curtains and bedspreads. Well I’ve got news for you, this stuff along with “furniture from home”, BURNS! This CMS guideline could turn the Skilled Nursing environment into a fire trap. Did ANYONE talk to a Fire Marshall about this guideline?
- YES! We want to provide a “home like” environment, but at what cost? The Skilled Nursing environment IS an institution and it is the job of the care giver and CMS to keep residents safe inside this institution. “Home like” should be an IMAGE, not a function. If this guideline is misunderstood and misapplied by a “well meaning” caregiver, the resident safety net will break down.
- California, fortunately, has a number of environmental regulations that conflict with THIS CMS guideline. CA TB 133 flammability standards, CARB toxic emission standards and other fire safety regulations are in effect in this market. Other states may not have this protection in place.
- Banned – Large centrally located nurse stations.
- Hmmm. This guideline may be putting the “COMPUTER CART before the horse”. On the surface I think this guideline will be a good idea but a lot of things need to happen before it will work. These include the implementation of MDS 3.0 and mobile assessment, RUGS IV, full computer automation in the facility, the installation of a facility wide wireless, encrypted, internet connection and the acquisition of a “work station on wheels” for each nurse.
- Oh yeah, and some place to store the workstations and re-charge them when not in use.
Here is the guideline … Chapter and Verse:
F252
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.15(h) - Environment
The facility must provide--
§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;
Interpretive Guidelines: §483.15(h)(1)
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment.
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of:
Overhead paging and piped-in music throughout the building;
Meal service in the dining room using trays (some residents may wish to eat certain meals in their rooms on trays);
Institutional signage labeling work rooms/closets in areas visible to residents and the public;
Medication carts (some innovative facilities store medications in locked areas in resident rooms);
The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network;
Mass purchased furniture, drapes and bedspreads that all look alike throughout the building (some innovators invite the placement of some residents’ furniture in common areas); and
Large, centrally located nursing/care team stations.
Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them.
Monday, August 3, 2009
CA TB 133 Flammability Standard
CALIFORNIA TECHNICAL BULLETIN 133 FLAMMABILITY STANDARDS (CA TB 133)
This commentary is written at the overwhelming request of our staff at HealthCare Source. Even though CA TB 133 has been in regulatory effect since March 1, 1992, our staff receives more questions about this standard than any other regulatory matter. Let’s see if we can answer some of those questions and lay to rest some misunderstandings.
WHAT IS CA TB 133?
CA TB 133 is one of two standards commonly used in the manufacture of commercial furniture. The other one is CA TB 117.
WHAT IS THE DIFFERENCE BETWEEN THE TWO STANDARDS?
CA TB 117 is the most common flammability standard for commercial furniture. It is used by manufacturers nationwide. CA TB 117 allows manufacturers to build furniture by selecting from an array of components that are pre-approved to be “CA TB 117” compliant. Frames, foam and fabric are the typical components. By complying with the CA TB 117 standards for all components, the manufacturer’s end product is predicted to burn slowly or not at all.
But CA TB 133 is a standard that measures only the completed product. A common misconception is that there are CA TB 133 approved fabrics. There are no CA TB 133 components! The CA TB 133 standard measures the compliance of the finished product in an actual burn test of that specific product (I won’t get into how the manufacturers achieve that testing standard in this article). Not only does the CA TB 133 standard measure the “flame spread” but it also measure the gasses given off by the burning furniture, and in doing so, corrects a major flaw in the CA TB 117 standard.
A flaw in the CA TB 117 standard? When the manufacturer selects the components that go into the CA TB 117 finished product, the frame material, the foam and the fabric might not burn but CAN create a pervasive toxic smoke that will kill faster than the fire. And so CA TB 133 measures the finished products to also protect from the off gassing of burning furniture.
WHO DOES CA TB 133 APPLY TO?
OK … here comes the list. Prisons, HOSPITALS, HEALTHCARE FACILITIES, BOARD and CARE, CONVALESCENT HOSPITALS, licensed child care facilities, stadiums, auditoriums, public assembly areas of hotels and motels used by 10 or more persons.
ARE THERE EXEMPTIONS TO CA TB 133?
Yes there are! Any fully sprinklered building serving the businesses listed above MAY be exempt, with the blessing of the local Fire Marshall. Not all buildings are rated as the same risk in case of fire. ONLY THE LOCAL FIRE MARSHALL CAN GRANT YOU AN EXEMPTION.
BUT BEFORE ASKING FOR AN EXEMPTION…
…You should know about the history of the Dupont Plaza fire in Puerto Rico. On New Year’s Eve in 1986, three disgruntled employees set a fire in some new furniture which was scheduled to be installed. The idea was to scare away hotel guests. The stacked furniture reacted to the fire like “stacked pallets at a college pep rally”. The fire burned higher and hotter than anyone imagined. The result was 97 deaths and 140 injuries, and one of the largest liability suits of its time.
The most interesting part of the litigation was that the CA TB 133 flammability standard was used as the “due diligent” standard of the day, even though CA TB 133 did not go into effect in California for five more years.
PLEASE take the time to contact your risk manager and determine whether or not pursuing a CA TB 133 exemption is “worth it”.
This commentary is written at the overwhelming request of our staff at HealthCare Source. Even though CA TB 133 has been in regulatory effect since March 1, 1992, our staff receives more questions about this standard than any other regulatory matter. Let’s see if we can answer some of those questions and lay to rest some misunderstandings.
WHAT IS CA TB 133?
CA TB 133 is one of two standards commonly used in the manufacture of commercial furniture. The other one is CA TB 117.
WHAT IS THE DIFFERENCE BETWEEN THE TWO STANDARDS?
CA TB 117 is the most common flammability standard for commercial furniture. It is used by manufacturers nationwide. CA TB 117 allows manufacturers to build furniture by selecting from an array of components that are pre-approved to be “CA TB 117” compliant. Frames, foam and fabric are the typical components. By complying with the CA TB 117 standards for all components, the manufacturer’s end product is predicted to burn slowly or not at all.
But CA TB 133 is a standard that measures only the completed product. A common misconception is that there are CA TB 133 approved fabrics. There are no CA TB 133 components! The CA TB 133 standard measures the compliance of the finished product in an actual burn test of that specific product (I won’t get into how the manufacturers achieve that testing standard in this article). Not only does the CA TB 133 standard measure the “flame spread” but it also measure the gasses given off by the burning furniture, and in doing so, corrects a major flaw in the CA TB 117 standard.
A flaw in the CA TB 117 standard? When the manufacturer selects the components that go into the CA TB 117 finished product, the frame material, the foam and the fabric might not burn but CAN create a pervasive toxic smoke that will kill faster than the fire. And so CA TB 133 measures the finished products to also protect from the off gassing of burning furniture.
WHO DOES CA TB 133 APPLY TO?
OK … here comes the list. Prisons, HOSPITALS, HEALTHCARE FACILITIES, BOARD and CARE, CONVALESCENT HOSPITALS, licensed child care facilities, stadiums, auditoriums, public assembly areas of hotels and motels used by 10 or more persons.
ARE THERE EXEMPTIONS TO CA TB 133?
Yes there are! Any fully sprinklered building serving the businesses listed above MAY be exempt, with the blessing of the local Fire Marshall. Not all buildings are rated as the same risk in case of fire. ONLY THE LOCAL FIRE MARSHALL CAN GRANT YOU AN EXEMPTION.
BUT BEFORE ASKING FOR AN EXEMPTION…
…You should know about the history of the Dupont Plaza fire in Puerto Rico. On New Year’s Eve in 1986, three disgruntled employees set a fire in some new furniture which was scheduled to be installed. The idea was to scare away hotel guests. The stacked furniture reacted to the fire like “stacked pallets at a college pep rally”. The fire burned higher and hotter than anyone imagined. The result was 97 deaths and 140 injuries, and one of the largest liability suits of its time.
The most interesting part of the litigation was that the CA TB 133 flammability standard was used as the “due diligent” standard of the day, even though CA TB 133 did not go into effect in California for five more years.
PLEASE take the time to contact your risk manager and determine whether or not pursuing a CA TB 133 exemption is “worth it”.
Saturday, August 1, 2009
Purchasing Decisions
REGULATIONS AND REIMBURSEMENT DOMINATE THE HEALTH CARE PURCHASING DECISION
We all know that the health care is one of the most heavily regulated businesses in America. On top of that, the health care provider deals with a dizzying array of ever changing reimbursement systems; insurance, local, state and federal.
By the time the health care facility manager has spent his capital equipment budget on regulatory and reimbursement driven equipment and services, there isn’t much budget left to spend on discretionary items.
But, have you ever stopped to think how the regulatory and reimbursement systems impact manufacturers?
Having been the head of purchasing for two different multi-billion dollar health care companies, thousands of health care products have come across my desk over the years. To deal with that volume of contacts (all of whom wanted a lot of my time) I developed some qualifying criteria based on current and pending regulatory and reimbursement guidelines. Those five categories were:
Never going to be! This doesn’t mean these aren’t good products or good ideas. It means that either they don’t have a regulatory or reimbursement application or the manufacturer is selling in the wrong health care distribution channel. I believe there are four distinct health care distribution channels. Look at hospital type beds for example. There are hospital beds, long term care beds and home health (DME) beds. All these beds are, generically speaking, “hospital beds”. Yet, each style bed is pretty much worthless to the other two distribution channels.
Potential! These are products that may not have current regulatory or reimbursement support but pending changes or operational efficiencies make them attractive to know about and support. I always try to keep one of these in the HealthCare Source basket of products (more on this later).
Current commodity. HoHum… These are the products and manufacturers who currently have a regulatory or reimbursement niche, but are also engaged in the toxic, downward spiral of copying other manufacturers and then value engineering that product. “Value engineering”, there is a term that has become an oxymoron at the hands of some health care manufacturers. Too often the purpose of the product is lost in the process of copying and value engineering. Also, gimmicks are often proffered as solutions by these companies.
Innovative Alternative! These are products developed by manufacturers who have a current regulatory or reimbursement niche, AND they are seeking/finding innovative new ways to fill the niche, AND they are constantly developing new products to be current with our ever changing industry. These are also the manufacturers who “deliver value” not “engineer” it. HealthCare Source draws the majority of its manufacturers from this category.
Used to be. Due to regulatory or reimbursement changes, some products and manufacturers become obsolete. Sad, but true!
So we all know that Dennis prefers to spend his time with products in the Potential and Innovative Alternative categories … get on with your story Dennis!
I thought that those of you who are interested in product development, might like to keep watch on a product that MAY transition from the “Potential” category to a “double hit” regulatory AND reimbursement “Innovative Solution”.
The product, Live-Vu, is a low band width, remote, medical assessment system. If you want to know more about the product you need to schedule a demo.
What you need to know for this article is that this product is a unique, well tested, innovative solution. It is well channeled in the Long Term Care distribution segment, but because it did not match up to regulatory or reimbursement criteria, the manufacturer was left to fighting for that very small pool of discretionary dollars that is available at the end of the budget year.
AND THEN, ALONG CAME RUGS-IV!
RUGS-IV (resource utilization groups) is the new MediCare reimbursement companion to MDS 3.0. Both are scheduled to be implemented nationwide in October 2010.
What is intriguing is that CMS is planning to run a demonstration test of the RUGS-IV program starting in October of this year. Four states will participate in that test program.
The demonstration is called NHVBP (Nursing Home Value Based Purchasing). As I understand the program (no one really knows yet, it’s brand new), RUGS-IV is a value calculation that includes four new domains: Staffing, Appropriate Hospitalization, MDS outcomes, and survey deficiencies. Again, as I understand it, superior NHVBP ratings will pay incentive bonuses to the facilities getting superior ratings.
So what is the big deal?
Live-vu is a unique product that should help facilities to be 100% compliant within the “appropriate hospitalizations” domain. If true, that application hits the perfect nexus of product, regulations and reimbursement!
Hey, there is a lot more to learn about the RUBS-IV and MDS 3.0 systems, and this initial assessment by HealthCare Source is based only on what we have read about the program, so far … but like I said, it will be fun to watch.
I’ll keep you updated as things progress.
We all know that the health care is one of the most heavily regulated businesses in America. On top of that, the health care provider deals with a dizzying array of ever changing reimbursement systems; insurance, local, state and federal.
By the time the health care facility manager has spent his capital equipment budget on regulatory and reimbursement driven equipment and services, there isn’t much budget left to spend on discretionary items.
But, have you ever stopped to think how the regulatory and reimbursement systems impact manufacturers?
Having been the head of purchasing for two different multi-billion dollar health care companies, thousands of health care products have come across my desk over the years. To deal with that volume of contacts (all of whom wanted a lot of my time) I developed some qualifying criteria based on current and pending regulatory and reimbursement guidelines. Those five categories were:
Never going to be! This doesn’t mean these aren’t good products or good ideas. It means that either they don’t have a regulatory or reimbursement application or the manufacturer is selling in the wrong health care distribution channel. I believe there are four distinct health care distribution channels. Look at hospital type beds for example. There are hospital beds, long term care beds and home health (DME) beds. All these beds are, generically speaking, “hospital beds”. Yet, each style bed is pretty much worthless to the other two distribution channels.
Potential! These are products that may not have current regulatory or reimbursement support but pending changes or operational efficiencies make them attractive to know about and support. I always try to keep one of these in the HealthCare Source basket of products (more on this later).
Current commodity. HoHum… These are the products and manufacturers who currently have a regulatory or reimbursement niche, but are also engaged in the toxic, downward spiral of copying other manufacturers and then value engineering that product. “Value engineering”, there is a term that has become an oxymoron at the hands of some health care manufacturers. Too often the purpose of the product is lost in the process of copying and value engineering. Also, gimmicks are often proffered as solutions by these companies.
Innovative Alternative! These are products developed by manufacturers who have a current regulatory or reimbursement niche, AND they are seeking/finding innovative new ways to fill the niche, AND they are constantly developing new products to be current with our ever changing industry. These are also the manufacturers who “deliver value” not “engineer” it. HealthCare Source draws the majority of its manufacturers from this category.
Used to be. Due to regulatory or reimbursement changes, some products and manufacturers become obsolete. Sad, but true!
So we all know that Dennis prefers to spend his time with products in the Potential and Innovative Alternative categories … get on with your story Dennis!
I thought that those of you who are interested in product development, might like to keep watch on a product that MAY transition from the “Potential” category to a “double hit” regulatory AND reimbursement “Innovative Solution”.
The product, Live-Vu, is a low band width, remote, medical assessment system. If you want to know more about the product you need to schedule a demo.
What you need to know for this article is that this product is a unique, well tested, innovative solution. It is well channeled in the Long Term Care distribution segment, but because it did not match up to regulatory or reimbursement criteria, the manufacturer was left to fighting for that very small pool of discretionary dollars that is available at the end of the budget year.
AND THEN, ALONG CAME RUGS-IV!
RUGS-IV (resource utilization groups) is the new MediCare reimbursement companion to MDS 3.0. Both are scheduled to be implemented nationwide in October 2010.
What is intriguing is that CMS is planning to run a demonstration test of the RUGS-IV program starting in October of this year. Four states will participate in that test program.
The demonstration is called NHVBP (Nursing Home Value Based Purchasing). As I understand the program (no one really knows yet, it’s brand new), RUGS-IV is a value calculation that includes four new domains: Staffing, Appropriate Hospitalization, MDS outcomes, and survey deficiencies. Again, as I understand it, superior NHVBP ratings will pay incentive bonuses to the facilities getting superior ratings.
So what is the big deal?
Live-vu is a unique product that should help facilities to be 100% compliant within the “appropriate hospitalizations” domain. If true, that application hits the perfect nexus of product, regulations and reimbursement!
Hey, there is a lot more to learn about the RUBS-IV and MDS 3.0 systems, and this initial assessment by HealthCare Source is based only on what we have read about the program, so far … but like I said, it will be fun to watch.
I’ll keep you updated as things progress.
Wednesday, July 29, 2009
Wireless Call Systems
Wireless Call Systems: Federal Standards vs. State Standards
Subject: F 252 and F 463 as they relate to the design of call systems in long term care facilities.
CMS released a series of changes to the Federal Survey Guidelines, effective last month (June 12, 2009). These new changes, as a group, are referred to as “the home like environment” survey guidelines.
One area of resident care that is specifically addressed in these new guidelines is related to the institutional image that is imparted to residents and visitors of Skilled Nursing Facilities where lights and buzzers, typically associated with HOSPITAL emergency call systems, are frequently “alarming” and creating unnecessary noise, distraction and disruption in the Skilled Nursing environment. The new guidelines highlight the fact that alarm bells and lights associated with the traditional call system are not only potentially harmful to residents, but unnecessary because of alternative technology that is available. “Hospital style” call systems are the antithesis of what you would find in a normal, home-like environment.
History:
While other states still use hospital type emergency call systems in Skilled Nursing Facilities, most states recognize wireless, silent call systems as an approved alternative. In California, the same wireless option is not currently available to Skilled Nursing Facility operators. OSHPD regulations have “institutionalized” the use of lights and buzzers in the Skilled Nursing environment by mandating that the same standard be used for emergency call systems IN BOTH Hospitals and Skilled Nursing Facilities. The regulatory standard used by OSHPD for call systems is the recently revised version of UL 1069 (effective 11/1/2008).
We believe that you will find that the CMS survey guidelines cited in this article DIRECTLY conflict with California’s OSHPD specifications and requirements for call systems. The OSHPD specifications favor hardwired call systems (a more expensive option) and mandate lights and audible alarms.
Two wireless call system manufacturers achieved UL 1069 certification in 2006 under the pre- 11/1/2008 criteria. New installations of these previously approved SILENT, WIRELESS call systems were terminated by OSHPD on 11/1/2008, when the modifications to the UL 1069 standard went into effect. Existing silent, wireless call system installations, completed prior to 11/1/2008, are still in place and have been “grandfathered in” by OSHPD.
Please see the guidelines below. These guidelines have been copied directly from the CMS notice. After reading the guidelines please review our commentary located near the end of this document: We encourage you to respond with comments of your own.
F252
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;
Interpretive Guidelines: §483.15(h)(1)
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment.
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of:
A number of other products are also listed in this section. We have copied the portion only relating to Call Systems to conserve space. We will cover the other products in future articles.
The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network;
F463 (Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.70(f) Resident Call System
The nurses’ station must be equipped to receive resident calls through a communication system from--
(1) Resident rooms; and
(2) Toilet and bathing facilities.
Intent: §483.70(f)
The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means of directly contacting caregivers. In the case of an existing centralized nursing station, this communication may be through audible or visual signals and may include “wireless systems.” In those cases in which a facility has moved to decentralized nurse/care team work areas, the intent may be met through other electronic systems that provide direct communication from the resident to the caregivers.
Interpretive Guidelines: §483.70(f)
This requirement is met only if all portions of the system are functioning (e.g., system is not turned off at the nurses’ station, the volume too low to be heard, the light above a room or rooms is not working), and calls are being answered. For wireless systems, compliance is met only if staff who answer resident calls, have functioning devices in their possession, and are answering resident calls.
HealthCare Source’s opinion:
We feel there are a number of problems with the OSHPD mandated call system standard, not the least of which is that the revisions to the UL 1069 standard occurred as a result the hard wire call system industry’s open and aggressive lobbying campaign. The lobbying effort began after wireless call systems were finally able to attain UL 1069 approval under the prior standard. But setting the issues of cost and special interest lobbying aside, we feel that there is more than enough CLINICAL conflict to justify a change in the OSHPD standard.
Those of you who know us well are familiar with the fact that we have argued since June 2005 that OSHPD approved audible, lighted call systems are in conflict with Federal Survey Guidelines F 315 and F 316. Those guidelines address resident incontinence. It is our contention that the lighted, audible call systems used at night undermine the bowel and bladder training provided by Skilled Nursing daytime staff.
At the introduction of the revised F 315 and F 316 Survey Guidelines in June 2005, an attached pre-amble said, “90% of all residents entering SNF facilities become incontinent within 90 days”. The guideline actually states that more than 50% of all Skilled Nursing residents have incontinence issues. Whichever statistic you use, how much could it be worth, socially and financially, if we reduce that number by even a small percentage?
California has a long tradition of being a leader in the area of regulatory safety, and when the California regulations exceed the Federal standards, I generally support the stricter California standard as being the better alternative. Examples of current ground breaking positive regulations are the CA TB 133 flammability standard and the new California Air Resources Board ATCM toxic emissions standard.
But we feel that when a regulation’s values conflict with and/or undermines quality of care and quality of life values, then the conflicting regulation should be rescinded or modified
It is our contention that OSHPD mandating the new UL 1069 standard for call systems in Skilled Nursing Facilities conflicts with the Federal Survey Guidelines F 252, F 463, F 315 and F 316. That is, in our opinion, enough reason for the Skilled Nursing industry to take action and challenge the OSHPD call system standard.
We can only hope that OSHPD will respond quickly and re-institute Skilled Nursing approval for those SILENT, WIRELESS call systems that met by the old UL 1069 standard. That could be a fast, safe and simple solution to this problem.
Subject: F 252 and F 463 as they relate to the design of call systems in long term care facilities.
CMS released a series of changes to the Federal Survey Guidelines, effective last month (June 12, 2009). These new changes, as a group, are referred to as “the home like environment” survey guidelines.
One area of resident care that is specifically addressed in these new guidelines is related to the institutional image that is imparted to residents and visitors of Skilled Nursing Facilities where lights and buzzers, typically associated with HOSPITAL emergency call systems, are frequently “alarming” and creating unnecessary noise, distraction and disruption in the Skilled Nursing environment. The new guidelines highlight the fact that alarm bells and lights associated with the traditional call system are not only potentially harmful to residents, but unnecessary because of alternative technology that is available. “Hospital style” call systems are the antithesis of what you would find in a normal, home-like environment.
History:
While other states still use hospital type emergency call systems in Skilled Nursing Facilities, most states recognize wireless, silent call systems as an approved alternative. In California, the same wireless option is not currently available to Skilled Nursing Facility operators. OSHPD regulations have “institutionalized” the use of lights and buzzers in the Skilled Nursing environment by mandating that the same standard be used for emergency call systems IN BOTH Hospitals and Skilled Nursing Facilities. The regulatory standard used by OSHPD for call systems is the recently revised version of UL 1069 (effective 11/1/2008).
We believe that you will find that the CMS survey guidelines cited in this article DIRECTLY conflict with California’s OSHPD specifications and requirements for call systems. The OSHPD specifications favor hardwired call systems (a more expensive option) and mandate lights and audible alarms.
Two wireless call system manufacturers achieved UL 1069 certification in 2006 under the pre- 11/1/2008 criteria. New installations of these previously approved SILENT, WIRELESS call systems were terminated by OSHPD on 11/1/2008, when the modifications to the UL 1069 standard went into effect. Existing silent, wireless call system installations, completed prior to 11/1/2008, are still in place and have been “grandfathered in” by OSHPD.
Please see the guidelines below. These guidelines have been copied directly from the CMS notice. After reading the guidelines please review our commentary located near the end of this document: We encourage you to respond with comments of your own.
F252
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;
Interpretive Guidelines: §483.15(h)(1)
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment.
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of:
A number of other products are also listed in this section. We have copied the portion only relating to Call Systems to conserve space. We will cover the other products in future articles.
The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network;
F463 (Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09)
§483.70(f) Resident Call System
The nurses’ station must be equipped to receive resident calls through a communication system from--
(1) Resident rooms; and
(2) Toilet and bathing facilities.
Intent: §483.70(f)
The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means of directly contacting caregivers. In the case of an existing centralized nursing station, this communication may be through audible or visual signals and may include “wireless systems.” In those cases in which a facility has moved to decentralized nurse/care team work areas, the intent may be met through other electronic systems that provide direct communication from the resident to the caregivers.
Interpretive Guidelines: §483.70(f)
This requirement is met only if all portions of the system are functioning (e.g., system is not turned off at the nurses’ station, the volume too low to be heard, the light above a room or rooms is not working), and calls are being answered. For wireless systems, compliance is met only if staff who answer resident calls, have functioning devices in their possession, and are answering resident calls.
HealthCare Source’s opinion:
We feel there are a number of problems with the OSHPD mandated call system standard, not the least of which is that the revisions to the UL 1069 standard occurred as a result the hard wire call system industry’s open and aggressive lobbying campaign. The lobbying effort began after wireless call systems were finally able to attain UL 1069 approval under the prior standard. But setting the issues of cost and special interest lobbying aside, we feel that there is more than enough CLINICAL conflict to justify a change in the OSHPD standard.
Those of you who know us well are familiar with the fact that we have argued since June 2005 that OSHPD approved audible, lighted call systems are in conflict with Federal Survey Guidelines F 315 and F 316. Those guidelines address resident incontinence. It is our contention that the lighted, audible call systems used at night undermine the bowel and bladder training provided by Skilled Nursing daytime staff.
At the introduction of the revised F 315 and F 316 Survey Guidelines in June 2005, an attached pre-amble said, “90% of all residents entering SNF facilities become incontinent within 90 days”. The guideline actually states that more than 50% of all Skilled Nursing residents have incontinence issues. Whichever statistic you use, how much could it be worth, socially and financially, if we reduce that number by even a small percentage?
California has a long tradition of being a leader in the area of regulatory safety, and when the California regulations exceed the Federal standards, I generally support the stricter California standard as being the better alternative. Examples of current ground breaking positive regulations are the CA TB 133 flammability standard and the new California Air Resources Board ATCM toxic emissions standard.
But we feel that when a regulation’s values conflict with and/or undermines quality of care and quality of life values, then the conflicting regulation should be rescinded or modified
It is our contention that OSHPD mandating the new UL 1069 standard for call systems in Skilled Nursing Facilities conflicts with the Federal Survey Guidelines F 252, F 463, F 315 and F 316. That is, in our opinion, enough reason for the Skilled Nursing industry to take action and challenge the OSHPD call system standard.
We can only hope that OSHPD will respond quickly and re-institute Skilled Nursing approval for those SILENT, WIRELESS call systems that met by the old UL 1069 standard. That could be a fast, safe and simple solution to this problem.
Tuesday, July 28, 2009
CARB Regulations
§ 93120. Airborne Toxic Control Measure to Reduce Formaldehyde Emissions from Composite Wood Products.
Notes on CARB Compliance issues specifically for the Health Care Industry.
What does HealthCare Source think this regulation means to the health care industry???
Notes to the health care industry:
What might you do to protect yourself?
Notes on CARB Compliance issues specifically for the Health Care Industry.
- HealthCare Source has received many inquiries from manufacturers, specifiers and end users regarding the California Air Resources Board (CARB) requirements for the Airborne Toxic Control Measure (ATCM) compliance of wood products and furniture used in health care facilities. We thought posting a document addressing some of these questions and providing links to the regulators might prove helpful to our clients.
- These new CARB standards apply to all hardwood plywood, particleboard and medium density fiberboard components used in ANY and ALL new finished products sold in California. This means the CARB ATCM standard applies to all new furniture and wood finishing products (i.e.: Crown Molding) which we typically see used in health care facilities.
- Should you care to read and interpret for yourself the information regarding this regulatory change, you can link directly to the California Air Resources Board at: http://www.arb.ca.gov/toxics/compwood/compwood.htm
- You can read the chapter and verse of the CARB ATCM regulations at the following site: http://www.arb.ca.gov/regact/2007/compwood07/fro-final.pdf
What does HealthCare Source think this regulation means to the health care industry???
- Starting with the raw material suppliers, everyone in the production and distribution cycle of wood based products must keep “chain of custody” records. In the case of imported products, the importer is liable for owning and maintaining the chain of custody database. Everyone who participates in the sale of non compliant wood based products in California is deemed liable to the regulation until they are individually cleared of culpability by CARB. The violations are adjudicated by CARB on a case by case basis. The investigation of a violation could include any dealers, buyers and specifiers, along with the manufacturers, importers and distributors of non-compliant products.
- Some of the wood furniture and products sold in California are manufactured in Europe and are advertised as being built to the E1 emissions standard. This standard is very close to the Phase 1 version of the CARB ATCM standard. Those manufacturers producing products that meet the E1 standard will more easily adapt to the new CARB regulations, but E1 certification does not automatically mean that those products have also attained CARB compliance. They must additionally certify that the composite wood components used in the production of their product meet the CARB standards in order to be approved for sale in California.
- California is often a leader in establishing regulatory safety standards and the CARB ATCM standard appears to be no different. Minnesota and Oregon are already considering adopting this standard for their region, and the U.S. EPA recently sent out a Federal Register notice regarding their intent to create a Federal standard for composite wood and composite wood products. We expect that the EPA will adopt a standard similar to the California standard for the entire nation.
Notes to the health care industry:
- We have all heard enough stories about lead paint on toys, melamine in milk and recalls of peanut butter to know that we should be vigilant about the products we buy and where we use them. This caveat applies with a greater urgency to health care providers because of the vulnerability of those for which they care.
- And while we might teasingly think of CARB enforcement in the same context as “the mattress police”, the emissions from unregulated furniture have actually been tested as being very toxic. Therefore, we don’t believe that it will be “the mattress police” who enforce this guideline on the health care industry. Enforcement will come from the State, but it will also come from attorneys looking for another route in a liability action. This possibility renders CARB awareness for the health care industry as being a RISK MANAGEMENT issue.
- Health care operators should also know that there is a window in which existing, non compliant furnishings can still be sold FROM INVENTORY by stocking DEALERS. The fact that this window exists does not preclude the health care operator from the associated RISK of exposing the patient/resident/client to the toxic emissions of the “grandfathered” furniture.
- Expect that Dealers and Distributors WILL BE DUMPING (very attractive pricing) non-compliant inventory, trying to get rid of it prior to the final disposal deadline (the RETAIL deadlines have recently been extended due to the economy. Refer to the CARB website link above for the most current deadline dates). All new products sold to health care facilities on or after January 1, 2009 and any new products built or imported beginning January 1, 2009 must be CARB compliant.
- BE AWARE that as of the date of the publication of this article, non compliant RETAIL “ON-HAND INVENTORY” stored in California can be sold in California through July 2010. Health care providers who are significant consumers of these types of products should take the time to create a policy addressing how they plan to comply with the CARB ATCM standard and how they will avoid purchasing non-compliant products.
What might you do to protect yourself?
- Insist that any furniture you buy be CARB compliant and demand that it be indicated as such on the label.
- Only buy furniture “factory direct” until the implementation period is over (currently July 2010). Do NOT buy from stock inventories unless you KNOW the furniture is compliant.
- Do not purchase ANY retail furniture for your facility. Especially retail seating which probably is also not CA TB 133 flammability compliant.
- Refer back to your recent furniture purchases starting from January 1, 2009 to present. If they do not have CARB compliant labels, demand the chain of custody information from the manufacturer/importer/dealer so you can defend any litigation.
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