May 18, 2011 | | Comments 0
Print This Post
Email This Post

Mac’s Safety Space: Harvester of Data: Data collection—your pathway to compliance

At this point, if you’ve been managing your environment for any length of time, you know where, what, etc. you are likely to find at any given moment in terms of environmental opportunities—door wedges, unsecured oxygen cylinders, corridor clutter, penetrations, doors that don’t latch, uncovered linen carts, missing refrigerator temperatures, missing actions for out-of-range refrigerator temperatures—the list (well, my list anyways)  is endless.

These are the things that can go wrong during a survey—the 2011 survey year is bringing more eyes for more days—and how long do you think everyone in your organization can be “perfect” (less than perfect will get you loads of citations—ask anyone in your neighborhood who’s been surveyed this year)?

Your responsibility as a safety professional is to manage those imperfections in such a way as to minimize the negative impact of these failure modes (and that’s exactly  what they are, boys and girls) on the safety of the occupants. But how do you know if you’re doing that effectively (a rather good question, wouldn’t you say?)? In the nascent days of performance improvement, it was generally sufficient to know what got improved (or as we say in Boston, “got bettah”), but now things are starting to move in the direction of the next level of paradigm—you can know that something was improved, but the important metric is: How do you know it was improved?

Going back to the endless list at the beginning of this epistle—think of your “heavy hitters,” “frequent flyers,” whatever descriptor you’d like, and ask yourself the question: Has this imperfection moved closer to perfection, and if we think it has, do we have the measurements to back up that assessment?

We collect tons and tons of failure mode data; we issue work orders, we track those work orders, sometimes we make folks come to the EOC Committee to atone for their sins. But do we know what our compliance rate is for any of these opportunities? I certainly hope so, and I’ll tell you why.

In the past, during the post-Joint Commission survey clarification process, you could “audit” your compliance post-survey and use that as the basis for removing citations from the survey, as long as (for the most part—there are always exceptions, like those pesky “A” performance elements) you could demonstrate that you were at a compliance rate of 90% or better and you make the findings go away. Lately, it appears that there has been a shift away from accepting “current” compliance and a shift towards your compliance rate over time.

And so, I exhort you to start using all that data you’re harvesting and start looking at the compliance journey that it represents. Not everything gets better all the time and the closer handle we have when things start to slip-sliding away, we have a fighting chance of intervening before things get ugly.

Entry Information

Filed Under: Environment of care

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

RSSPost a Comment  |  Trackback URL