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What is a nonpatient care area?

Catching up on some recent e-mail questions, there was one regarding hazard surveillance activities and the oversight of off-site buildings (not identified under the hospital’s license) where there are no patient services provided. So the question became whether these locations had to be included in the hazard surveillance program and whether they would be subject to a Joint Commission visit during survey.

So, taking a look at the Joint Commission “role,” while it is most unlikely that the survey team would visit an off-site location with no patient services (not quite 0%, but something very close to that), a pain-in-the-butt surveyor might check the hazard surveillance round documentation vs. the list of hospital departments. Now the standard/elements in question, EC.04.01.01, EPs 12 and 13, only refers to patient and nonpatient care areas, so I think the thing to do is to be very specific in identifying locations in the scope of your management plans (I mean, what exactly is a nonpatient care area? A nonpatient area—got that; a patient care area—got that. But this hybrid is a little vague). Ultimately, the whole process sets up based on what you’ve identified as the appropriate inclusions, etc., so you can certainly make the determination of what would rule in to the program, or indeed rule out of the program.

That said, I have a concern in the event that OSHA were to rear its ever so lovely head. It would be of critical importance to demonstrate some sort of oversight; one strategy that comes to mind would be to develop a self-inspection process for those areas and fold that into the formal surveillance process. As a safety professional, I’m having a hard time saying that these “other” locations can be culled out of the main process (in my experience, it is never a good thing for people to think that they are somehow being ignored or not appropriately tended). I think the thing to do is to set up a less-invasive process that will allow some sort of feedback loop if environmental issues crop up in these other locations. Better you find out about issues than to have somebody drop a dime to the big “O.”