August 23, 2011 | | Comments 2
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Reasons (not) to be cheerful, part 3

Or perhaps it should be “hit me with your Joint Commission stick”?

What follows is a compendium of recent survey findings, some from The Joint Commission (TJC), some from me. So in no particular order:

  • Rooftop isolation exhaust fans and other “biohazard” areas should be appropriately labeled to identify the hazard. I’d expand this a little to include soiled utility rooms (particularly in outpatient settings) in which medical waste is collected and stored.
  • If you have key utility components (e.g., emergency generators and the like) outside your building, make sure that they are appropriately secured from unauthorized entry. And once you’ve determined what “appropriately secured” means for your organization, document the risk assessment, so if a surveyor just happens to disagree with how you are managing things, you have the basis for a clarification of the finding. Same goes for your solid waste compactors—make sure nobody can monkey with them (all due respect to monkeys).
  • Make sure everyone in the kitchen can locate and explain the operation of the fire suppression system. This is kind of a follow up from an earlier blog post outlining the monthly inspection of the kitchen fire suppression system. TJC recognizes that we, the primary stakeholders in the management of the care environment, have our act together. More and more, the focus has gone to the point of care/point of service staff. Safety lives in the trenches. We need to keep those folks in the loop.
  • Make sure your main supply shutoff valves, including your main oxygen valve, are appropriately labeled. And if you should choose to decide that, for reasons of security, that is not an appropriate strategy, make sure you document the risk assessment that led you to that determination.
  • Make sure you know where you need to have eyewash stations and where you don’t and why. Not every potential exposure requires an eyewash station—OSHA is very specific in that regard—potential exposure to corrosive materials is the determining factor. If you want to adopt a slightly stricter standard, the American National Standards Institute expands things to include corrosive and caustic materials. Beyond that, including blood and other potentially infectious material, you don’t “have to” have eyewash stations for exposure response. As a related aside, try to convince the folks in environmental services (and by extension, infection control) to promote the use of cleaning products that are not corrosive or caustic—that will help you identify an appropriate response capability.
  • Don’t forget those pesky compressed gas cylinders—other than penetrations and doors not latching, I think the most frequently cited specific condition is the unsecured cylinder. And please promise me you won’t say that you have to do additional education. Folks know they’re not supposed to leave the cylinders hither and thither. Find out the root cause of why they can’t do the right thing. And if you find out anything useful in that regard, please let the rest of us know.

Th-th-th-that’s all folks. For now…

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Filed Under: AdministrativeOSHA


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

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  1. You must be reading my mind Mac. Ive been a safety leader for 14 years now. Today I finally told Quality Committee that education is NO longer the correct answer; the correct answer is leadership accountability for their staff and their areas!

  2. thank you, thank you, thank you- I am so tired of “education” as the answer to everything be it influenza vaccination, hand hygiene or EOC safety concerns. I have been an IP for 20 years now- it is the starting point but is not the end solution. Compliance needs to be an expectation!

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