August 26, 2011 | | Comments 2
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Your mother should know…but what if she doesn’t?

I’ve noticed a little word popping up in recent survey reports, a word that strikes fear in my heart. I don’t know how widespread this might be, so if you folks have an opportunity to weigh in on this conversation, I’d be really interested in what you all are seeing out there. And so, today’s word of the day is “should.” Now scream real loud!

I think we are all pretty familiar with those things that are legitimately (perhaps specifically is a better descriptor) required by the standards. I like to refer to those requirements as “have to’s” – we have to test certain fire alarm components at certain frequencies, we have to conduct quarterly fire drills, etc. Now I’m certainly not someone who is going to complain when a regulator (of any stripe) provides us with concrete strategies (this is where we move from the “have to’s” to the “how’s,” inching ever closer to “should”) for achieving or maintaining compliance.

But the question I keep coming back to is how are we supposed to know about these unwritten requirements (we used to call them ghost standards—boo!) if they are, as noted, unwritten. And the reason I keep coming back to this question is because I’ve been seeing a number of findings lately that revolve around what an organization “should” do. And please, I am not necessarily disagreeing with the wisdom engendered in many, if not most of these findings (we’ll mention a couple of examples in a moment), but there is a point at which the line between what is consultative advice and what is actually required blurs so completely that any tipping point, compliance-wise, is almost completely subjective.

As an example (and remember, I’m not disagreeing with the concept), a recent survey report included a finding because the “clean” side of central sterile was negative to the adjacent corridor, with the qualifier “air flow should always be positive from clean areas to less clean areas”. Concept-wise, I’m down with that (I’m not loving the use of “always” in this type of context—how long is always, or maybe it should be how frequently is always, but I digress), but where in the Joint Commission standard does it say that, apart from the all-encompassing appropriate provision of pressure relationships, etc. That “should” really undercuts the whole statement. Is this something we “must” do within the context of the standard or are we trying to leverage behaviors by acting like something is deficient when it is not necessarily the case?

Another “should” that came up recently involved the results of a vendor’s testing of the medical gas system. Now you and I both know that our vendors are not always the most efficient when it comes to providing written documentation of their activities. In this particular instance, the testing had been done in June, and the report had been delivered in August, mere moments before the survey started. Within the report, there were some issues with master alarms that required repair work—repair work that had not yet been completed. Now, as near as I can tell, each organization still gets to prioritize the expenditure of resources, etc., presumably based on some sort of risk assessment (that’s a “should” for all you folks keeping track), but the finding in question ends with a resounding statement that the facility “should” have required the vendor to provide a deficiency report at the time of the inspection. Conceptually, you’ll get no argument from me, and as consultative advice I will tell you that it is a positively stupendous idea to know what problems are out there before your testing vendors leave the premises. Remember, you “own” the fixes as soon as they are identified, and if there are delays, you’d best have a pretty gosh-darn good reason for it. In fact, I would have to consider that strategy as a best practice in managing maintenance and testing activities, but where does it say that in the standards?

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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. I agree, I wish Joint Commission would define what they mean by “should”. When an organization reviews their findings report or standards, does the word mean “could”, “might”, “definately”, “must”, “up to the organization to decide”. They also need to define other words like “ongoing”, “periodic”, and “frequently”.

  2. Steve MacArthur

    Point well taken; ultimately, I think the simplest approach is to interpret this as “up to the organization to decide”, but what wreaks havoc during survey is when you’ve made a decision (perhaps, if not most likely, not even a conscious decision) and the surveyor disagrees with that decision. Going back to the original situation, I don’t think anyone ever consciously tells a vendor – “you don’t need to let me know what’s going on – I can wait until I see your report” (they might want to some days, but to actually utter the words? I don’t think so), but unless you tell your vendor otherwise, that is the likely result.

    Again, it all goes back to good (best) practice – it makes way more sense to have the deficiency information in your hands (and in your head) when the vendor leaves your facility. Unless your organization’s coffers are overflowing with cash, anything a vendor finds that is not covered under their contract, it’s going to cost you, and you’re going to need to plan for that. And, the sooner you start planning, the sooner the process can move forward towards resolution.

    My advice – don’t let any of your maintenance and testing vendors out of your house until you know what’s going on. This is yet another case of what you don’t know can hurt you – and haven’t we dealt with that enough already?

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