January 18, 2012 | | Comments 3
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From the muddy banks of compliance

Let’s break from form a little bit and start with a question:

How often are you (and by you, I mean your organization) screening contracted staff, including physicians, physician assistants, nurse practitioners, etc.?

A recent TJC survey resulted in a finding under the HR standards because the process was being administered on a biannual cycle. The finding vaguely referenced OSHA guidelines in identifying this deficiency, but the specific regulatory reference point was not provided (though apparently a call to Chicago validated that this was the case). Now, anyone who’s worked with me in real time knows that I have an exhaustive (and, at times, exhausting) curiosity about such matters. The deficiency “concepts” are usually sourced back to a “they;” as in, “they told me I had to do this” “they told me I had to that.” I am always, always, always curious as to who this “they” might be and whether “they” were good enough to provide the applicable chapter and verse. The answer, more often than not, is “no.” Perhaps someday we’ll discuss the whimsical nature of the” Authority Having Jurisdiction” (AHJ) concept, but we’ll save that for another day.

At any rate, I did a little bit of digging around to try and locate a regulatory source on this and in this instance, the source exists; however, the standard is not quite as mandatory as one might first presume (If you’re thinking that this is going to somehow wrap around another risk assessment conversation, you are not far from wrong). So, a wee bit of history:

Back in 1994, the CDC issued their Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf) which, among other things, advises a risk-based approach to screening (Appendix C speaks to the screening requirements for all healthcare workers, regardless of who they work for. The guidance would be to include contract folks. The risk level is determined via a risk assessment (Appendix B of the Guidelines is a good start for that). So, for a medium exposure risk environment, CDC recommends annual screening, but for a low exposure risk environment, they recommend screening at time of hire, with no further screening required (unless your exposure risk increases, which should be part of the annual infection control risk assessment).

But, in 1996, OSHA issued a directive that indicates annual screening as the minimum requirement , even for low-risk exposure risks, and even while referencing the CDC guidance: (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=1586) with medium risk folks having semi-annual screening and high-risk folks being screened on a quarterly basis. So, friends, how are you managing folks in your environment, particularly the aforementioned contracted staff? Do you own them or is it the responsibility of their contracted employer? Does this stuff give you a headache when you think about it too much? It sure gives me one…occupational hazard, I guess. At any rate, it’s certainly worth checking to see whether a risk assessment for TB exposure has been conducted. The OSHA guidance document clearly indicates that if you haven’t, it’s the responsibility of the surveyor to conduct one for you, and I don’t know that I’d be really keen on having that happen.

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant based in Bridgewater, 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 stevemacsafetyspace@gmail.com.

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  1. Mac. You are full of good news. The OSHA enforcement documents came out in 1996, about the time we in health care were scrambling to get TB testing programs back up and running again.

    CDC has updated their information a few times since this was published and continues to say that low risk facilities do not need to do annual testing? Of course, CDC does not have regulatory powers and OSHA does.

    Another example of two government regulatory agencies in conflict and the Employer caught in the middle.

    We do test all staff at hire, including contracted, students and even salespersons that may go into patient seeing areas.

    BUT, we stopped doing annual TB testing years ago. We did not find it added to the detection of any TB and freed us up to provide more education and training on TB prevention. Not to mention saving us a lot of time,effort and cost.

    Any suggestions on what we do now that we have seen this OSHA document? I think you would have a pretty good argument if you are following CDC guidelines.

  2. Here is a link to OSHA interpretation explaining that as long as you are following the most current CDC Guidelines you are in compliance with the “general duty clause”.

    http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=27569

    “Scenario: Your letter acknowledges that OSHA’s current policy (see CPL 02-00-106, Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis) requires annual TB skin testing for low risk personnel which was based on the CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities, 1994 (MMWR October 26, 1994; Vol. 43, No. RR-13). Since that time, the CDC updated their guidelines in December 2005, which modified TB screening procedures for settings (or HCWs) classified as low risk.”

    “Question: What is OSHA’s current interpretation of CPL 02-00-106 now that CDC updated their guidelines in 2005 which no longer requires annual testing for HCWs whose duties do not include contact with patients or TB specimens in settings classified as low risk?”

    “Reply: OSHA’s current compliance directive (CPL 02-00-106) references the 1994 CDC guidelines which, as you know, recommended TB skin testing to be conducted at least annually for all healthcare settings. The Agency’s current means of enforcement of worker protection from TB in large part falls under the provisions set by Section 5(a)(l) of the Occupational Safety and Health (OSH) Act, the general duty clause. Under the general duty clause, an employer could be cited if he/she did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees exposed to the hazard of being infected with Mycobacterium Tuberculosis. An employer’s adherence with the recommendations of the most recent CDC guidelines would be considered to meet the provisions of the general duty clause.”

  3. Steve MacArthur

    Howdy folks,

    This has resulted in a lot of good discussion – lots of information shared – everything this blog had hoped to “accomplish” (a little hyperbolic, but sometimes…) I just wanted to loop back around on this a bit to reiterate that this was a Joint Commission survey finding and was not in any way validated by/for OSHA. I think, in many regards, this is a good example of a surveyor having just enough information / knowledge to be dangerous. The long and short of this is that a hospital has had to “fix” something that wasn’t broken because their surveyor adamantly identified a compliance issue – and that identification was endorsed by the “home office”. This is how (and hopefully where) our safety community becomes stronger and better informed. Julie’s link to the interpretation is a good one to hold onto folks – so many thanks to Julie for her diligence in the archaeology of compliance – you rock!

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