January 04, 2016 | | Comments 0
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Fear is not sustainable

A Welshman of some repute once noted that “fear is a man’s best friend” and while that may have been the case in a Darwinian sense, I don’t know that the safety community can rely as much on it as a means of sustainable improvement. I’ve worked in healthcare for a long time and I have definitely encountered organizational leaders that traded in the threat of reprisal, etc., if imperfections were encountered in the workplace (and trust me when I say that “back in the day” something as simple as a match behind a door—left by a prickly VP to see how long it stayed there—could result in all sorts of holy heck), it typically resulted in various recriminations, fingerpointing, etc., none of which ended up meaning much in the way of sustained improvement. What happened was (to quote another popular bard—one from this side of the pond), folks tended to “end up like a dog that’s been beat too much,” so when the wicked witch goes away, the fear goes too, and with it the driving force to stay one step ahead of the sheriff (mixing a ton of metaphors here—hopefully I haven’t tipped the obfuscation scales).

At any rate, this all ties back to the manner in which the accreditation surveys are being performed, which is based on a couple of “truisms”:


  1. There is no such thing as a perfect building/environment/process, etc.
  2. Buildings are never more perfect than the moment before you put people in them.
  3. You know that.
  4. The regulators know that.
  5. The regulators can no longer visit your facility and return a verdict of no findings, because there are always things to find.
  6. See #1.

Again, looking at the survey process, the clinical surveyors may look at, I don’t know, maybe a couple of dozen patients at the most, during a survey. But when it comes to the physical environment, there are hundreds of thousands of square feet (and if you want to talk cubic feet, the numbers get quite large, quite quickly) that are surveyed—and not just the Life Safety (LS) surveyor. Every member of the survey team is looking at the physical environment (with varying degrees of competency—that’s an editorial aside), so scrutiny of the physical environment has basically evolved (mutated?) since 2007 from a couple hours of poking around by an administrative surveyor to upwards of 30 hours (based on a three-day survey; the LS surveyor accounts for 16 hours, and then you will have the other team members doing tracers that accounts for at least another 16 hours or so) of looking around your building. So the question really becomes how long and how hard will they have to look to find something that doesn’t “smell” right to them. And I think we all know the answer to that…

It all comes back (at least in my mind’s eye) to how effectively we can manage the imperfections that we know are out there. People bump stuff, people break stuff, people do all kinds of things that result in “wear and tear” and while I do recognize that the infamous “non-intact surface” makes is more difficult to clean and/or maintain, is there a hospital anywhere that has absolutely pristine horizontal and vertical surfaces, etc.? I tend to think not, but the follow-up question is: to what extent do these imperfections contribute to a physical environment that does not safely support patient care? This is certainly a question for which we need to have some sense of where we stand—I’m guessing there’s nobody out there with a 0% rate for healthcare-acquired infections, so to what degree can we say that all these little dings and scrapes do not put patients at risk to the extent that we cannot manage that level of risk? My gut says that the environment (or at least the environmental conditions that I’m seeing cited during surveys) is not the culprit, but I don’t know. As you all know by now (if you’ve been keeping tabs on me for any length of time), I am a big proponent of the risk assessment process, but has it come to the point where we have to conduct a risk assessment for, say, a damaged head wall in a patient room? Yes, I know we want to try and fix these types of conditions, but there are certain things that you can’t do while a patient is in the room and I really don’t think that it enhances patient care to be moving patients hither and yon to get in and fix surfaces, etc. But if we don’t do that, we run the risk of getting socked during a survey.

The appropriate management of the physical environment is a critical component of the safe delivery of healthcare and the key dynamic in that effort is a robust process for reporting imperfections as soon as possible (the “if you see something, say something” mantra—maybe we could push on “if you do something, say something”) so resources can be allocated for corrective actions. And somehow, I don’t think fear is going to get us to that point. We have to establish a truly collaborative, non-knee-jerk punitive relationship with the folks at the point of care, point of service. We have to find out when and where there are imperfections to be perfected as soon as humanly possible, otherwise, the prevalence of EC/LS survey findings will continue in perpetuity (or something really close to that). And while there may be some employment security pour moi in that perpetual scrutiny, I would much rather have a survey process that focuses on how well we manage the environment and not so much on the slings and arrows of day-to-day wear and tear. What say you?

Entry Information

Filed Under: Environment of careLife Safety CodeThe Joint Commission


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 stevemacsafetyspace@gmail.com.

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