May 10, 2017 | | Comments 0
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That’s the FAQ, Jack!

It may be that I am covering one topic of conversation more than necessary (it’s getting to the point where this might eclipse the discussion of eyewash stations—yow!), but I cannot help but be very concerned about the amount of play that the management of the environment in which we place behavioral health patients is receiving in the annals of The Joint Commission. April 24 saw an electronic update announcing the “birth” of a new standards FAQ regarding ligature risks that appears to be aimed at dovetailing with Sentinel Event Alert #56 and includes mention of a “Suicide Risk Booster” (who comes up with these names?!?). As we have discussed before, FAQs, Sentinel Event Alerts, and stuff that finds its way into Perspectives all take on the weight of standards when applied in the field, so clearly organizations need to have all their ducks in a row. (And this is starting to look like a whole mess o’ ducks to be “rowed”, which brings new meaning to that Willie Nelson classic “On The Rowed Again,” but I digress—and who wouldn’t?) The question I keep coming back to is whether there’s been an uptick in actual events in which patients have come to harm as the result of poorly or inappropriately managed ligature risks. Or is this the result of surveyors in the field citing organizations for having ligature risks and not being able to produce a risk assessment of the existing conditions and the identification (and communication to staff—key point, that one) of mitigation strategies to manage the identified risks?

Part of the challenge with this particular issue (and this is true of a great many things in the physical environment) is that it is virtually impossible to provide an environment that is entirely, absolutely (please insert your favorite qualifier here) impossible to provide a completely risk-free environment—at least on this planet (perhaps there are safer planets in the Federation, but I couldn’t say for sure), so there’s always going to be something with which patients intent on hurting themselves might use to that end. Now I know that not every healthcare setting is set up to deal with behavioral health patients (and somehow, I do think that for any hospital that has not come face-to-face with the management of BH patients in areas not designed for that purpose, it is just a matter of time) and I also know that the BH patient volumes can be very mercurial. Even if you have one “safe” room, there are no guarantees that, at any given moment, that will be enough to handle however many patients you have in the queue—and you really can’t leave these folks out in the waiting room. Again, I’m not convinced that the issue here is that there is data to support that folks are not managing things appropriately, but rather more along the lines of not being able to consistently communicate the process for assessing and identifying risks, educating staff to be able to speak to the mitigation strategies being used to manage the identified risks, etc. I would (as I have been for a while now) encourage you to really take this topic and do a deep dive into the particulars of your organization. I firmly believe that this is not going to be one of those “one and done” instances of risk assessment and that you will be well-served by periodically revisiting the initial assessment (if it has been completed) to ensure that the conditions upon which you based your initial assessment have not changed (and that includes the volume and acuity of the patients). There is every indication that TJC is going to be hammering on this for some time to come (remembering that EC.02.06.01 was the most frequently cited standard in 2016; the ligature risk findings tend to show up there when cited) and, much as issues with the surgical environment and interim life safety measures, process gaps can get you in a heap of trouble. A little extra work on this (and those others) can only increase your chances for a successful survey (or at least a not spectacularly ugly survey).

As a closing note, after a dinner discussion with my wife (who happens to be a nurse), I’ve been contemplating how the role of the safety professional has changed over the last 10-15 years, including my surprise when I encounter evidence of “old school” approaches to safety. To my mind (such as it is), where safety compliance was once the result of (more or less) coercion, sustained compliance can truly only come as the result of collaboration with the folks who have to manage the environment on a day to day basis—pretty much everyone at point of care/point of service. It is not enough for a safety professional to periodically stroll through an area and point out deficiencies, there has to be a conversation and there has to be problem-solving. I think the old coercive style was based on something approaching a lack of faith in the folks out in the environment to be able (or willing) to “do the right thing.” But in this era of “just” culture and empowerment, etc., safety has to happen all the time and that, my friends, can only come with an atmosphere of collaboration. If people hide stuff or behave more appropriately when they hear you are coming, then it makes the surveillance process less useful. And if you don’t work with folks to figure out how to resolve the issues that you “keep finding,” the likelihood of it fixing itself on its own is pretty remote. I freely admit that problem-solving is my favorite part of my safety consulting work (meeting folks is also a fave); there is nothing better than talking through a problem and achieving some sort of consensus on how to proceed. It’s not always easy, but it is worth every moment you put into it!

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Filed Under: CMSEnvironment of careEnvironmental protectionThe Joint Commission

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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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