April 02, 2018 | | Comments 0
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While I hate to do anything to muddy the waters…with paper clips!

Or ear buds…

In the absence of anything particularly controversial on the regulatory front, I tend to go back and cover “old” ground just to see if there are any new resources, altered realities, etc. So, last week I was doing some work that involved helping folks with their ligature risk assessment and was pondering the availability of ligature-resistant fire alarm notification appliances. This pondering led me to my usual primary source for such things, The Design Guide for the Built Behavioral Health Environment (now an offering from the Facilities Guidelines Institute); we’ve discussed the particulars of the Design Guide on any number of occasions, most recently back in late 2016, and hopefully by now everyone has obtained a copy for their e-library. At any rate, I was poking around looking for ligature-resistant fire alarm notification appliances and, lo and behold, I couldn’t find any.

So (as I am wont to do) I headed off to the Googlesphere to see what might be out and about and (in yet another lo and behold moment) found the latest edition of the New York State Office of Mental Health’s Patient Safety Standards, Materials and Systems Guide. As near as I can tell from the webpage, this is the 19th edition of this particular guide, though I will tell you that this is my first encounter and I think it’s pretty spiffy (I’m guessing you folks in the Empire State knew about this and kept it to yourselves…). One of the most interesting elements is that it covers what they recommend (including whether they’ve found the products, etc., to be effective based on the acuity of the setting), but they also list stuff that they have tested and found does not work as advertised (I will admit to being fascinated with the idea that some of these ligature-resistant products can be defeated by strategies as simple as paper clips and/or ear buds—I guess necessity remains the mother of invention). Admittedly, there could be different philosophies in other jurisdictions, but I can really appreciate the thought, analysis, and general effort that went in to this resource and I think the risks/benefits/alternatives are sufficiently clear cut that you could communicate the issues very effectively to those reluctant surveyor types. At any rate, I encourage you (yet again) to add this one to your resource library.

I’ve also learned that as folks work through the various and sundry parameters of the regulatory guidance sets floating around, folks have been considering the management of risks in relatively unsecured (at least in terms of ligature-resistance) common areas (lobbies, stairwells, offices), which (surprise, surprise surprise!) got me to thinking…

I think the appropriate strategy for these other areas needs to start with whatever clinical assessment/determination would need to occur before patients would be able to access unsecured common areas; to my mind, patients that are legitimately at risk of self-harm either need to have services come to them on the secured units or they are sufficiently escorted (sufficiently meaning enough folks to control a situation should it start to get out of hand). By nature, every organization has areas of greater and lesser levels of security, so the “burden of the process” (if you will) is to ensure that patients are not unilaterally exposed to risks greater than their (or, indeed, our) capacity to manage them. While the minimization of physical risk is a safety “function,” ensuring that patients are managed in an appropriate environment is a clinical “function” based on the needs/condition, etc., of the patients. For example, if a patient is clinically “well” enough to have access to the advocate beyond the advocate coming to see them on the unit, then my expectation would be that that determination would be made by the clinical folks, with full knowledge of the involved risks. I think (at least until CMS or someone else provides additional/different interpretations) that going with the stratification used by The Joint Commission, which for all intents and purposes parses out into inpatient psychiatric unit environments, acute care inpatient environments and emergency department environments, should remain the focus of your assessment and risk management activities. After all, the clinical management of the patient must work in concert with efforts to decrease risk in the environment and vice versa—everyone working together is the only thing that’s going to bring us success (which is rather a common strategy…).

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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 stevemacsafetyspace@gmail.com.

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