May 09, 2018 | | Comments 1
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Why can’t we have anything nice? Hardwiring safety improvements: Finding fault vs. facilitation

It seems of late I’ve been encountering tales of much fingerpointing, heavy sighs, and the like in the lead-up to a date with our friends from Chicago. To my way of thinking, if there are outstanding/longstanding issues relating to compliance (and it can be just about anything relative to compliance), how much help can it be to keep pointing out the deficiency without working with folks to find some sort of rational/operational strategy for managing their environment? For example, where can one put stuff? I’ve been working the consulting beat for almost 17 years (as I wrap up my 40th year in healthcare—more on that as we approach that momentous July anniversary) and I can tell you with pretty much absolute certainty that there is not a single hospital anywhere that has enough (which would equate to too much) storage space. Clearly some of that deficit is a function of revenue generation potential as an algorithm for space allocation, but even your biggest money-makers tend to have more stuff than space. But I come back to the reality of kicking department managers for the same compliance concern(s) time and time again and (again, this is my interpretation) it just seems like a buck-passing exercise for the folks conducting the rounds— “well, I told them they couldn’t do that—and they keep doing it.” And try as I might, I can’t equate that type of process with anything that approaches performance improvement.

While I recognize (and observe in certain instances) that organizations have made, and continue to make, improvements over time, what is important is not to lose sight of the hardwiring of processes that are designed to sustain those improvements. As noted in the storage example, the physical plant is traditionally not considered a revenue generating concern, but the impact of ongoing maintenance of the physical environment on the delivery of excellent patient care has never been scrutinized more closely. It is of critical importance to develop and implement strategies that allow for those tasked with maintaining the physical environment to focus on those tasks, utilizing point-of-care/point-of-service staff to the fullest extent in the not just identifying, but facilitating management of “imperfections” in the environment.

Not to belabor the point, but the current level of focus on conditions in the physical environment, particularly as a function of the environment’s impact on infection control and prevention, calls for a greater degree of coordination amongst the primary stakeholders. While there is no specific dictate relating to the circumstances under which infection control risk assessments must be conducted; risk management strategies implemented (either through a hardwiring of basic risk reduction in standard operating procedures for certain activities, including repair and renovation activities on patient units), and a reliable process for notification of, and follow-up for, conditions that might nominally be described as “breaks” in the integrity of the environment. Certainly, the proliferation of leaks, stained ceiling tiles, damaged wall and flooring surfaces, etc., would indicate that the current management of this process does not provide enough of a “safety net” to serve the organization and its mission of continuous survey readiness. At this point, the administration of the survey process is clearly aimed at the removal of the “final” barriers between “clinical” and “non-clinical” functions in hospitals. The survey process is based on a clear sense/understanding that the entire hospital staff is engaged in patient care, regardless of their role in that care. The organizations that fare the best during survey are the organizations that have been able to grow the culture in a direction that results in a truly seamless management of the environment as the outer “ring” of the patient care continuum. Each staff member is a caregiver; each staff member is a steward of the physical environment.

I don’t think we can ever hope to be successful until we starting working towards a sheriff-less approach (based on that old saw “There’s a new sheriff in town”). One of the fundamentals of just culture is holding folks accountable, but not without working with them to achieve that nirvana state. I think if punishment (I consider reiteration of sins to be punishment) worked, we’d have a lot fewer findings in the physical environment. I can remember a time when you could get away with a more dictatorial approach to managing the environment, but I don’t think that time is coming back any time soon.

Unfortunately, the regulatory folks aren’t quite poised to embrace the facilitation/consultation model of accreditation surveying, which leads me to my closing thought/suggestion for this week. I am still “anxious” about the whole water management program issue as a function of the accreditation survey process and how it will play out. I’ve heard (but not seen) that TJC has cited folks for (presumably) inadequate water management programs, and I’ve learned over time that these types and numbers of findings tend to escalate before they de-escalate. Certainly, this is something we have to “do” very well, because to do otherwise puts people at risk. As I have in the past, I would encourage you to check out Matt Freije’s latest thoughts on all things water management programs. I suspect that everyone is a different point along the “curve” with this one, but I know one thing—you don’t want to have an outbreak relating to the management of waterborne pathogens. Talk about being “sheriffed”…

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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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  1. Well written article on the Engineering challenges and how it includes all the hospital staff.

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