RSSAuthor Archive for Steve MacArthur

Steve MacArthur

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

Brother, can you spare any change…

In the interest of time and space (it’s about time, it’s about space, it’s about two men in the strangest place…), I’m going to chunk the EM and LS risk areas that are now specifically included in the Focused Standards Assessment (FSA) process (previously, the risk areas were only in the EC chapter). Next week, I want to take one more chunk of your time to discuss now the FSA process (particularly as a function of what EPs the folks in Chicago have identified as being of critical importance/status). But for the moment, here are the add-ons for 2016:

Emergency Management


  • participation of organizational leadership, including medical staff, in emergency planning activities (you need to have a clear documentation trail)
  • your HVA; (interesting that they’ve decided to include this one—they must have found enough folks that have let the HVA process languish)
  • your documented EM inventory (I think it’s important to have a very clear definition of what this means for your organization)
  • participation of leadership, including medical staff, in development of the emergency operations plan (again, documentation trail is important)
  • the written EOP itself (not sure about this addition—on the face of it, it doesn’t necessarily make a lot of sense from a practical standpoint)
  • the annual review of the HVA (my advice is to package an analysis of the HVA with the review of the EOP and inventory)
  • annual review of the objectives and scope of the EOP
  • annual review of the inventory
  • reviewing activations of the EOP to ensure you have enough activations of the right type (important to define an influx exercise, as well as, a scenario for an event without community support)
  • identification of deficiencies and opportunities during those activations—this means don’t try to “sell” a surveyor an exercise in which nothing went awry—if the exercise is correctly administered, there will always, always, always be deficiencies and/or opportunities. If you don’t come up with any improvements, the you have, for all intents and purposes, wasted your time… (Perhaps a little harsh, but I think you hear what I’m saying)

Life Safety


  • Maintenance of documentation of any inspections and approvals made by state or local fire control agencies (I think you could make a case for having this information attached to the presentation of waivers, particularly if you have specific approvals from state or local AHJs that could be represented as waivers)
  • Door locking arrangements (be on the lookout for thumb latches and deadbolts on egress doors—there is much frowning when these arrangements are encountered during survey)
  • Protection of hazardous areas (I think this extends beyond making sure that the hazardous areas you’ve identified are properly maintained into the realm of patient spaces that are converted to combustible storage. I think at this point, we’ve all see some evidence of this. Be on the lookout!)
  • Appropriate protection of your fire alarm control panel (for want of a smoke detector…)
  • Appropriate availability of K-type fire extinguishers (this includes appropriate signage—that’s been a fairly frequent flyer in surveys of late)
  • Appropriate fire separations between healthcare and ambulatory healthcare occupancies (a simple thing to keep an eye on—or is it? You tell me…)
  • Protection of hazardous areas in ambulatory healthcare occupancies (same as above)
  • Protection of fire alarm control panels in ambulatory occupancies (same as above)


I would imagine that a fair amount of thought goes into deciding what to include in the FSA (and, in the aggregate, the number of EPs they want assessed in this process has gotten decidedly chunkier—I guess sometimes more is more), so next week we’ll chat a bit about what it all means.

Plus ça change, plus c’est la même chose: Vive Le Joint Commission!

I apologize for not having gotten to this sooner, but sometimes the wind comes out of nowhere and you find yourself heading in a rather unexpected direction (I’ve never spent so much time in Texas!).

With the advent of each new year, our three-lettered friends in Chicago unveil the changes to the accreditation standards for the upcoming cycle. Most of the changes in the EC/LS/EM world (with a couple of fairly notable exceptions—more on those in a moment) have to do with a shift in focus for the Focused Standards Assessment (FSA) process as a function of the various specific risk areas (I will freely admit that this is a wee bit convoluted, but should not necessarily come as a surprise). At any rate, as part of the accreditation process, each organization is supposed to evaluate its compliance based on specific areas of concern/risk identified by The Joint Commission. Thus for 2016, some of the risks to be evaluated have gone away (at least for the moment) and other have been added to the mix:

Please remember: These are not going away entirely, they just don’t have to be included in your organization’s FSA process!

So, we bid adieu to specific analysis of the safety, hazardous materials, medical equipment, and utility systems management plans (leaving security and fire safety in the mix) and we say bonjour to the identification of safety and security risks (as you may have noted, I’m not indicating the specific standard and EP numbers—our friends get a little protective of their content, but if you really need to check out the numbers, please see your organization’s accreditation manual).

We say goodbye to implementing our hazardous material and waste spill/exposure procedures, the monitoring of gases and vapors, and proper routine storage and prompt disposal of trash; and say hello to the hazardous materials and waste inventory, the actual written hazmat and waste spill/exposure procedures, minimization of hazmat risks, ensuring that you have proper permits, licenses, etc., for hazardous materials, and labeling of hazardous materials.

We say howdy to a focused look at fire drills, including the critiques.

We greet a focus on the testing documentation relating to duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes and smoke detectors, as well as the documentation relating to fire dampers.

We say auf wiedersehen to focusing on the selection, etc., of medical equipment, the written inventory of medical equipment, SMDA reporting, inspection, testing and maintenance of non-high risk medical equipment, and performance testing of all sterilizers.

We say guten tag to the written utility components inventory, written frequencies for maintenance, inspection and testing of utility system components, written procedures for utility system disruptions, and minimization of pathogenic, biological agents in aerosolizing water systems.

We say konichiwa to a focus on the provision of safe and suitable interior spaces for patients and the maintenance of ventilation, temperature and humidity in all those other pesky areas (e.g., soiled utility rooms, clean utility rooms, etc.).

We say hola to a focus on whether or not staff (including LIPs) are familiar with their roles and responsibilities relative to the environment of care (I predict that this is one is going to start showing up on the top 10 list soon unless there is a dramatic shift in survey focus).

And we say “Hey-diddly-ho, good neighbor” to the use of hazard surveillance rounds to identify environmental deficiencies, hazards, and unsafe hazards, as well as ensuring that you have a good mix of participants in your EC Committee activities, particularly the analysis of data—clinical, administrative, and support services have to be represented.

Now, there are three standards changes that went into effect on January 1, 2016: one a shift to a different spot in the standards, one a fairly clarifying clarification, and one about which I am not quite sure what to make, though I somehow fear the worst…

The requirement for the results of staff dosimetry monitoring (CT, PET, nuclear medicine) to be reviewed at least quarterly shift from Safety to Hazardous Materials. The EP number remains the same (and I can give you 17 reasons for that…), but it’s only a shift in where it would be scored (another important reason for making sure that you have a solid relationship between your EOC Committee and your Radiation Safety Committee—I’m a great believer in having compliance information in a location where surveyors are more likely to encounter it: EOC Committee minutes).

The requirement for managing the risks associated with smoking activities was clarified to indicate that the risks have to be managed regardless of the smoking types (e-cigarettes and personal vaporizers are officially in the mix); I’m presuming that this is helpful to folks who have perhaps faced some resistance in this area.

And finally (we’ll cover the EM and LS changes next time—nothing particularly scary, but a little too voluminous for this rather dauntingly wordy blog post), the requirements based around the inspection, testing and maintenance of non-high-risk utility system equipment components has gone from a “C” Element of Performance (EP) to an “A” EP (they did remove the Method of Success requirement for a deficient finding in this area—I suspect that was as much for their own sanity as anything else. Plus, it never really made a great deal of sense to figure out how to monitor something over four months’ time that frequently occurs every six or 12 months). My sense is that they are making the change to increase the “cite-ability” of managing utility systems equipment; now they only need to find one instance of noncompliance for a finding. I don’t know that I’ve seen a ton of findings in this area, but I can’t honestly say that I’ve been doing a close count of the OFI section of the reports, so it may be that they’re seeing a trend with the non-high-risk utility equipment that makes them think we’re not doing as good a job managing as we should, but that is wholly and completely conjecture on my part. I will, of course, be keeping a close eye on this one; I have a sneaking suspicion that the focus on utility systems equipment is going to continue into the immediate future and this might just become another pressure point.

As a closing thought relative to the FSA and risk area discussion, I think we can reasonably intuit that (particularly since the FSA process, represents a process for self-reporting) the expectation is for folks to be looking very carefully at the requirements contained within the above-noted areas and that your compliance plans relative to those requirements will be well in hand come survey. For some reason, this shift “smells” like an approach that’s going to be that much more focused on organizational leadership when there are gaps (and ask anyone who’s had a bumpy survey these past couple of years—leadership gets dragged into the fray on a regular basis). The fact of the matter is that they will find something deficient in your facility—if they don’t, they didn’t look hard enough. It’s about having processes in place to recognize and manage those deficiencies appropriately (and yes, I recognize that I am running the risk of repeating myself). This is big-time crazy focus on this stuff—and we need to be continuously improving how we go about doing it (whatever “it” might be).

Back next week to cover the EM/LS stuff. Arrivederci for now!

This American Hospital: HAIs resulting from exposure to lead

As I think I’ve mentioned in the past, I listen to a fair amount of public radio when I’m in the car, and this past Saturday, I stumbled (I’ve found that my errands don’t always coincide with the start and end of programs—thank the gods of radio for podcasts and other forms of re-broadcast) into the middle of a story that I found quite compelling. The program itself is called This American Life and emanates from WBEZ in Chicago; the nominal purpose of the program is to provide a forum for the airing of stories about (natch!) This American Life, which allows it to cover a lot of ground. I always find the stories pretty interesting/compelling, etc., but this past weekend’s episode really got me thinking about the ongoing struggles faced by hospitals as they try to balance security, workplace violence management, the management of behavioral health patients, education of staff in being able to effectively manage crisis situations, etc. Basically, the whole gamut of issues relating to the continuing disenfranchisement of the behavioral health patient community. There are some places that do pretty well with this, but I think the opportunities to do better far outweigh the improvements made so far (that’s as close to editorializing as I’m going to do for the moment).

As I think about it, while Joint Commission compliance is probably THE hot button item when it comes to the management of risks and conditions in the physical environment, I truly believe that, at least for the folks who are typically responsible for managing the physical environment, this topic is by far the more complicated—very much in line with the prevention of healthcare-acquired infections—and, interestingly enough, there can be a crossover, but more on that in a moment.

The story deals with a “delusional” (my quotes) patient who, in the course of his stay in a hospital (you can find out a lot of the details by listening to the episode, which can be found here) encountered a situation in which he did indeed contract an HAI because of an exposure to lead, namely a bullet fired by a police officer in this patient’s hospital room. Now (trying not to sound too old), back in my days of operational responsibility, I have overseen dealings with behavioral health patients, on-duty police officers discharging their weapons in the ED, folks injured as a result of physical encounters with patients, etc. But I have to tell you (and at least some of this is the power of the storytelling in conjunction with the story being told), the sequence outlined in the episode is about as harrowing as you could imagine: not very good decisions are made and sustained; family members are perhaps not embraced as a source of useful information (I’m trying to avoid more editorializing—but tell me the story doesn’t ring some bells with you, particularly  if you’ve had operational responsibility for security), staff are perhaps not as well-prepared as they might otherwise be—a real cluster of ugliness.

I know things are never as cut and dried as they seem to be in the aftermath; you might find the “official” response from the hospital a little curious (I did as well, but I understood the forces in play—sounds like there might still be some lingering litigation), but this type of confluence of events is all too easy to imagine. I think it’s definitely in the best interests for the safety/security community to advocate for the management of these types of patients based on the underlying causes (mental illness, behavioral health issues) and not just a panicked response to the symptoms. Yes, we will always have that quotient of patients who are just [insert epithet of your choice here]. But safe care can’t be sacrificed in the rush—safe for the patients, safe for the staff.

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

More portal chortlings—under the god(s) of compliance

I guess one could say that it took them a wee bit to get around to the topic of the requirements (and survey vulnerabilities) relating to the built healthcare environment, but they’re really going full bore on EC.02.06.01, particularly as a function of making sure that the responsibility of organizational leadership is recognized as a (if not the) critical component of compliance. I know we’ve already covered the latest fireside chats from Messrs. Mills and Woodin, but if you have not already done so, I would encourage you to do two things (and part of me is a little anxious as this smacks a bit of endorsement, but I think this is important):


  • Include a viewing of the fireside chats at your EOC Committee meetings; I don’t know that I would do all of them at once, but they are certainly brief enough to do one a month. I think it’s crazy important for everyone on the Committee to review the contents of the videos and while I know that you could just furnish the links to the Committee members and have them view on their own, I suspect that there might be some very valuable discussions to be had if you watch it as a group (heck, you could even make some popcorn—multigrain, no butter, perhaps a light dusting of sea salt), with maybe 10 minutes of discussions. While there is not much in the way of epiphanies in the content of the videos (I think everyone kind of recognizes what needs to happen), again, I think you could have a pretty good discussion regarding some of the concepts covered and the practical application of those concepts in your organization. You might even invite folks from procedural environments that are not typically members of the Committee. This is a huge focus of the survey process at the moment and the closer we can get to an intimate understanding of the dynamics, the better off we’ll all be.
  • Share the video with your boss (and if you can do it, your boss’s boss); the fact of the matter is that findings in this area could very well (it’s almost a likelihood) result in a finding under the Leadership standards, which ostensibly ties this up (and back) to the governing board of your organization. I don’t think that you’ll have a very easy time of managing the built healthcare environment without the knowledge and support of your organization’s leaders. We can no longer act as though this stuff is the responsibility of a few folks in the “trenches”; the management of the physical environment extends from point of care/point of service all the way to the top of the organization. It’s all about stewardship and everyone’s role in that pursuit.

Now I’m sure some folks are getting tired of me harping on this dynamic, but until we start managing the physical environment in a proactive, risk-aware manner, the Top 10 is going to continue to be EC Corner—and I don’t think any of us want that.

To assist in providing information to leaders, the latest update to this part of the portal is a downloadable file of the contents of the videos and the posted materials (not quite a transcript). Hopefully you have a leadership team that’s on board with this stuff, but if not, you’ve got to keep hammering on it. Visit this link to get a refresher on the materials.



If anyone has some success stories in this regard, I (for one) would love to hear about them. We are a community of safety professionals; the success of one can be the success of all, so let’s make it happen!


Does closing rooms due to environmental conditions always make the best sense?

Every once in a while, someone asks me a question about why (or as is more the case here, “how”) a certain approach or response “becomes” the standard of practice, etc. For instance, a lot of times, I will find Interim Life Safety Measures policies that always seem to drive implementation, almost in direct opposition to the level of risk engendered by the deficiency (one caveat: I think you really have to tend towards over-implementing for construction and renovation activities, if only because you can have so little actual control over contractor behaviors. You need think only of the number of truly successful above the ceiling work permit processes—almost makes Powerball sound like a sure thing, but I digress). Anyways, to bring this back to today’s topic, I am reasonably certain (I was going to say “know,” but since I haven’t been everywhere) that many, many folks (very close to all) have intermittent struggles with the management of environmental conditions in surgical procedure areas. If we can use the number and type of Joint Commission findings as any indicator, the struggles continue.

I think we can operate under the assumption that there are very few surgical procedure areas that are perfectly configured every moment of every day (I don’t think that’s a stretch, but please let me know if you have found perfection in this regard). But what I see all the time are policies for which the response to out-of-range values (once you’re done with the call tree) is to make the decision to continue with cases or to close the rooms until the conditions can be resolved. Now I know there are instances in which you need to be a little more careful; I can see the risks of continuing with an invasive surgical procedure if your air pressure relationships are bit squirrelly. But what about the actual risks associated with out-of-range temperature and/or humidity? I mean, if you have an upper humidity limit of 60% (which I think is fairly common), a condition of 60.1% RH is an out-of-range value, but I don’t see where it would necessitate closing the room, delaying cases, etc.

I did a little poking around to figure out the genesis of the “closing the room” dynamic and I have been unable to make anything close to a real determination of where this started. Anecdotally, I got some indication that CMS was the perpetrator, but I’ve heard the same thing about CMS and the general prohibition of cardboard, so I think this may very well reside in that vast wasteland of healthcare compliance mythology (and no Mythbusters to tackle these pressing issues—bugger!). At any rate, I’m wondering if anyone out there has really analyzed the increasing/decreasing risk factors relative to out-of-range (low and/or high) humidity or temperature conditions. I can’t help but thinking that we can do better in this regard, so if someone has something to share (perhaps this would be a very good improvement project for 2016). There’s got to be a point where the risk of the environmental condition(s) actually outweighs the risk of delaying treatment/procedures, etc. Maybe it’s time to figure out exactly where those tipping points live…

We can be heroes

Very much a quick peek this week at more of the latest offerings from our friends in Chicago as they turn to some updated emergency management references. For those of you that have not yet book marked it, first and foremost, you can find the Joint Commission Emergency Management portal here.  The portal homepage includes links to information already published, including a Q&A blog from John Maurer’s 2013 presentation at the JCR Annual Ambulatory Care Conference; while the questions primarily relate to ambulatory settings, some of the general concepts certainly carry over. As I look over the materials, I hope that Mr. Maurer finds more opportunities to write (maybe he could fill in for Mr. Mills once in a while); I don’t know about you, but I like to read different “voices” from time to time and I’ve always found Mr. Maurer very informative and useful in helping folks understand what compliance can look like. At any rate, three’s lots of links to lots of stuff—definitely worth checking out (though I will say that perhaps it’s time to remove the 2013 date from the Joint Commission requirements section at the bottom of the home page; I know that 2013 was the last time that the standards were revised, but it makes things look a little dated).

So, on to the new stuff. First up is an update of general references; this includes links to the CDC Hospital Disaster Preparedness Budget Model, which is an Excel-based tool to assist in estimating resource needs across key departments and to help calculate funding reserves that would be needed for response and recovery (I think a lot of folks are good on financing response, but I’m not so sure about recovery—what say you?). Also, there’s a link to ASPR TRACIE (Technical Resources Assistance Center and Information Exchange—which came first, the acronym or the title?), which aims to provide “timely and innovative disaster information, tools and practice guidance for hospitals and community-based providers”; as well as a link to a Religious Literacy Primer for Crises, Disasters, and Public Health Emergencies. Finally for this page, there’s a link to the 5th edition of the Hospital Incident Command System Guidebook, so, basically, the latest and greatest IC stuff. I still think that the toughest thing about IC is getting consistent buy-in from leadership (sometimes it’s hot, sometimes it’s not), but perhaps edition #5 has the key to their hearts.

Lastly, but certainly not leastly, we have some information regarding the management of vulnerable populations, which can be found here.

There is a wide-ranging batch of information here (I would have liked to see a little more for adult behavioral health; they do touch on the pediatric behavioral health population, but maybe that will be in future missives), much of which I think you’ll find pretty helpful, if only to prompt discussion of the various populations served by your organization.

As with any materials published/shared by TJC, there is always the potential that surveyors will start to equate compliance with each organization’s efforts in dealing with this wealth of information. As always, not everything published is going to be as effective everywhere, so it certainly comes down (back?) to the individual organization’s to determine what preparedness looks like for their organization (and it never looks the same across organizations—even organizations that are in the same system). Emergency preparedness is very much a customizable undertaking—one size fits all does not apply very effectively across organizations (in fact, it would be much closer to one size fits none). You know what works best in your house (and, of course, you used the risk assessment process to make that determination, you clever boys and girls!), so don’t be afraid to set something aside because it is not a good “fit” for your organization. You are the best judge of what you need to do, have in place, educate for, etc. Be confident (but not cocky—that never plays well during a survey…).

Don’t be a Haz-been (or perhaps Haz-not would be more appropriate…)

I would like to take this opportunity to draw your attention to the two most recent issues of Perspectives, for a couple of reasons. First, as the articles (part 1 and part 2) deal with EC.02.02.01, which is on the top 10 list for most-cited standards during 2015, and Joint Commission interpretation relative to the wonderful world of hazardous materials (and it is, indeed, a wonderful world). Second, these articles introduce a new “voice” into the mix, Kathy Tolomeo, CHEM, CHSP, who is one of the engineers at The Joint Commission’s Standards Interpretation Group and is one of the folks in Chicago who reviews clarifications, ESC submittals, perhaps (presumably) PFIs, etc. In that context, I think it’s important to have a sense of how individual reviewers “see” the regulatory compliance landscape, and these articles provide some sense (I will stop short of saying insight) of compliance strategies.

As a starting point, those are good reasons to check out the articles. But I also found these articles particularly helpful in that compliance strategies are discussed in some detail (I mean the articles are only a couple of pages long, so there are limits to how much detail), including an example (in the December Perspectives) of a hazardous materials inventory form, which I think paints a very nice (and perhaps most importantly, clear) picture of what you need to have in place (I’ve encountered a lot of folks struggling with what is expected for the HazMat inventory). There are discussions of eyewash stations and lead PPE, ventilation, and risk assessments (imagine that!) in the December Perspectives; the January issue covers hazardous gases and vapors, permits, licenses, manifests, and other documentation, labeling, monitoring for radiation exposure, proper routine storage, and prompt disposal of trash.

I guess you could say it’s a bit of hodgepodge in terms of ground covered, but that is the wonderful world of hazardous materials and waste. Check out these articles and maybe, just maybe, you can keep yourself off this year’s (or next year’s, depending on when you’re going to be surveyed) Top 10 list.

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?

IFU? No, you IFU!

As this little screed represents the closing of the 2015 blogging season (I figure there’s gotta be a lumberjack tie-in—blogging and logging are just too close for words), I’m going to try and keep it relatively brief. If brevity is indeed the soul of wit, then I tend to be rather more witless than not…

Another recent trend in survey findings relates to the management of some of your more “peripheral” patient care equipment, particularly the stuff that gets used by the good folks in the rehabilitation/physical therapy world: hydrocollators, paraffin baths, etc. While I do believe that we have things well in hand from a medical equipment standpoint (most of the equipment being cited falls very clearly into the low-risk/no-risk category), where this is skidding a bit sideways is when the devices in question are not being maintained by the end users in accordance with the manufacturer Instructions For Use (IFU). Now, I will freely indicate that some of the equipment we’re talking about is almost Biblically ancient and the IFUs might not be easily obtainable, but in the absence of a risk assessment to indicate that maintaining this stuff in a manner that is not in strict accordance with the IFUs results in an acceptable level of operational performance/reliability/cleanliness, etc. then you’re at risk for yet another of the (seems like) gazillion little imperfections that are gracing survey reports across the continuum. Interestingly enough, these findings do seem to be “clumping” under the Infection Control standards (pretty much IC.02.02.01, EP 4, which deals with the storage of supplies and equipment), so this may not be on everyone’s radar at the moment. That said, it might be a good idea to poke around a little bit—including any offsite rehab/PT locations—to see if you have any survey risk exposure. Once again, I’m not convinced that this represents a significant risk to patients, but my being convinced (or not) doesn’t necessarily keep you out of trouble during survey. We need to be very sure about where we “stand” in relation to what manufacturers are recommending and what practices and conditions provide appropriate levels of safety, cleanliness, etc. The Joint Commission doesn’t tell us how to do these things, but we need to be able to respond definitively when the questions are (and there is a certain inevitability here) raised during survey.

And on that note, I wish each and every one of you a most prosperous, safe, and successful 2016. See you next year!