RSSAuthor Archive for Steve MacArthur

Steve MacArthur

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

Maybe this time we should do things a little differently…

This may be a “me” thing, but it seems to me that I’ve seen a lot of annual evaluations recently that only minimally make note of organizational response to the pandemic. I know there are no “rules” about the contents of the annual evaluation and it seems unlikely (unless you have a very high-powered crystal ball) that response to a pandemic would have been a key point in identifying goals for 2020 (though I suppose if you’re using the fiscal year as your calendar and you had a starting point in the middle of 2020). Clearly, consideration of things relating to pandemics and emerging infectious diseases is going to be front and center for the foreseeable future (for good or ill), but I still have this (perhaps unreasoning) fear that we’re going to lose a ton of “good stuff” as we come out the other side of the current emergency.

And that “good stuff” that might be lost are the missteps that periodically intruded upon the response protocols that were, to a fair degree, made up on the fly. Innovation was definitely the overarching result, and there were certainly great successes, but there had to be some stuff that didn’t work. It seems I continue to hear about setting up tents, taking tents down, setting them up again, and on and on…

So my thought is: Go back to all those hotwashes and AARs that were written in the heat of battle and see if there were any items that really didn’t make the grade—and memorialize ’em! My sincere hope is that the learned lessons won’t have a practical application any time soon, but the reports of a resurgence of hospitalizations make me think that we’re not quite done with this sucker.

Stay tuned…

Night time in the switching yard: Listen to the train(ing) whistle whine…

I suspect that, amongst all the other things that have been pounding on the metaphorical rooftops, you saw the updated guidance from OSHA relating to the Emergency Temporary Standard. I don’t know that there’s a great deal in play that would be particularly problematic, but I think the training requirements might be worth a little bit of work to ensure that the required elements are readily discernible to a regulatory surveyor. That said, I wouldn’t necessarily consider these “new” requirements, as with so many of the post-pandemic “requirements,” it’s all kind of based on what you would do if you were facing whatever event was coming down the pike. I really don’t think this is anything about which you should be concerned, but I figure it can’t hurt to get the list out and make sure that your program speaks eloquently to the individual components.

Here they are:




The employer must ensure that each employee receives training, in a language and at a literacy level the employee understands, and so that the employee comprehends at least the following:


COVID–19, including how the disease is transmitted (including pre-symptomatic and asymptomatic transmission), the importance of hand hygiene to reduce the risk of spreading COVID–19 infections, ways to reduce the risk of spreading COVID–19 through the proper covering of the nose and mouth, the signs and symptoms of the disease, risk factors for severe illness, and when to seek medical attention;


Employer-specific policies and procedures on patient screening and management;


Tasks and situations in the workplace that could result in COVID–19 infection;


Workplace-specific policies and procedures to prevent the spread of COVID–19 that are applicable to the employee’s duties (e.g., policies on Standard and Transmission-Based Precautions, physical distancing, physical barriers, ventilation, aerosol generating procedures);


Employer-specific multi-employer workplace agreements related to infection control policies and procedures, the use of common areas, and the use of shared equipment that affect employees at the workplace;


Employer-specific policies and procedures for PPE worn to comply with this section, including:


When PPE is required for protection against COVID–19;


Limitations of PPE for protection against COVID–19;


How to properly put on, wear, and take off PPE;


How to properly care for, store, clean, maintain, and dispose of PPE; and


Any modifications to donning, doffing, cleaning, storage, maintenance, and disposal procedures needed to address COVID–19 when PPE is worn to address workplace hazards other than COVID–19;


Workplace-specific policies and procedures for cleaning and disinfection;


Employer-specific policies and procedures on health screening and medical management;


Available sick leave policies, any COVID–19-related benefits to which the employee may be entitled under applicable federal, state, or local laws, and other supportive policies and practices (e.g., telework, flexible hours);


The identity of the safety coordinator(s) specified in the COVID–19 plan;


The requirements of this section; and


How the employee can obtain copies of this section and any employer specific policies and procedures developed under this section, including the employer’s written COVID–19 plan, if required.

Note to paragraph (n)(1). Employers may rely on training completed prior to the effective date of this section to the extent that it meets the relevant training requirements under this paragraph.


The employer must ensure that each employee receives additional training whenever:


Changes occur that affect the employee’s risk of contracting COVID–19 at work (e.g., new job tasks);


Policies or procedures are changed; or


There is an indication that the employee has not retained the necessary understanding or skill.


The employer must ensure that the training is overseen or conducted by a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.


The employer must ensure that the training provides an opportunity for interactive questions and answers with a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.

Again, I feel pretty confident that these elements have been in place in most instances (PPE, risks associated with COVID, health screening, any changes to procedures, etc.) and (presumably) the effectiveness of the education process supported by data of COVID-related illnesses amongst the workforce. But it might be a good idea to “pull” these elements out as a syllabus (if that makes sense) to be able to walk a surveyor through the elements.

Protection is improvement, improvement is protection: Keeping folks safe from workplace violence

When it comes to the management of workplace violence considerations, I think we all have experienced the many, many ways in which these risks can manifest themselves in the healthcare environment. And now that the tides of COVID appear to be receding, the sense of gratefulness that existed (at least for a little while) seems to be on the decline as well. Now that ambulatory volumes are picking up and waiting rooms are becoming more congested, tempers grow ever shorter and put your frontline folks back to the more traditional risks associated with managing those interactions. It’s hard to say whether the folks not working in healthcare are sufficiently with familiar with the stresses and stressors endured by folks working in healthcare over the past 15-18 months, but it does seem that the sense of healthcare workers as “heroes” (which they most definitely—as they were before the pandemic and will be when we’ve moved on to the next thing) is not enabling good behaviors on the part of patients and their families as might have the case a year ago. In my own, very informal, data collection, there are an awful lot of sick people that are now comfortable enough to seek treatment for long-standing issues, which likely means that folks are scared (but not COVID-scared) and folks that are scared can have a tendency to lash out. This points to making sure that our workers are as well-prepared to deal with patient (and family) concerns before things escalate to the point of violence.

To that end (kind of), our friends in Chicago are implementing a number of “new” requirements to provide a framework for the survey of workplace violence concerns and how effectively hospitals are managing those risks. You can find the details of the standards (they’ll become effective on January 1, 2022) here. There’s also a resource page related to workplace violence.

In noting the use of quotation marks around the “new” requirements, I don’t know that the programmatic elements they’ll be looking for are anything beyond what is typically administered in a credible safety program. I don’t know that I’ve been to an organization in the last decade or so where workplace violence was not an issue to some degree. But much as we’ve had to work hard to protect workers during COVID and in light of the expansion of protections to whistleblowers, I think we should be approaching this as an opportunity to cover as many bases as possible in ensuring all staff (throughout every level of your organization—organizational leadership is clearly on the hook for supporting this endeavor) are effectively prepared to manage the risks associated with workplace violence, particularly de-escalation education. When you break down the requirements, it’s a fairly straightforward “ask”; beyond establishing a mandated frequency for review of the workplace violence prevention program, I don’t think that there’s anything here folks aren’t already doing to some extent. I suspect the education component may require some “ramping up,” particularly if the existing education programs were aimed at an identified group of “at risk” staffers; at this point, anyone working in healthcare, regardless of the environment in which they work have to be considered at risk and would benefit from de-escalation, etc. education. Also, if you’ve not made a concerted effort to include folks in leadership positions in your organization—they need refreshers, too.

So, what will they be looking for?

  • An annual worksite analysis of the workplace violence program, including mitigation or resolution of risks identified in the analysis, based on an analysis of the work environment, investigation of incidents, analysis of supporting policies and procedures, education programs, etc. As a somewhat related aside, keep an eye on your OSHA 300 logs to make sure any occurrences are being captured and communicated (especially to leadership—more on that in a moment);
  • An workplace violence training/education program (at time of hire, annually, when changes occur) for leadership, staff, and licensed practitioners; there is an allowance for determining the contents and to what extent workers need the education (based on their roles and responsibilities), but I don’t see where you can draw the line such that any group (or individual, for that matter) would rule out of the education. And for those of you with skilled nursing facilities, you could argue that they are working in one of your highest risk environments (second, perhaps, to the behavioral health environment), so you need to make sure that you’re including them in the education mix.
  • From a leadership perspective, there needs to be an individual designated leading the workplace violence prevention program (developed by a multidisciplinary team—can be existing) that includes policies and procedures; a process to report incidents and manage the data associated with trends, etc.; a process for follow up and support to folks affected by workplace violence (victims, witnesses); and reporting incidents to the governing body.

My best consultative advice, particularly if you are in the survey window, is to start working on pulling these elements together if you have them or to work to start looking at these considerations as a function of the requirements. Recognizing that the requirements are surveyable by some regulators beginning in January, there are other regulators who are predisposed to looking at this right now. Unfortunately, workplace violence occurrences are going to happen, but we need to consider every occurrence as an opportunity to improve the process and then act on the analysis. This is not going to be a simple fix, but if we can get everybody on the same page in terms of competencies, etc., in this regard, we should be able to demonstrate improvement over time.

If you remember nothing else: Nothing happens in isolation…

With the (presumed) onset of regulatory surveys including a more thorough review of survey results past, I would imagine that everyone out there in the listening/reading audience can name at least a couple (if not more) instances of non-compliance that were (for want of a better term) “missed” during survey. Just to use a simple example (which we touched upon back in the wilds of winter), your most recent surveyor may have stopped looking for improperly labeled breakers (spares in the on position; breakers in the on position not labeled, etc.). But the question becomes: How many more are out there…and how carefully did someone look post-survey? Certainly, whatever was identified would have been corrected as part of the plan of correction—you can’t be telling regulators that you did something that you didn’t do, now can you? But what about other potential findings? Now, I recognize that using this particular example is (hopefully) a wee bit hyperbolic in that (again, hopefully), the low risk findings are going to get a mulligan if there are recurrences. If you have really crappy luck, you could have an exit sign burn out every time you have a survey or something similar (can anyone say “improperly segregated compressed gas cylinder”?) but I would think that the little stuff is not going to drive a seriously negative survey result, with perhaps one exception.

The exceptional item (or items) are those in which the management of the care environment crosses into the realm of infection control and prevention: damaged/non-intact surfaces, stained ceiling tiles, etc. The reason for my concern with this stuff is it is really hard to manifest a solid process for managing these incidental conditions without hard-wired participation of point-of-care/point-of-service folks. I don’t know, I’m just having a hard time wrapping my head around taking issue with findings/conditions similar to those found in previous surveys. Now, if we’re talking widespread versus isolated, I can see widespread issues maybe pushing a survey in the wrong direction, but I still think the severity has to come in to play to some degree, as well as the (ever-present) potential for recurrence. To my mind, the stuff that gets broken/damaged tends to be because those are the things that suffer the most “abuse” (and I use that in the most general of meanings). It’s like the fire doors near the loading dock—tell me they don’t have a significantly greater potential for damage, during a survey or not.

At any rate, I think the important thing is to work diligently to ensure that those isolated findings are not the tip of a widespread iceberg. I don’t think we can just stop with what was cited anymore.

Next week, we’ll spend a little time with the “new” expectations relating to the management of workplace violence; I’m still trying to figure out if there’s anything that is truly “new” (I tend to think no, but you never know what might be hiding in the nuances), but we should at least start the discussion of where things seem to be going.

Hope you had a safe and festive Independence Day!

In your eyes: The light, the heat, the flushing fluid…

As is often the case (it probably says more about me than anything else, but what can one do?), it seems that there are always conversations to have about the practical nature of the risks of occupational exposure to injurious chemicals and how eyewash stations figure in the greater reality that is healthcare. In general, we know that eyewash stations are only “required” when there is a risk of occupational exposure to injurious chemicals (here’s a reasonable reinforcement of that interpretation), but somehow, everywhere I go there are eyewash stations in areas for which there is no risk of occupational exposure, etc. It’s possible that there might have been in the past, but the organization was able to make good use of the hierarchy of controls to reduce the risk of occupational exposure by either eliminating the hazard or substituting the product with something that is not injurious. That is not always going to be the case, but it occurs to me that rather than just talk about eyewash stations as a going concern, let’s look at what you can do to either remove ones you have or forego having to ever install an eyewash station in the first place. Which reminds me, if you are building new or renovating existing space, make sure the architects/designers with whom you are working understand when eyewash stations are actually required. I’m finding a lot of eyewash stations in new construction that don’t belong—soiled utility rooms, etc. It’s probably worth asking them for a list of locations where eyewash stations are earmarked for installation; it might save you some aggravation in the future.

At any rate, in the previous passage, I noted the “good use” of the hierarchy of controls, so I thought that this might be a good opportunity to walk through that general concept. Fortunately, this is a topic about which the good folks at NIOSH have given some thought. What follows is rather along the lines of a (very basic) primer, but there’s lots of good content available through the CDC/NIOSH portal.

Hierarchy of controls

  • Elimination: Remove the hazard
  • Substitution: Replace the hazard
  • Engineering Controls: Isolate people from the hazard
  • Administrative Controls: Change the way people work
  • PPE: Protect the worker with personal protective equipment

You may notice that eyewash stations don’t really figure in to the hierarchy, primarily because the role of eyewash stations is in the event of an emergency as the result of a failure of the above-noted controls to prevent the exposure (again, it’s kind of basic, but nonetheless true for its simplicity). I don’t know that there’s necessarily a right or wrong answer for any of this (which has a lot to do with why this is such a perennial consideration in the safety field), but I do know that using the hierarchy to work through how you manage risks of occupational exposure makes a great deal of sense (well, at least it does to me). Please look over the available information and let me know what you think.

I wish each of you and your families a most safe and festive Independence Day (the year is half over—who’d a thunk?!?). See you next week!

They blew the horns…and the walls came down!

Continuing our intermittent discussion about returning to normalcy on the facilities operations front, I’ve been reflecting on the monumental amount of facility modifications that have occurred over the last 15-18 months and what those modifications might portend for the future. I’ve seen all matter of materials used to facilitate containment of patient care units and I was wondering, now that there is lessening need for a lot of these temporary structures, if folks have been thinking about how they would “do it again next time” as they deconstruct the temporary walls. In some instances, I’m sure we’ve had loads of fun removing tape residue from various surfaces (where would we be without tape!?!) and perhaps gone back to review those pesky ILSMs that sprouted up over time. I’m still not sure how ILSM assessment will “play” with the 1135 waivers: Are they required, are they not, are they in the “eye of the beholder”?

At any rate, I’m hoping that somewhere in the hive mind of your organization there is a clear picture of what modifications were made on the fly, which prompted me to do a little poking around on the interwebs regarding the practical application of temporary barriers and I ran across this, which (if you’ve not seen it) I think you’ll find useful as a thought provoker (provocateur?).

Clearly, we are all about wanting to do things better and I think the questions/concerns/considerations raised in the article are definitely worthy of conversation as we plan for the next event. The “good” thing about temporary containment is we don’t have to wait for the next pandemic to get familiar with the modular concept. There are likely going to be construction and renovation projects coming your way and what better “test market” for containment?

So, that’s it for this week. I continue to hope that the true onset of summer will provide some level of opportunity for down time. The older I get, the more I appreciate the “beauty” of time off—even if it’s time off for home projects. Just to be able to focus on stuff that’s not related to “work” is pretty awesome—try it—you’ll like it!

Wishing you wellness and safety!

Every once in a while…

…I make good on the promise of brevity. Let’s see if this is one of those weeks.

As we continue to wind down from the various and sundry modifications that were made to the physical environment to provide appropriate care for patients (and appropriate levels of safety for staff) during the pandemic, it might be a good point to ascertain whether any of the persisting conditions/practices are representative of Life Safety Code® (LSC) or other compliance issues. I am very hopeful that folks are going to be able to “take some time off” this summer (working on the thought that last year, not so much), so my thought is to add (at least) one last go-round before the solstice is upon us—that way, if any regulatory f(r)iends show up over the next few months, you will have a defensible position for any lingering programmatic elements that could raise questions.

To aid in that endeavor, you might consider this article from Healthcare Facilities Management that provides some guidance on just that. There remains the whole notion that we have 60 days after the suspension of the Public Health Emergency (which was renewed in April) to “return to normal,” but it also can tie into whether your organization is still responding to the emergency. If your incident command structure has been discontinued, you may want to really start preparing for bridging any compliance gaps that may still be in place. As you know (by now), I tend to be a proponent for the risk assessment process and any time the future of compliance is uncertain, risk assessments are our best strategy for demonstrating compliance.

One other item for this week. I would encourage you to check out the capabilities of Smart911; while this may not be entirely work-related as a suggestion, from a peace of mind standpoint, ensuring that emergency responders have access to as much pertinent information (and you can decide what is, and what is not, pertinent—hmmm, could be another risk assessment). The more information responders have at their disposal (including your whereabouts if you’re notifying them on a mobile phone), there more quickly and effectively they can respond to the emergency. With all the issues of privacy, etc., there are certain entities that would be more effective in their response, and I think Smart911 makes a lot of sense to be included in trusted sources (hopefully that is not a fleeting thought). Check ’em out and see for yourself. If you’re not comfortable with the process, I get it, but reach out to your local emergency folks to see how they feel about it before you elect not to participate.

Just about a week left of spring 2021. I hope this finds you well and perhaps just a wee bit less anxious about your existence. Until next time…

Bye bye, business occupancy?

To my fairly certain knowledge, I’ve tried to stay away from anything that might approximate “click bait,” though I will freely admit that this week’s “headline” bumps up against it as a general concept. That said, I do think that the current shifting of survey focuses is such that it may be more sensible in the long run to modify the ways in which we “use” business occupancies as a survey preparation methodology.

What prompted the thought (beyond all the hubbub regarding the new section of the Joint Commission’s Life Safety chapter that deals specifically with business occupancies) is the whole notion of the slow envelopment of the “healthcare facility” descriptor as the go-to term for all care locations, be they inpatient or outpatient in nature/design. It does appear that a day could come in which the business occupancy designation means little or nothing from a compliance standpoint—I shudder to think. When you think about it, the “sharp edge” that separated care locations by occupancy classifications has become rather more blurred than not, some of which is the result of there not being clearly defined expectations/standards. Clearly, the business occupancy section of the LS chapter is a step towards a codification of those expectations—and what that means going forward.

If you look at the overview section of the LS chapter in the online manual, there is a note that the first two standards in the chapter (dealing with general expectations, including the management of life safety drawings, and the practical application of Interim Life Safety Measures) apply to all occupancy types. Truth be told that “note” has been sitting there for a while now, but with the creation of the business occupancy section of the LS chapter, I think we can probably intuit that the “general” requirements are going to be more of a focal point during survey. Past experiences tell us that this stuff won’t all get chased right out of the box, but I think one of the pressure points is going to be what you have for life safety drawings for your outpatient locations. Hopefully, that thought will prove to be most incorrect, but I get this feeling…

Another element in the outpatient setting is the practical application of all things relating to infection control; much as is the case with the physical environment in general, the currently drawn lines are not sharply defined, so it becomes the charge for each organization to define the lines of compliance. A good recent example is this article in Health Facilities Management magazine. I’ll let you read this on your own, but it does speak to a fair level of due diligence in determining what is actually required by code and what is the best strategy for your organization. High-level disinfection, sterilization, management of instruments, etc., is likely to continue as a significant survey touch point—and they’re going to kick those tires fairly exuberantly. You need to have a solid foundation for what constitutes compliance for your organization to present as bulletproof a façade as possible, so if you’ve got any of these IC-related processes “living” in your outpatient settings (and odds are that you do), it’s time to start kicking those tires before the folks with the pointy shoes show up…

Hope you all are well and staying safe through this current transition. While I am optimistic about the future, my personal observations during my travels the past couple of weeks is that hand hygiene numbers are starting to tail off a bit. I guess there are some folks that will only wash their hands if they think it’s a matter of life and death…

Stop making sense: Normalizing abnormality…

A brief foray this week, though I hope that is very much in keeping with you all being able to grab a few moments for yourselves over the holiday weekend. It was rather dreary up here in the land of the New English, but the rain is much needed, so if there was a bit of dampening of the spirits, it should take the edge off any fire risks up this way. I would be happy to share with the more parched regions of the country, but it appears that rain (like many other things) is rather more capricious than not…

First up: If you have not had the opportunity to get back to the grind that is the hunt for expiring/expired product, please remember that a ton of products were purchased about a year ago and it does seem like I’ve been running into a bunch of stuff that is reaching the end of its (sometimes not so) useful life. Wipes and sanitizer proliferated quite extensively last spring into early summer, so make sure someone in your organization is worrying about that one.

Next up, the only EC-related item in the June edition of Perspectives (and it is a little bit of a stretch) deals with the Sentinel Event Alert on infusion pump safety. It seems somehow that improvements to medical equipment technology manage to create more challenges for the folks in clinical engineering. The more a device can do, the more stuff that can go wrong. This is not to say that these are in any way a problem in and of themselves, but it seems like there are always gaps in the education process when these things roll out, so best of luck on that front. Medication safety is clearly going to be a focus moving forward and if we have learned nothing over the last little while is that everything ties across the physical environment eventually.

As a closing reiteration (we did touch upon this a couple of weeks ago), just a reminder to try and capture as much of the last year as you can. Many (if not most) of the lessons learned are pretty hard-wired into our response protocols, etc., but it’s also important to take stock of what didn’t work particularly well so we can avoid repeats in the future. One of the consistent challenges I’ve noted over the years is when an organization learns of a process, etc., that has worked really well at another organization and adopts that process lock, stock, and barrel. And a lot of times, that “perfect” process involved a fair amount of stumbling around to get to the point of perfection—and for some reason, folks don’t always share the missteps. It reminds me of that oft-told aphorism regarding doom and repeating history, but let us leave doom to others…

Hope you all are well and making the most of the moment!

If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

  • It’s OK for your response process to be the same for multiple risks/hazards
  • Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
  • It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
  • It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
  • It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

  • They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
  • Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
  • Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
  • Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
  • Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
  • Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
  • Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
  • Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!