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

Is there anybody out there?

I’ve yapped away here for a couple of months now. The warmth of the summer has faded, up here in the Northeast the vivid hues of autumn have also faded, and there are way more leaves on the ground than there are in the trees.


We’ve gone from a fair amount of certainty relative to all things safety to a pretty much wide open expanse of hope, denial, angst, expectation, questions, and answers. Our relatively calm little pool has been whipped into a froth of the unknown. So how are you going to spend the holidays?


When we started this little blogopoly (the spirit of M. Colbert lives), the intent was always to foment (or ferment–sometimes the vernacular gets a little fruity) a conversation for which I would periodically pitch some bon mots to keep the conversation going.


I have heard from some of you (keep those cards and letters coming), but it’s time to see if we can draw some folks a little more out into the light of the blogosphere.


Earlier this month during an audioconference about the known Joint Commission EC changes afoot, we asked folks what they thought their most challenging issues would be in 2008. Now it’s your turn.


What’s turning what little hair you have left to gray? What makes you linger almost lovingly in the antacid section of the big-box warehouse store?


See that little “Comments” link below my post? Click and register, and then you’ll be set up to post your thoughts to my query or any other topic I write about. It’s time to stand up and be counted, heard, and recognized. We want this space to be yours, too.


Let’s get ready to grumble!

Temporary partitions, permanent expectations

Watch your temporary partitions during construction and renovation. Make sure the contractor understands the expectations, such as:

  • “Smoke-tight” means, for all intents and purposes, no holes
  • “Debris removal” means removing the debris, not piling it up until it’s in the way

Yes, I know that there are allowable gaps in certain circumstances, but do you want to split hairs with the construction folks over stuff like that? Me neither!

ILSM approaches should change with project phases

My experience has been that sometimes activities that result in Life Safety Code problems have an ebb and flow to them. As a broad example, how you ensure safety during a demolition phase is different (maybe not substantially different, but different) than what you do during a construction phase, which can be different than what you would do when the project is finishing up.

When you do the assessment for a project of a fairly lengthy duration (and no, I’m not going to tell you how long that is–you have to figure it out), phase your ILSM plan. Maybe you start with additional fire drills throughout the house and maybe finish with drills in the immediate area.

Or maybe you can change the “arc” of your surveillance round process: Start out with daily (or even more frequently during demolition) and maybe end with weekly. The language of EC.5.50 provides all the opportunity you need to make these determinations for yourself, so take full advantage.

EC standard conspiracy or coincidence?

Just when I’ve memorized all the EC numbers, The Joint Commission proposes to change them in 2009.

Evidence of a vast regulatory conspiracy or merely coincidence? You decide.

Don’t get tied down with event-specific emergency management plans

You will find surveyors who look for specific emergency response plans for each of your vulnerabilities identified in the HVA, which is not really a standards-based requirement.

That’s not to say there wouldn’t be a certain benefit to having some event-specific response plans–there are, after all, standards-based requirements for having specific plans relating to utility systems disruptions and medical equipment failures.

Only develop emergency response plans for specific events in a manner that makes sense to the organization. For instance, those hospitals in the northern half of the country probably don’t have to do a ton of planning relative to winter weather. Do you really need to have a documented policy or procedure to deal with a snow storm? I’d be inclined to think not.

As with just about anything in the EC that doesn’t involve specific requirements, what you do (or choose not to do) should be based on your risk assessment and then discussion at your safety committee or disaster planning committee.

The Joint Commission expects you to:

  1. Look at the risks involved
  2. Identify strategies for appropriately managing those risks
  3. Implement those strategies
  4. Monitor performance to make sure that everything turns out as you thought it would

When The Joint Commission reconfigured the emergency management standards, it moved towards a performance improvement model. I think we’ll see more of that kind of thing as the commission rolls out future standards revisions.

EC standards are grounded in regulation, albeit sub-rosa at times

When it comes to looking beneath the surface of an EC standard, I think we can stipulate that anything approaching a specific requirement is grounded somewhere in a code or regulation (e.g., NFPA, OSHA, EPA, etc.).

While it would certainly be nice to see the code reference right there in a given EC standard (sometimes it is, sometimes it ain’t), it defaults to us, as professionals, to make sure we understand the intricacies of compliance.

When a Joint Commission EP goes “ghost”

Suppose we have a pre-Nixon-era building in which we have not yet introduced emergency power into the patient rooms (no recent renovations of significance, etc.), but we do have emergency power outside each of the rooms.

The area complies with EC.7.20, EP #11 (providing emergency power for areas where electrically powered life-support equipment is used) because patients in this location don’t require ventilators and the usual run of life-support type equipment. If we had to provide emergency care, the defibrillator is plugged into emergency power out in the hall and, if really pressed, we could run an extension cord on a temporary basis into the room until the patient was stable enough for transport.

I mean, after all, we do have emergency power in this area “where electrically powered life-support equipment is used,” according to EP #11, so we-re on solid ground here–yes? Also, we’ve identified as a PFI plans to address this improvement opportunity, so again, we seem good to go.

Ah, not so fast grasshopper! It appears that, from a compliance standpoint, EP #11 is a veritable onion of a standard, with several layers of requirements that come into play.

Note EC chapter references to the American Institute of Architects’ Guidelines for Design and Construction of Hospitals and HealthCare Facilities (2001 edition) and NFPA 99, Standard For Healthcare Facilities (1999 edition).

Both of these august tracts reference a section of NFPA 70, National Electric Code, that requires hospitals to provide one duplex emergency power outlet per bed, connected to the critical branch of the emergency power distribution system, in general care patient rooms.

You might argue that when this building was constructed, these codes referenced above weren’t in effect, and you would be correct. But in a similar real-life case that I’m familiar with, an intrepid Joint Commission surveyor did not quite see it that way, resulting in an RFI under EC.7.20.

It took several back and forths with The Joint Commission before the determination was made that we had been in compliance with the EP as it was written in the standards, but the underlying NFPA 70 requirements had “caused” the noncompliance. Further relief came as the result of grandfathering this area’s configuration due to it not having been updated, since adoption of the applicable codes came long after the condition had been established.

So, the take-home lesson? It is in your best interest to use The Joint Commission’s clarification process and always:

  • Look at what the surveyor has identified as the issue
  • Lock at which EP is cited as the result of that identification
  • Keep at it until you get relief

When a survey ends and you have any number of RFIs, start the clarification process as quickly as possible. Work with your organization’s survey coordinator, your Joint Commission account representative, even engage the assistance of a consultant–the important thing is to leave no stone unturned.

The last thing you want to have to do is to fix something that is not broken. In the long run, you have enough other things that legitimately require your attention.

Examples of immediate threat to life and safety, Joint Commission style

In my last posting, I talked about when surveyors invoked an immediate threat to life and safety. Let’s take a stroll through the list of “threats” we’ve encountered during client surveys, shall we?

Consider these:

  • Lack of master alarms for medical gas systems
  • An unreliable fire pump
  • Inoperable fire alarm system
  • Fire doors throughout the facility not closing and latching
  • Penetrations in fire walls not sealed with a fire-rated material
  • Main circuit breaker not tested or maintained and raw sewage leaking from pipes in a crawl space beneath a hospital
  • Lack of procedures to identify and maintain fire protection (i.e., lack of an effective means to transmit a fire signal to an external point and the responsible person not knowledgeable on the use of the fire alarm system)
  • No means of exit in an emergency and lack of implementation of interim life safety measures

Do you see a pattern developing? Well, neither do I–just kidding. Some of these situations seem fairly straightforward, but thinking about the fire doors and penetrations (not to mention how one would define an “unreliable” fire pump), there does appear to be some room for surveyor interpretation. As they might say here in the Boston area, that’s a shockah!

I think if I had to give you a piece of advice, it would be to make sure that everyone on your team has a pretty good understanding of how EC issues interrelate and how your organization ensures that all of these working parts come together and result in the safest possible environment for patient, staff members, and visitors.

And staff members may need to articulate this when you’re not around (unless you’re planning on no vacations until the next survey–I know I’d be tired).

If your survey will be between now and the end of the year, then start preparing now. If your survey was last week, start now. If your survey won’t be until at least 2009, start now. This is one of those things that is not at all well-served by procrastination.

Are you threatening me? Do I look like I’m threatening you?

One of the more precipitous aspects of the survey process is the invocation of an immediate threat to health or safety. This would the moment of a survey in which your entire world turns into manure.

Hopefully, such a plight will never darken the hallowed halls of your organization, but there is some indication that this problem has been occurring more frequently of late, so it seemed a good opportunity to cast a little light into this shadowy corner of accreditation lore.

Basically, the ball starts rolling when surveyors believe that they have encountered a situation that has, or may potentially have, a serious effect on someone’s health or safety, and thus requires immediate action to remedy the condition.

The survey comes to a screeching halt, your CEO gets to hear the fabulous news, Joint Commission headquarters near Chicago gets a call, even “appropriate government authorities” are in the loop-it’s all just too lovely. Of course, the impact on your accreditation status can be swift and painful, too. I’ll take root canals for $1,000 please, Alex.

Then there are the things you have to do to get out from underneath this damnation:

  • Take immediate action to completely remedy the situation
  • Prepare a thorough and credible root cause analysis
  • Adopt systems changes that prevent future recurrence of the problem

There are a number of conditions I’ve heard about in the environment of care that have resulted in the invocation of an immediate threat to life and safety. I’ll get into them in my next posting.

Stay safe,

Steve Mac.

24 + 24 + 24 + 24 = ?

In visiting with hospitals across the country since the unveiling of the new emergency management standards, there’s been an increasing murmur relative to the presence of a certain temporal indicator that you can find under EC.4.12, EP #6.

96 hours. Four days. 5,760 minutes.

That time span brings with it some questions:

  • Is this a long time to be without the support of the local community?
  • Does it vary within the six critical areas of EC.4.13 through EC.4.18 (communications, resource and asset management, safety and security, management of staff, management of utilities, and management of clinical and support activities)?
  • Does it mean I need to have four days worth of stuff in my warehouse?
  • What if I don’t have a warehouse?
  • How prepared is prepared?

These are all excellent questions for which your organization is going to have to identify answers. For good or ill, there are no correct responses for these questions, and the practical applications are going to vary from organization to organization.

What’s important to remember is that this particular EP is not telling you that you have to do one thing or another (like having 96 hours worth of stuff in your warehouse). What is required is that you have a sense of what would happen if you were cut off from support for those 96 hours. Some organizations might be able to do 96 hours on their own with very little difficulty, while others might struggle to get to 48 or even 24 hours (probably not many in that group, but it is possible). The ultimate questions are: How far can you go? And what do you do when you’ve gone as far as you can go?

One of the clear lessons learned in the aftermath of Hurricane Katrina is that holding on past the point of reason is, well, not a reasonable strategy. But prior to recent tragedies, it’s almost as if the “defend-in-place” strategy of life safety management was carried across to the annals of emergency response. Right or wrong, getting out appeared to be entertained very infrequently in our response plans.

Now we know that in order to even approximate the safe management of a catastrophic event, we must consider the inconsiderable, think the unthinkable, try to gain some measure of control over situations that are, for all intents and purposes, uncontrollable.

What would we do if faced with an event of such magnitude? How far can we go? How do we tell when we’ve crossed that threshold? All questions to answer-and soon.