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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

There’s gold in them thar minutes

Howdy folks,

I’ve been doing a fair amount of post-survey work with hospitals this year, and I can tell you that the stories you’ve heard about the environment of care being subject to a lot of attention are absolutely on the up and up.

And you know what? The focus isn’t necessarily the result of the life safety surveyor. Everybody on the survey team is looking very closely at the EOC.

I have noted a couple of trends that I’d like to share with you. Hopefully they will help keep you out of hot survey waters.

Let’s start with safety committee meeting minutes.

My personal practice has been to periodically go back (at least once a year, though I like every six months or so) and review your EOC committee minutes — including those reports that maybe didn’t get covered in full during the regular meeting.

A key point is to verify that you don’t have any unresolved issues lurking around in the past (before they take on the rosy hue of nostalgia).

Make sure that any interventions resulted in the improvements you were expecting, and confirm any monitoring of performance did in fact occur. Also, check that there are no issues for which action was deferred until a later date (that later date is probably in the past) without any further resolution.

The review of your committee minutes is designed to ensure that you have a process for making improvements in the environment. Don’t let that review be an opportunity for surveyors to point out where those improvements didn’t occur.

I’ll have more to say about this topic later this week.

Steve Mac.

Is the clock ticking when it comes to NFPA fire watches?

Hi again everyone. A reader asked me recently about the rules for fire watches–specifically whether there any other codes that indicate watches should be done every 15 or 30 minutes, as opposed to hourly.

The place to look is the NFPA’s Life Safety Code. Upon review, I have to admit that the code is a little less draconian in its demands than I had thought (a good thing, if you ask me).

Paragraph in the code states:
Where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

An annex note to says that fire watches should include “special action beyond normal staffing, such as assigning an additional security guard to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.”

So as you see, the code doesn’t really set time frames for fire watch frequencies.

I’d advise folks to look over their fire watches process and see if anything “falls out” compliance-wise when compared to the guidelines from the code.

Getting back to whether surveyors are always correct

Since I sort of went off on a tangent in my last posting, I neglected to come right out and answer the question of whether surveyors are always correct. The answer to which is, of course, a great big fat NO.

Let’s back up and trace what happens: A surveyor will see something at an organization that he or she really likes, for whatever reason. Maybe it’s something different, nifty, or simple. The surveyor asks for a copy of the policy, form, etc., and then–flash, bam, alakazam–that form becomes the “standard” for that particular surveyor.

Just now, as I was penning this missive, I received an e-mail from a survey coordinator feeling the hot, fetid breath of a surveyor on his neck. The issue? The organization couldn’t document performance and safety testing of medical equipment between patient uses. Crikey–that’s some standard!

Just step back for a moment and consider EC.6.20, element of performance #2, which states that the “hospital documents performance and safety testing of all equipment identified in the equipment management program before initial use.”

It appears the surveyor in question has extrapolated “before initial use” to equate with “before initial use on each patient.” Can you imagine how big your clinical engineering staff would have to be to meet this mandate? How could you possible capture every single piece of equipment in the program, like infusion pumps and blood pressure devices? Can you imagine the chaos? In a flash, why you’d probably need to have as many clinical engineering techs as nurses. Ouch!

You need to have a very clear sense of what makes the mark and what doesn’t. There are surveyors who are fond of the devil’s advocate question, just to see how comfortable you are with your process. If they cite something out in the environment that is clearly not compliant, you can certainly take your lumps.

But if surveyors start chasing you about “how” you are doing things, then keep all your options open, such as:

  • Special resolution time with that particular surveyor or with the team leader
  • Red-flagging the citation for review at Joint Commission headquarters
  • Making full use of the clarification process post-survey

Don’t make the error in thinking that because you are not perfect, you are thus not in compliance with a standard. A lot of the elements of performance are rate-based, but surveyors only need to find three instances of noncompliance with any “C” element to issue a requirement for improvement. For “C” elements, if your compliance level is greater than 90%, then you are considered compliant; you don’t have to be perfect.

I can tell you from personal experience, there are few things more frustrating than trying to “fix” something that is not truly broken. You’ve got more than enough to do–don’t go looking for more work (last clich

Are the surveyors always correct?

In looking over various survey results from the past six months or so, I keep running into instances in which the surveyors either:

  • Over-interpreted a standard, usually in the form of requiring a process that is not specifically called for in the standard or,
  • On at least one occasion, the surveyor “ignored” (I use quotation fingers for this as I wouldn’t want to unjustly accuse anyone of ignorance) instructions given to them by The Joint Commission

A close review of the standards reveals a fairly limited number of prescriptive standards–including annual program evaluations, the frequencies for the various life safety equipment inspections, hazard surveillance rounds, and so on.

The rest of the elements o performance involve such matters as:

  • “The hospital ensures that a process exists . . .”
  • “The hospital controls access to and egress from . . .”
  • The all-purpose “The hospital identifies and implements ________ procedures”

Thus, it’s up to you, as the person designated by leadership to oversee safety, to decide what “ensures,” “controls,” and “identifies and implements” mean for your organization.

I have a number of sayings that, if truth be told, are probably as much clich

Welcome to the jungle…

I had planned on jumping right in on a favorite subject of mine (the infallibility of Joint Commission surveyors), but upon reflection it seemed a bit precipitous to leap without some words of introduction and maybe a quick look at the ol’ crystal consulting ball before we roll on the serious subjects.

That said, the first order of business ought to be the tenor this new forum is likely to take. While the subjects we will discuss are nothing but serious, please don’t mistake my lightness of tone for a lack of respect or a lack of understanding of how these things impact your every day lives.

I worked at an acute-care hospital in southeastern Massachusetts for some 23 years–starting out in environmental services and finishing my tenure as that organization’s safety officer. Since becoming a consultant six years ago, I’ve completed a number of interim staffing assignments at hospitals throughout the Northeast, in addition to the “regular” consultant-type assignments.

I know exactly the nature and intensity of the pains generated by day-to-day hospital safety operations (sometimes too exactly, but we’ll talk more about that on a slow news day).

I’m sure that over time this forum will evolve to one degree or another–hopefully with much participation from all of you. That said (and yes, I am absolutely aware that I use “that said” a lot, probably more than is necessary), if there’s something you guys would like to see covered in more depth, less depth, Johnny Deppth (alright, a cheap joke, but I couldn’t resist), then write to me. No topic is too obscure or too common to fall out of consideration.

So, bottom line–serious topics, somewhat irreverent responses and opinions, and rock-solid advice. This blog is your blog, this blog is my blog. Let’s make everything we can from it.

Trash containers in soiled utility rooms

There was a posting on Safety Talk recently about whether any regulations exist governing the size of trash containers in soiled utility rooms. In this particular case, the room had no trash chute, was one-hour-rated, and had sprinklers.

There are requirements in the Life Safety Code for this type of arrangement, based on, which sets size limits for soiled linen and trash containers.

However, also notes that facilities are exempt from these limits if containers are in hazardous areas protected by a one-hour fire barriers or sprinklers (see

So, in the Safety Talk poster’s situation, it appears that particular facility met the protection criteria for such a space.

On an unrelated note, please enjoy a most freewheeling 4th!

Beyond cell phones

I still hear a lot of discussion about whether to limit cell phone use within hospitals, but sometimes I think that cell phones are the least of our worries.

I still find that organizations haven’t really come to grips with the other communications technologies that are much more likely to result in electromagnetic interference–primarily two-way radios used by security officers, maintenance crews, etc.

Also, emergency response plans for communications system disruptions usually include provisions for a mix of cell phones and two-way radios as backups.

Now I’m not saying that’s a bad thing in and of itself, but you have to provide guidelines when staff members use these communication devices. Make sure all related policies and procedures are consistent in their application of any prohibitions, too.

New isolation guidelines are out

Don’t know if anyone else heard this yet, but maybe it’s of interest–the CDC released its updated isolation precautions guidelines, which you can view here:

One more thing about ratings of patient bedroom doors

Regarding my post yesterday about rated doors, perhaps a little clarification is in order. My note was aimed at exiting healthcare occupancies under Chapter 19 of the Life Safety Code.

In looking through the code for other occupancies for which this door requirement might be applicable in sleeping areas (e.g., dormitory/hotel, residential board and care), I could find no other mention.

Thanks to those who asked me about this.

Rating of patient bedroom doors

A colleague recently asked me whether patient bedroom doors should be 20-minute-rated-and the answer is yes, they should. But there are some qualifications on that answer, depending on sprinkler protection.

Under paragraph, the 2000 Life Safety Code requires doors protecting corridor openings to resist the passage of smoke and be constructed of the following:

  • 1 3/4-in. thick, solid-bonded core wood
  • Material that resists fire for at least 20 minutes

There are two exceptions to, though:

  • Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that don’t contain flammable or combustible materials don’t need to meet’s provisions
  • In smoke compartments protected by sprinklers, the door construction requirements of aren’t mandatory, but the doors must resist the passage of smoke