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And in the spirit of giving…

I couldn’t find any indication that I’d covered this before (mea culpa, mea maxima culpa), so it’s probably past time—but it’s a pretty quick one. One thing to put on the pre-survey to-do list is to inspect the environments in which your emergency generator (or generators, if you are fortunate to have multiples) are located and check to see if you have battery-powered emergency lights in those locations. Now, you can correctly indicate that there is no TJC requirement to have battery-powered emergency lights in emergency generator locations—and you’ll get no disagreement from me. However, as an Authority Having Jurisdiction, The Joint Commission can indeed cite you for not having them, based on the introduction of this requirement (I will use the 2010 edition of NFPA 110 for the source on this; other editions of 110 include this requirement, but for this discussion, we’ll say NFPA 110-2010: 7.3.1).

Also, you probably want to be sure that you have battery-powered emergency lighting in any other spots that might benefit from some illumination if your generator fails and you need to do some work (I’m thinking transfer switch locations would be good). At any rate, I think it makes perfect sense (even if it weren’t required somewhere) to have provisions in place for providing illumination to certain areas if your generator poops out. (I’m almost certainly over-simplifying this, but I think the key piece of this is to look and see what you have and make sure that you can effectively deal with an equipment failure that results in very little in the way of illumination).

You know, I really find you quite attractive (human vs. technological magnetism)

Sometimes, particularly around the solstice, I struggle to come up with something (relatively) fresh upon which to pontificate—something that goes a little beyond the typical closing out of the safety year. Fortunately (at least for me; hopefully for you, the readers, as well), there have been enough funky things coming out of Joint Commission surveys this year to provide plenty of material. And today’s topic is the result of what appears to be an uptick in findings relating to MRI safety.

Now, the unfortunate aspect of all this is when the human and technological elements meet in combat, it would seem that it is the TJC surveyors that “win,” which is a very much less than desirable outcome.

At any rate, there’s certainly been a lot of information regarding safety in the MRI environment, first (and probably foremost) being the guidance provided by the American College of Radiologists (ACR). You can find lots of very good information on the topic on the ACR’s MR Safety page. And then, of course, our friends from Chicago felt this was important enough to warrant a Sentinel Event Alert (back in 2008…imagine that!).

Then, effective July 2015, we have the addition of two Elements of Performance (EC.02.01.01, EPs 14 and 16) dealing with some rather specific elements of MRI safety, particularly processes to ensure that folks who access the MRI restricted areas are educated/trained in MRI safety or screened by the folks controlling access to the restricted areas. I think we can reasonably point out that any time TJC adds EPs that indicate specific risks, etc., they are not convinced that hospitals well and truly have their collective acts together. And I guess, to a certain degree, they may have a point, but I think it may be more a question of managing behaviors than anything else (which I’m sure comes as a surprise to everyone in the studio audience).

Based on some TJC reports, the common theme that I’ve noted in recent survey seems to revolve around the management of surveyors when they trace patients into the MRI (and with the pervasive use of MRI in diagnostic medicine, I think I can safely say that if you have an MRI in your “house”, then there will be a patient tracer in to that environment), particularly as a function of screening the surveyors before they enter restricted areas. Now, part of me would like to craft a policy that requires a full screening (and yes, I am talking about a “full” full screening…hah!) of any and all regulatory surveyors—that might get them to shy away from being so obstreperous with these types of findings! That said, I think there is something to say about screening policies/protocols—make sure your MRI staff understand whatever screening process you’ve implemented, and (perhaps more importantly) prepare them for interactions with surveyors as a function of the screening process. Too many findings have come at the hands of surveyors that cited organizations for not having access that is “well controlled” or “adequately secured” based on MRI staff not putting the surveyors through the full screening process.

All that said, I would strongly encourage you to look at the process (and the policy, if you should happen to have a MRI screening/access control policy) for controlling access to the MRI restricted areas, including the mechanism for screening individuals (keeping in mind that “screening” can take different forms). EP 16, among other things, requires hospitals to restrict the access of everyone not trained in MRI safety or screened by staff trained in MRI safety from the scanner room (Zone IV, for those of you keeping score) and the area that immediately precedes the entrance to the MRI scanner room (typically Zone III). Now, you would think (and upon that thought, perhaps make an assumption) that The Joint Commission would provide some level of MRI safety training to their surveyors. That being the case, one could then have a process that does not require screening of the surveyors, based on their training in MRI safety. I think that MRI staff would need to specifically ask the surveyor if he or she had received MRI training before allowing the surveyor to proceed (and I guess the question for you folks in the audience would be whether you think the MRI staff would be comfortable asking the surveyor the question—it might be worth practicing). Even if the surveyor is in the company of folks from your organization that the MRI staff would “know” have been trained in this regard, is that enough to consider the risk as being appropriately managed—that sounds an awful lot like a risk assessment, if you ask me (yes, I know you didn’t, but you know I can’t resist invoking the mighty assessment).

So, it’s probably worth a concerted look during your end-of the-year surveillance activities (unless, of course, you’ve already done your second visit to the MRI this year, but may be worth a revisit); the sentinel event data published most recently by TJC (http://www.jointcommission.org/assets/1/18/2004-2015_3Q_SE_Stats-Summary.pdf) provides no hard evidence (or at least hard, discernible evidence) that hospitals are not appropriately managing the risks associated with the MRI environment, but I think we could probably consider any sentinel event involving the magnet as something to be avoided (much like findings relating to MRI safety). If you have a solid process, then great. But if not, might be a good opportunity to harden that particular survey target.

A most excellent start…

Recently, the AORN Journal published an editorial penned by Kelly Putnam, the managing editor, highlighting the role nurses play in preventing surgical fires (see here for detail). The piece raises a lot of interesting points about some of the operational considerations that come into play when it comes to appropriately managing fire risks in the surgical environment. But what really caught my eye—and my imagination—was the conclusion, which goes a little something like this: “Perioperative nurses are integral to a team approach to fire safety. Nurses are responsible for performing preoperative risk assessments and informing other team members of the risks associated with each procedure, identifying potential fire hazards, helping to find system fixes that improve patient safety, and conveying the details of fire-related incidents to other stakeholders at the institution.”

Now those of you who’ve been following this space for a while will no doubt note the presence of one of my favorite (okay, pretty much #1 on the hit list) phrases: risk assessment. And not only does the risk assessment get a shout out, it’s within the framework of a team approach to managing fire safety in surgery. As I pondered this, I was thinking, wouldn’t it be cool if we could use this as a jumping off point for nursing involvement in a team approach to risk assessment that focuses on the management of the whole darn care environment? I’ve been yammering at just about every opportunity my “sense” that one of the desired end products of the current focus on the care environment by regulatory surveyors is the demolition of the “barrier” that exists (in smaller doses than formerly, to be sure, but not entirely gone) between the “clinical” and “non-clinical” functions of any healthcare organization. It is my firm belief that the organizations that will most effectively manage the survey process are those organizations that have developed a true collaboration of staff across the care continuum. In a very real sense, everyone in your organization is taking care of patients—directly or indirectly, everyone influences the “patient experience.” And at the end of the day (and yes, I recognize that the Urban Dictionary refers to that little turn of phrase as a “rubbish phrase used by many annoying people…”): CARING FOR THE PATIENT IS CARING FOR THE ENVIRONMENT!

Start printing up the t-shirts and bumper stickers…

Now be thankful…

While the events of recent weeks seem to focus our attentions on the darker side of humanity, before jumping into this week’s “serious” topic, I did want to take a moment to wish you all a most joyous Thanksgiving. Your continued presence in this community is one of the things for which I am thankful, so I will, in turn, thank each one of you for that presence—without you, there wouldn’t be much purpose to this little rant-o-rama! And a special thanks to Jay Kumar from HCPro, who manages to keep things going!

And so, onto the business at hand. In the aftermath of the Paris terror attacks, the folks at the Department of Homeland Security are encouraging hospitals and other healthcare organizations to review our security plans and to work towards exercising them on a regular basis (you can read the full notice here). The notice contains a whole bunch of useful information, including indicators to assist in identifying suspicious behaviors and to build a truly robust process for reporting suspicious activity. It’s always tough to say how much of an event could have been prevented if folks were more skilled in identifying threats before they are acted upon, but I guess we always have to use such events as a means of improving our own situations. At any rate, I think it would behoove everyone in the audience to take a look at the materials referenced in the notice. A lot of times, I think we find ourselves “casting about” for direction when it comes to the practical application of how we become better prepared, particularly in the healthcare world of competing priorities. I also know that it is sometimes challenging to get folks to seriously participate in exercises—I don’t know that we’ll ever completely get away from having to deal with what I will characterize as moderate indifference. The events in Paris (and Mali) only point out that this is a risk shared by everyone on the planet, whether we would want it or not. And the more we educate folks to recognize threatening situations, the better able they will be to keep themselves safe. I wish there were a simple solution to all this, but in the meantime, the strategy of increased vigilance will have to do.

May I? Not bloody likely! The secret world of ‘NO EXIT’ signs

There’s been something of a “run” on a particular set of findings and since this particular finding “lives” in LS.02.01.20 (the hospital maintains the integrity of egress), one of the most frequently cited standards so far in 2015 (okay, actually egress findings have been among the most frequently cited standards pretty much since they’ve bene keeping track of such things), it seems like it might not be a bad idea to spend a little time discussing why this might be the case. And of course, I am speaking to that most esoteric of citations, the “NO EXIT” deficiency.

For my money (not that I have a lot to work with), a lot of the “confusion” in this particular realm is due to The Joint Commission adopting some standards language that, while perhaps providing something a little bit more flexible (and I will go no further than saying perhaps on this one, because I really don’t think the TJC language helps clarify anything), in doing so, creates something of a box when it comes to egress (small pun intended). The language used by NFPA (Life Safety Code® 2000 edition 7.10.8.1) reads “any door, passage, or stairway that is neither an exit nor a way of exit access and that is arranged so that it is likely [my italics] to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.” To be honest, I kind of like the “likely” here—more on that in a moment.

Now our friends in Chicago take a somewhat different position on this: Signs reading ‘NO EXIT’ are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may (my italics, yet again) be mistaken for an exit. (For full text and any exceptions, refer to NFPA 101 – 2000: 7.10.8.1.) If you ask me, there’s a fair distance between something that “may” be mistaken for something else, like an exit and something that is likely to be mistaken for something else, like that very same exit. The way this appears to be manifesting itself is those pesky exterior doors that lead out into courtyard/patio areas that are not, strictly speaking, part of an egress route. Of especially compelling scrutiny are what I will generally describe as “storefront doors”—pretty much a full pane of glass that allows you to see the outside world and I will tell you (from personal experience) that these are really tough findings to clarify post-survey. Very tough, indeed.

So it would behoove you to take a gander around your exterior doors to see if any of those doors are neither an exit nor an access to an exit and MAY be mistaken for an exit. For some of you this may be a LIKELY condition, so you may want to invest in some NO EXIT signs. And please make sure they say just that; on this, the LSC is very specific in terms of the wording, as well as the stroke of the letters: “Such sign shall have the word NO in letters 2 inch (5 cm) high with a stroke width of 3/8 inch (1 cm) and the word EXIT in letters 1 inch (2.5 cm) high, with the word EXIT below the word NO.” This way you won’t be as likely to be cited for this condition as you may have before…

Come together, right now over…more heavy breathing

Talk about your regulatory supergroups: it’s almost like the second coming of Crosby, Stills, Nash, Young and all manner of goodness or maybe the Fantastic Four (or in this case, the Spectacular Six)! Back on September 21, the modern healthcare environment equivalent of the Justice League (AAMI, ASHE, AORN, ASHRAE, APIC, and FGI) published a Joint Interim Guidance (JIG) on HVAC in the Operating Room and Sterile Processing Department. The intent of this JIG (sometimes acronyms can be fun) is to address what the Spectacular Six deem “the biggest challenge for owners and designers of health care facilities,” which is “to understand the purpose and scope of the various requirements” of the “conflicting and sometimes unclear” standards and guidelines for the management of heating, ventilation, and air-conditioning (HVAC) so “patient and staff safety and comfort can be managed.” You can check out the JIG document here.

Without spoiling too much of your interest in discovering all the particulars, the JIG speaks to the dichotomy inherent between the minimum design requirements and criteria that are used to construct an HVAC system (the FGI/ASHRAE/ASHE side of the equation) and the guidelines that “are intended to guide the daily operation of the HVAC system and clinical practice once the health care facility is occupied (this is where AAMI/AORN/APIC come in). As any number of you have experienced in real (and sometimes really painful) time, this dichotomy is very much at the heart of the regulatory survey process at the moment (somehow in my heart of hearts I knew that we could be continuing this conversation). But mayhap there is a light at the end of the tunnel (that is not an oncoming train!): the Spectacular Six have begun working towards a harmonization of the HVAC guidance in the various standards. They’ve been working on this since late April and the JIG is, for all intents and purposes, their first work product. I think it’s an excellent start and I hope that their work is allowed to continue with minimal interference from outsider influences (who that could be, I have no idea…).

An important part of the JIG is their advice to healthcare organizations (it’s on p. 2 of the document—I’ll let you reflect on it in your spare time) and those of you who’ve been following this space for a while will guess that my fave-o-rite topic is going to feature quite prominently in this movement: our old friend, the risk assessment! (Admit it, you knew it was going to go that route!) The goal of the assessment is to make a determination of HVAC operating parameters for critical areas that meet patient, personnel, and product storage needs, with an eye towards the identification of appropriate corrective measures to mitigate risk, etc. I think we’ve been honking this horn a bit as we’ve traversed this landscape, but I think the critical opportunity/challenge is going to be based on the Spectacular Six’s intent to communicate/advocate directly with the regulatory folks in this regard. I haven’t yet seen anything official from CMS in this regard, but based on its adoption of the tenets of the Joint Quality Advisory from January of this year (again, a number of web locales for info, including this one), I think we can reasonably anticipate some level of guidance to the surveyor corps in the not-too-distant future.

So perhaps we can work through this in relatively straightforward fashion; at the end of the day, our charge is to ensure that we are providing the safest possible environment for patients, staff, and visitors. But in meeting that charge, we also need to make sure that we are not writing checks that our building systems can’t cash. We should be able to identify appropriate, safe performance parameters that appropriately address all the risk factors and identify a response plan that we can effectively implement when we have conditions that increase the risk to unacceptable levels. If you ask me, that sounds like business as usual…

You better run for your life?

Every once in a while I like to dip into the ol’ mail bag when I get a question that I either haven’t answered before or conditions/practices have changed enough to update an initial response. In this particular instance, we’re covering some territory that I’m pretty sure we’ve not aired previously (as near as I can tell…).

Q: I would like to get your take on patient elopement (or simply leaving without signing, or refusing to sign AMA forms), and the longstanding practice of having security staff, maintenance staff, etc., pursue these patients. These types of things make corporate legal departments cringe, and it leaves Plant Operations directors caught in the middle of “should we respond or not” debates. 

A: Thanks for your question. I really think that your description of the reaction of legal departments to the “pursuit” of eloped/eloping patients is pretty much on the money and that’s why (in my mind), they are the ones that need to be the determining factor when establishing a response protocol for elopement. I have certainly worked with organizations for whom a “simple pursuit” protocol has ended very badly with patients injured, and in a couple of instances, worse (I’ll refrain from the details) during response to an elopement. Someone who is eloping tends to want to elude (or otherwise outrun) their pursuers and sometimes they’re not paying attention to where they are going (I liken it to chasing a toddler—the “state of mind” of some of your elopers is not so very far from a toddler—they spend a lot of time looking over their shoulder and not looking where they are going). At the hospital at which I used to work, the legal folks said if the patient eloping leaves the property, then you let them go and call the local authorities (recognizing that their response is going to be dependent on what’s going on in the community) and work (which you can certainly interpret to mean “hope) towards a good outcome. Unless someone is really mentally incapacitated, you can usually figure out where they are going, so that becomes information that can be shared with law enforcement.

All that said, it is of critical importance to have a specific response plan (you can leave a little leeway for specific cases, but you really need to have a consistent overall approach) that has been developed in collaboration with clinical (including physicians), legal, and support leadership. Everyone has to be on the same page if we are not going to be putting anyone (and that includes the folks responding) at risk.

I know this is something that faces healthcare organizations all across the country including, I suspect, some of the folks out there in the audience. So I put the question to you: How are you managing response for eloped patients? Is it a “let them go and call the cops” response protocol or more of a “bring ’em back” response? I suspect that we could have some interesting dialogue on this one, so please weigh in as you can.

I’m getting too old for this shift…

Because of the nature of the survey process as currently administered by our good friends in Chicago, I periodically have the opportunity to work with clients after they have been surveyed, sometimes developing cogent and not-too-ambitious corrective action plans, and sometimes working with them to try and clarify findings that were based on the surveyor(s) identifying the one or two imperfections in what was otherwise a pretty solid process. Generally speaking, these are “C” elements of performance, based in the concept that to demonstrate substantial compliance with the standard/EP in question, you would provide data to support an historical compliance rate of 90% or better. The classic example of a finding that one would always try to clarify is if the surveyor turns up a fire extinguisher (or two) with some missing monthly inspections (depending on how you inspect your fire extinguishers, there is always the possibility for something to get overlooked, etc.—again, an imperfection in the process). Classically, since each fire extinguisher has 12 monthly inspections per year, you could “miss” one of those 12 inspections and still have a compliance rate greater than 90%–in this instance, 91.66666666666667%, which I’m as positive as I can be is a numerical value in excess of the desired 90% level. So, unless you had a completely broken process for doing the monthly fire extinguisher inspections, even if they found a couple of missing months during survey, the overall picture would be workable through clarification. To take the example just a bit further, say you had 100 fire extinguishers in your inventory, which represents 1,200 potential data points over the course of a year, and the finding was that a fire extinguisher in each of two mechanical spaces was missing the two most recent inspections because the person who usually inspected them was out on leave. That would be four findings of non-compliance identified during survey, but if you compare those four instances of non-compliance to the 1,196 findings of compliance, you would have a compliance rate of about 99.6%, another numerical value that exceeds the 90% mark.

I think that’s pretty straightforward as a going concern, or at least it was until recently. (By the way, I have successfully used the above-noted strategy for clarifying fire extinguisher findings any number of times in the past. Really, this would be as close to a sure thing as anything I can think of.) In working with a client on a fire extinguisher clarification, the correspondence coming back from Chicago indicated that the clarification was not accepted because “100% of life safety devices are required to be inspected at the defined monthly frequency.” Without mentioning any names, I can say that this adjudication was issued by someone in the Engineering office with whom I am not familiar, so it may be that what we have here is an isolated strict, strict, strict interpretation (my choice is to remain hopeful until proven otherwise), but if this type of interpretation is to be applied to “C” Elements of Performance, then what indeed is the rationale for having the “C” Elements of Performance? I hear a lot of information regarding regulators trying to “work with” hospitals, but if the benchmark for maintaining everything under EC.02.03.05 is going to be perfection (and, presumably that requirement could be extended to elements in clinical engineering and utility systems management, both of which nominally fall under the aegis of NFPA 99, compliance with which is required by the Life Safety Code®), how are these most frequently cited standards going to subside in frequency? I understand that everyone involved (regulator and regulated) has a responsibility to ensure that patients, staff, and visitors are provided as safe and comfortable environment as possible, but if every swing of the bat has to be a home run, every pass downfield a touchdown (I could go on, but I will desist), the odds are very squarely stacked against the folks in the field who have to make this happen. And I, personally, do not think that that is a very good thing at all.

I suspect that I’ll have more to say about this through the coming weeks. Again, I will remain hopeful, but if this is the future, we’re in for a very bumpy ride!

One score and no years ago: Guess who’s 20?

John Palmer, who edits Briefings on Hospital Safety, among other nifty periodicals, asked me to weigh in on the 20th anniversary of the EC chapter, with a particular emphasis on how (or where) things are now in comparison to the (oh so very dark) pre-EC days. And he did this in full recognition of my tendency to respond at length (imagine that!). At any rate, I decided that these thoughts would be good to share with all y’all (I can’t absolutely swear to all the dates; I think I’m pretty close on all of them, but if there are temporal errors, I take full responsibility…)

Prior to the “creation” of the Environment of Care as a chapter (you can trace the term Environment of Care back to 1989), The Joint Commission had a chapter in the accreditation manual known as Plant Technology and Safety Management (PTSM). The PTSM standards, while significantly more minimalistic than the present-day requirements, did cover the safety waterfront, as it were, but with the advent of Joint Commission’s Shared Visions/New Pathways marketing (you may assume that I am using “marketing” as the descriptor with a little bit of tongue in cheek) of their accreditation services, I guess the term I would use most is a modernization of the various standards chapters began, including the “birth” of the EC chapter in 1995. With that, things became a little more stratified, particularly with the “reveal” of the seven EC functions (safety, security, hazmat, emergency, life/fire, medical equipment, utility systems). This raised the profile of the physical environment a bit, but a true concerted focus on the EC really didn’t occur until 2007, when the Life Safety surveyor program was introduced, primarily in response to data gleaned by CMS from validation surveys. The Joint Commission survey process, prior to 2007, really didn’t have a reliable means of capturing life safety and related deficiencies. Since then, the survey focus on the physical environment has continued to grow, much to the point that now it very much eclipses the clinical component of the survey process, at least in terms of the number and types of findings.

Are things “better”? I suppose one could make the case that things have improved incrementally over time, but it’s tough to say how much direct influence the EC chapter has had on things (and the subsequent “peeling off” of the Life Safety and Emergency Management chapters). Clearly, the healthcare environment is significantly different than 20 years ago, both in terms of the inherent risks and the resources available to manage those risks. (Increased technology is pretty much a good thing, but reductions in spending, probably not so much. I’m sure you can come up with a pretty good list of pros and cons without too much difficulty.) You could also make the case (purely based on the number of findings…and I think TJC has a dog in that fight) that if hospitals are safer, it’s because of the level of scrutiny. I tend to think that the “true” answer resides on the development of the healthcare safety professional as a vocational endeavor, with the added thought that unsafe places tend not to stay in business for very long these days. So perhaps somewhere in the middle…

Better? Worse? Different…definitely! I will say that I firmly believe that the amount of survey jeopardy being generated at the moment leans towards the hyperbolic; there are certainly organizations that need to get their acts together a little more fully than they do at present. But not every organization that ends up in the manure is completely deserving of that status. I recognize that TJC has to be super-diligent in demonstrating their value to the accreditation process. But being accredited can’t become the be-all, end-all of the process. The responsibility of each healthcare organization (and, by extension, each caregiver) is to take care of patients in the safest possible manner and being attentive to the survey process can’t come at the expense of that responsibility. Sometimes, I fear, it does just that. I could probably say something pithy about job security, but…

If being accredited by you is wrong, I don’t want to be right…

I’ve recently encountered some survey results that gave me pause and I wanted to take a moment to share some thoughts on the perceived infallibility of regulatory surveys (and consultants), some of whom are pretty much unassailable (the most dangerous of situations for an organization—if you read this as the organization represented by the moniker Charlie Mike Sierra, you’d not be far off the mark), others somewhat less so, but you need to be very careful when taking on any of the three-letter accrediting agencies. While they may be in error in citing something, it is of critical importance that you are sufficiently conversant with what compliance looks like to make your case.

I’m going to start with a somewhat non-EC related finding, but it serves as a pretty good example of how a survey finding can go awry. A recent survey (the surveyor in question had been a perioperative clinical director prior to becoming a surveyor) cited an organization for inappropriate storage of a medication in a secure dispensing system (you know, those big honking boxes that create such a lovely heat load in your medication rooms). The citation was very clear, very nicely framed, etc., but it was based on information that was out of date relative to the medication cited (at issue was the stability/expiration of the product when it was stored at room temperature). It seems that in the past, this particular product was only viable for 14 days once it was removed from refrigeration, so that became the nature of the finding. However, the organization knew (and was able to present documentation from the manufacturer) that the stability of the product was good for up to 91 days after being removed from refrigeration. Now, we’ve spoken a fair amount lately of the importance of manufacturers’ Instructions For Use (IFU) when it comes to appropriately managing storage and using equipment and such, so this would be the point where you would invoke the clarification process to have the finding removed from your survey report. That said, the point I really wanted to focus on was that the surveyor presented what appeared to be an unassailable (and thus, infallible) finding, but (at least in this case) that infallibility was very clearly in the past. Who knew infallibility was transient?

Another area where surveyors can raise a ruckus is in the behavioral health environment, particularly when you are dealing with a surveyor who is not a specialist in behavioral health. The tipping point is that behavioral health professionals recognize that is pretty much impossible to provide a completely risk-free physical environment for behavioral health patients (and I’m talking just about the way the facility is built, etc.) so the key to appropriately managing those risks is working towards minimizing the risks to the extent possible and then identifying the mitigation strategies (and this typically is where staff oversight and monitoring comes in). But then you have surveyors who see ligature points everywhere they look in the behavioral health environment and they start “dinging” you for all those “risks.” Strictly speaking, the only way that you can defend yourself is by making sure that you have a comprehensive risk assessment of the behavioral health environment, based on your state guidelines or on a resource such as the Design Guidelines for the Built Behavioral Health Environment (now available from our friends at the Facilities Guidelines Institute), in your back pocket. But (and this is perhaps the most important piece of this) you also need to periodically revisit the assessment. I don’t know about your experiences, but mine have shown that the behavioral health patient population is not anything close to being static—the types of patients seen, the acuity and diagnoses—and, by extension, the risks will change over time. My consultative recommendation would be to include specific mention of the behavioral health environment when you do your annual evaluation of the safety management program at your organization (I’m a big fan of using the annual evaluation process to affirm/reaffirm the validity of your risk assessment processes). I know things can get a little crazy when it comes to this stuff, but there’s also be a spate of survey findings relating to risk assessments not completed for a specific concept (for example, where your organization chooses to have emergency medical response equipment and procedures beyond calling 911—talking about off-site clinics, etc.) or not updating the risk assessment in response to a regulatory survey finding.

(I have a hard time getting my head around this one: A “competing” regulator comes in, cites you for a condition, you engage in a corrective action plan with that regulator and then, about six months later, you get cited for not having updated the risk assessment to reflect the findings from the earlier survey. It just seems like a bit of “piling on” to me.)

At any rate, every time you do hazard surveillance rounds, you are (hopefully) collecting compliance data. Make sure you use that data to perform an analysis of “the state of the environment” and make the determination of whether risk is being managed appropriately/effectively. As I tell folks about once a week (and sometimes more), regulatory surveyors will always reserve the right to disagree with anything they (or anyone else) have told you, or, indeed, any decision that you have made relative to the management of risk (I guess this blooms out of the whole infallibility thing). And while you don’t necessarily want to get into a urination competition with a surveyor at the time of survey, as long as you “know” and can demonstrate that you are appropriately managing the risk and have a process for periodic evaluation of the risk management process, then you are in a position to use the post-survey clarification process. Surveyors can be incorrect (or, as a kinder, gentler descriptor) or mistaken about how a condition they encounter in your organization is in compliance with the standards, but you have to be quite clear within yourself how what you are doing is in compliance. It’s the only way to push back. Surveyors can be exquisitely convincing in the moment—and make you doubt what you’re doing—but you know what works best in your organization. You have intimate knowledge of the organization’s culture, how processes work (or not), etc. They’ve only just met you and while they have a job to do, you also have a job that you’ve been doing. That, in my mind, gives you a bit of a leg up on the outsiders…but that may just be me!