RSSAll Entries Tagged With: "CMS"

A clear case of compliance interruptus

Greetings one and all from high above the 2012 Life Safety Code® (LSC) compliance track with a quick update on CMS plans for administering surveys, etc., in the wake of official adoption of the 2012 LSC. I’m climbing out on a limb just a little bit as the latest missive in this regard from The Joint Commission indicates that it will begin surveying to the requirements of the 2012 LSC on July 5 (Happy freakin’ Independence Day), but it appears that CMS has other ideas. In a member alert disseminated late last week, our friends at the American Society for Healthcare Engineering (ASHE) are reporting that a memorandum was issued by CMS to the various and sundry accreditation agencies (TJC, DNV, HFAP, M-O-U-S-E) indicating that hospitals have until November 7, 2016 before this new shiny hammer is wielded during accreditation surveys. Now, I think it was likely that there would be some sort of transition period for this process (the accreditors would have to update their standards manuals, etc., and I don’t think that happens overnight, but maybe there are manual elves that come in under cover of darkness), so I guess that has come to pass and the end date for that transition is November 7 (I guess they didn’t want to wait until the following month’s day of infamy).

As I’ve noted in this space recently, a lot of the basic tenets of compliance are going to pretty much stay the course. We will continue to manage rated barriers (walls, decks, doors); we will continue to manage egress (perhaps a little more simply, but clutter will still be clutter) and so on. There may be some efficiencies to be gained in the practical application of the various fire alarm and fire suppression system inspection, testing, and maintenance processes (I’ll have to do some edumacation on those), but I really think that the devil in all these details is going to come from how the requirements of NFPA 99 Standard for Health Care Facilities are administered and/or otherwise enforced. NFPA 99 has always kind of hovered in the background, but I think is going to be very much a coming out party. At any rate, ASHE has made available a fair number of resources (some readily accessible, some for members) and I would encourage you to do a little digging if you have not already done so. I still think the physical environment is going to figure quite strongly in the survey process, but maybe this is where we get to share the most frequently cited standards lists with the clinical folks.

On a closing, and most somber note, in the wake of events in Orlando this weekend (thoughts and prayers to all the victims, their families, the community at large, and pretty much everybody else), I can’t help but think that there’s got to be a better way. I know the circumstances that can lead up to events like these are extraordinarily polarizing—and I’ve noted that the polarization didn’t waste any time manifesting itself in the halls of social media. I wish that I had some sage bit of advice or encouragement, but nothing is coming right now beyond this old cliché (doesn’t make it any less useful or true)—cherish your loved ones…right now! We will all be better for it.

News flash: Vacuum cleaner sucks up budgie! Is you is or is you ain’t my baby?

As we continue our crawl (albeit an accelerated one) towards CMS adoption of the 2012 edition of NFPA 101 Life Safety Code® (LSC), we come face to face with what may very well be the final step (or in this case, leap) in the compliance walkway. While there is some language contained in the final rule (and in the press release) that I feel is a little contradictory (but after all, it is the feds), the summary section of the final rule does indeed indicate that “(f)urther, this final rule will adopt the 2012 edition of the Life Safety Code (LSC) and eliminate references in our regulations to all earlier editions of the Life Safety Code. It will also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions.” I suspect that there will be multiple machinations in the wake of this, but it does appear that (cue the white smoke) we have a new pope, er, Life Safety Code®! You can find all 130+ pages here.

Interestingly enough, the information release focuses on some of the previously issued categorical waivers seemingly aimed at increasing the “homeyness” (as opposed to homeliness) of healthcare facilities (primarily long-term care facilities) to aid in promoting a more healing environment. It also highlights a couple of elements that would seem to lean towards a continuation of the piecemeal approach used to get us to this point, so (and again, it’s the feds), it’s not quite framed as the earth-shattering announcement that it appears to be:

  • Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date. So, the clock is ticking for you folks in unsprinklered tall buildings
  • Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler system is out of service for more than 10 hours. So, a little more flexibility on the ILSM side of things, though that building evacuation element seems a little funky (not necessarily in a bad way).
  • For ambulatory surgery centers (ASC), all doors to hazardous areas must be self-closing or must close automatically. To be honest, I always considered the requirements of NFPA 101-2000:8.4.1.1 to be applicable regardless of occupancy classification, but hey, I guess it’s all in the eye of the beholder.
  • Also, for ASCs, you can have alcohol-based hand rub dispensers in the corridors. Woo hoo!

I guess it will be interesting to see what happens in the wake of this final rule. I guess this means we’ll have to find something else upon which to fret…

As a related aside, if you folks don’t currently subscribe to CMS News, you can sign up for e-mail updates by going to the CMS homepage and scrolling down to the bottom of the page. I will tell you that there’s a lot of stuff that is issued, pretty much on a daily basis, much of it not particularly germane to the safety community, but every once in a while…

It’s a new dawn, it’s a new day, it’s a new life for you. What do you plan on doing now?

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

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

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

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

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!

If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”

And then came the last days of May…

This year has brought a lot of CMS work this year, both in preparation for impending visits and in response to endured visits. There’s just nothing particularly pleasant about the process, but I guess there’s naught that can be done for it.

One of the interesting, and extra not-pleasant developments in this realm is the use of the Plan for Improvement (PFI) process during CMS surveys to bludgeon facilities professionals into pretty much abandoning any pretense of being able to plan/prioritize the resolution of existing Life Safety Code® (LSC) deficiencies. As I think we’ve discussed, one of the changes in the Joint Commission final report is that (if your surveyor remembers to accept them) it includes a listing of all your PFIs, which gives the CMS LSC surveyors a ready-made starting point for their report (CMS has really never bought in to the whole PFI process for managing LSC deficiencies, which is very unfortunate). Recently, I worked with a client who had to complete all their damper repairs that were being managed through the PFI process and I started thinking about a number of folks who are managing their inaccessible dampers, etc., through the PFI process and then I start thinking, “Wouldn’t that suck a ton of eggs if the PFI report becomes a roadmap for CMS to have their way with folks?”

I guess this is all part of having to deal with the various authorities having jurisdiction (AHJ) and while I suppose not every AHJ is going to be prickly about this stuff, I am reasonably certain that there are those would who be more than happy to give folks a good regulatory thumping. We are in a time of great uncertainty and chaos as we are held to standards that are increasingly best noted as antiquities. But until we can get can somehow suborn a more rapid cycle of code/standard adoption, I guess we’re just going to have to spend far too much time and energy on things other than taking care of our patients.

Opinions are like…

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectations (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during TJC surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

The bottom line message is, more or less, based on the adage “Future expectations are not necessarily indicative of past experiences.” You have to look at everything you are doing as a function of how your practices/conditions actually comply with the standards. Just as there are many ways to skin the proverbial catfish (skinning a catfish makes more sense to me in this modern era than skinning a feline), there are many ways to comply with what are typically rather open-ended compliance standards. As long as you can “trace” the practice or condition back to compliance with the standards/performance elements, then, even if you have a surveyor who disagrees with your approach to things, you can feel comfortable that you can “go to the mat” post-survey, using the clarification process to demonstrate how your organization achieves compliance relative to the finding. As a somewhat related aside, it is important to remember that you are only required to respond to what is actually written in the finding. Very often I run into folks who want to respond to more than what is actually in the report, usually because they remember what the surveyor “said” during the survey. Surveyors, like everyone, have opinions about how and what and where, etc., and they certainly have every right to hold those opinions (sometimes in higher regard than is warranted, but I digress). Opinions are rarely based on an absolute standards-based requirement. So, the tip-off comes in different forms: Maybe they say you “should” do something in a certain way or something similarly non-definitive. They typically stay away from things that you “must” or “have to” do. You “have to” comply with the standards and you “have to” comply with your organization’s policies and procedures, but beyond those points, you have to chart your course of compliance. You know best what will work to effectively ensure that you have an appropriately managed care environment (and, presumably, the performance data to back up that knowledge).

Hair Plugs? Heck, No! Shameless Plugs? That’s another story!

While I would never want to be accused of overusing my little bully pulpit, I did want to bend your ears a bit by way of encouraging you to really consider signing on for next week’s webinar, Surgical Environment Compliance: Meet CMS and Joint Commission Requirements. The program is on Friday, May 8 @ 1 p.m. EDT (you can register here). Plus (and this may really sweeten the pot), I’m not the only speaker, so you won’t have to listen to me yap for the whole program. Sounds like a win to me…

To catch up a bit, I haven’t yet given you a rundown on the most frequently standards during TJC surveys in 2014 as there were some other pretty compelling topics (at least in my mind)—mostly because the year-end tally looked so very much like the mid-term results I figured the sense of urgency might not be quite as acute as it could be. But an interesting thing is happening in 2015 and it keys very much on the top three most-cited standards: EC.02.06.01, EC.02.05.01, and IC.02.02.01, all of which figure in the management of environmental conditions in (you guessed it!) in surgery (and other procedural areas). By the way, as a quick aside, who would ever have guessed that the EC-related standard to go to #1 on the charts wouldn’t have been Integrity of Egress (LS.02.01.20), which sits at a lowly #4. It’s almost like a boy band past its sell-by date, but I digress.

TJC is still looking at the issues related to the surgical/procedural environment and, doggone it, they’re still finding stuff that’s getting folks into trouble (that is, if you think, as I do, that having to endure a second visit from the Joint is rather more troublesome than not). I won’t tell you that I have a magic bullet for this, but my colleague Jorge Sosa and I will be discussing how this issue fits into the grand scheme of things as well as hopefully helping identify the potential pitfalls. And, perhaps most useful of all, you’ll have the opportunity to ask questions that may be the difference between sailing through your next survey or getting hung up because one portal in your OR isn’t pressurized in the right direction (and believe me, it happens way more than you probably think). Lots of stuff to consider and the time and place to consider it.

Be there or be somewhere else that won’t be nearly as entertaining (unless you’re not at work…)

Join me on May 8 for the live webcast Surgical Environment Compliance!

My colleague Jorge Sosa and I wanted to take a moment of your time to remind you of our upcoming live webcast Surgical Environment Compliance: Meet CMS and Joint Commission Requirements to be held on Friday May 8 at 1 p.m. EDT. What a way to start the weekend! The 90-minute program will include a presentation of approximately 60 minutes with a 30-minute Q & A session to cover any questions you might have about the program content, or indeed anything else that strikes your fancy.

I really think you’ll find this program of great interest. The Joint Commission just unveiled the most frequently cited standards during 2014 surveys and the top three are all in the mix when it comes to managing conditions in the surgical environment (and beyond…we’ll cover that as well). We’ll be covering steps you can implement to avoid survey findings, as well as strategies for managing the process if you find yourself with some survey deficiencies.

At any rate, I’d like to invite you to join Jorge and me for a discussion of what is probably the most “dangerous” topic in the Environment of Care in maybe ever (this makes the management of Interim Life Safety Measures look like a walk in the park)!

Hope to “see” you on May 8. You can register for the program here.

An interesting security development: To arm or not to arm?

In a February 18 Joint Commission leadership blog post, Mark Crafton, TJC’s executive director of communications and external relations, focuses on the benefits of investigating different approaches for mitigating violence in hospitals. At least that’s where the conversation starts, but it ends up in kind of an interesting (and to my eyes, unexpected) direction: the question of whether hospital security officers are a more effective deterrent/mitigation strategy when they are armed. (N.B.: In Crafton’s post, he refers to security “guards”; call me whatever you like, but I think the term “guard” just doesn’t ring well with me. I’m okay with the terms “security staff” or “security officers,” but “guards” just gives me the vapors—metaphorically speaking, of course.)

In the course of the posting, Crafton points to an article in the Chattanooga Time Free Press that will likely generate some debate among healthcare security professionals, and I tend to agree with that thought. Apparently the article was the result of a healthcare system’s decision to disarm their security staff and adopt the “soft” uniform look (e.g., blazers, etc.) to more effectively emphasize the security officer’s role as a more customer-oriented (my description) countenance. Now we’ve touched on the subject of arming security officers in the past (it’s been a really long time) and it’s probably way past the time for looking at this topic, particularly as the good folks at CMS have some rather strong thoughts on the subject:

CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term  “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.

The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).

As you can well imagine, equipping security staff with weapons of almost any stripe can result in the classic slippery slope. My personal practice was to have a clear delineation between security staff and law enforcement responders. Security staff were provided ongoing crisis management education and worked closely with clinical staff to proactively manage at-risk situations. Law enforcement response was summoned when appropriate and the use of weapons was solely at the discretion of those responders. I know those lines can get pretty blurry in the heat of the moment, but specific roles are, I think, the best starting point for an effective security program.

At any rate, Crafton goes on to discuss the following: the cases for armed/not armed security staff; armed staff as authority figures vs. armed staff as a potential for raised anxiety of patients who are already distressed/stressed; and how do you make patients and staff safe, etc. There are, of course, good arguments on both sides, but ultimately (and this is one of the common threads when it comes to TJC standards and expectations), it is the responsibility of each organization to determine how best to manage, in this case, security risks. It doesn’t seem likely that peace, love, and understanding are going to be breaking out any time soon; the role of the security officer has never been more important.