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I don’t think you’re spending enough time in the restroom…

In preparation for our journey into the restrooms of your mind (sorry—organization), you might consider a couple of things. Practicing this during surveillance rounds is probably a good thing; increasing folks’ familiarity with the potential expectations of the process is a good thing. But in practicing, you can also consider identifying an organizational standard for responding to restroom call signals, that way you can build at least a little flexibility into the process, maybe enough to push back a little during survey if you can allow for some variability.

Another restroom-related finding has had to do with the restrooms in waiting areas in clinic settings (ostensible restrooms that can be used by either patients or non-patient who may be in the waiting area). There is a requirement for a nurse call to be installed in patient restrooms, but there is no requirement for a nurse call to be installed in a public restroom. So what are these restrooms in waiting areas? I would submit to you that, in general, restrooms in waiting areas ought to be considered public restrooms and thus not required to have nurse calls. Are there potential exceptions to this? Of course there are—and that’s where the risk assessment comes into play. Perhaps you have a clinic setting in which the patient population being served is sufficiently at risk to warrant some extra protections. Look at whether there were any instances of unattended patients getting into distress, etc. (attended versus unattended is a very interesting parameter for looking at this stuff). Also, look at what the patients are being seen for; maybe cardiac patients are at a sufficiently high enough risk point to warrant a little extra.

At the end of the process, you should have a very good sense of what you need to have from a risk perspective. That way if you have a surveyor who cites you for not having a nurse call in a waiting area restroom, you can point to the risk assessment process (and ongoing monitoring of occurrences, etc.) as evidence that you are appropriately managing the associated risks—even without the nurse call. In the absence of specifically indicated requirements, our responsibility is to appropriately manage the identified/applicable risks—and how we do that is an organizational decision. The risk assessment process allows us the means of making those decisions defensible.

More songs about risk assessments…

One of the more common questions that I receive during my travels is “When do you need to do a risk assessment?” I wish that there were a simple response to this, but (as I have learned ad nauseam) there are few things in this safety life that are as simple as I’d like them to be. But I can give you an example of something that you might be inclined to look at as a function of your risk assessment process: restrooms (oh boy oh boy oh boy)!

While I can’t honestly characterize this as a trend (I suspect that, at the moment, this is the provenance of a handful or so of surveyors), there seems to be an increasing amount of attentions paid to restrooms—both public and patient—during surveys. These attentions have included nurse call alarms (or lack thereof), the ability of staff to be able to “enter” restrooms to assist someone in distress, the length of the nurse call cords, etc. Now you might not think that there was a whole heck of a lot of trouble that could result from this type of scrutiny, but I can tell you that things can get a little squirrelly during survey (mostly the rescuing someone from the restroom) if you don’t have your arms around these spaces.

For example (and I think we’ve talked about this as a general observation a while back), there are some surveyors that will almost delight in locking themselves in a restroom, activating the nurse call system and wait to see how long it takes for staff to respond to–and enter!—the restroom (there is a Joint Commission performance element that requires hospitals to be able to access locked, occupied spaces; this would be one of those). Although there is no specific standards-based timeframe for response in these situations, the tacit expectation is that staff will be ready to respond, including emergency entry into the restroom, upon their arrival on the scene. This means that they would either immediately possess the means of entering the restroom or would have an immediate means at their disposal. This, of course, would be subject to the type of lock on the restroom door, etc., but for the purposes of this situation, we must assume that the patient is unable to unlock the door on their own. So, this becomes both a patient safety risk and a potential survey risk.

Stay tuned for some thoughts on how best to manage these types of situations.