Is compliance in the physical environment a solvable equation?

There always seems to be a lot of interest in how folks manage conditions in the environment, particularly how “other” folks are managing conditions in the environment. Clearly, the interest in all this is being reinforced on a regular basis by the accreditation organizations’ focus on the physical environment, at the behest of the lovely folks at CMS. Which begs the question: is it even possible to have an accreditation survey report with no findings in the physical environment? While I am sure that there are some exceptions that prove the rule, I suspect that unblemished survey reports are few and far between.

So, the follow-up question is: why is that the case? One would suppose that we’d be dealing with a simple equation: Finding + Reporting + Fixing = Compliance, but there are always variables in the mix (generally those of the human persuasion) that seem to bog down the process. You have to teach folks to be able to see deficiencies in the environment, then you have to get them to report those deficiencies in such a way as to allow for whoever comes to resolve the issue to actually track it down and resolve it. In an ideal world, the process as outlined would make the need for regular rounding obsolete, as the process would be (more or less) self-perpetuating.

This requires participation across the entire organization; I don’t know that you couldn’t be successful with a portion of the organization, but I would think it would have to be upwards of an 80% participation rate or having a small number of folks that are really adept at the finding/reporting dynamic. As I tend to remind folks, buildings are never more perfect than the moment before you let the people in—occupancy of a space tends to result in some level of wear and tear, even in the newest of facilities.

I remain steadfast in my belief that the greatest likelihood of success in this endeavor is to enlist the participation at the folks at point-of-care/point-of-service by working with department-level leaders to help model the behaviors that will drive compliance. Rounding should work as a means of educating/marketing the compliance program, not as an exercise in “gotcha” diplomacy. Sending a list of “stuff” to a department manager and expecting them to manage any corrective actions tends to not result in sustainable improvements, particularly in these days of rapid staff turnover. Start the “mission” in orientation—organizationwide and at the department level. Reward folks (within reason) for being part of the solution as opposed to a bystander to the process. Find a way to make compliance go viral in your house—it will pay dividends in the long run!

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as 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 Healthcare Safety Leader. Contact Steve at