How many bad report cards before you have to give up your phone…up, up & away!

By Steve MacArthur, Hospital Safety Consultant

In what has become one of the constants of the final quarter of the calendar year, our friends at CMS once again take aim at the disparities between their oversight of the accreditation process (through validation and complaint surveys) and what the various accreditation organizations are identifying during their survey visits. And, continuing the trend of the last few years, the physical environment once again is taking (somewhat) center stage in the disparities sweepstakes ( a sweepstakes in which the facilities being surveyed do not obtain any prizes).

You can find all the squalid details here:, but the focus of our discussion starts on page 55 in which the lines in the sand relative to the survey of the physical environment remain clear and present (and probably dangerous as well).

One interesting tidbit that I finally was able to reconcile in my noggin was the sense that, unless a complaint survey clearly involves an issue with the physical environment, there are typically very, very few findings when the state agency(s) are following up on a complaint. And, in (more or less) acknowledgement of that, complaint surveys don’t figure in the “accounting” of discrepancies / disparities relative to findings in the environment.

The report outlines how state agencies are identifying more condition-level findings in the environment than the accreditation organizations. What isn’t clear (or at least it isn’t to me, but I also recognize that sometimes you have to gaze into the infinite void for quite some time before revelations are attainable) is what the nature of those condition-level findings are. Is it because there are only four categories in the CMS matrix (Buildings, Life Safety from Fire, Facilities, and Maintenance) versus the multitude of standards/performance elements used by the accreditation organizations? If that is the case (and I suspect it might be the resurgence of what I like to term as “death by a thousand cuts”) then it is possible that a bunch of minor deficiencies could “roll up” to a condition-level survey result, so it will become more of a numbers game than a severity game.

And if you’re wondering where those numbers might come from, you might want to take a gander at the figure on page 76 of the report, which breaks down the Life Safety Code®-related deficiencies into what is nominally a Top-5 list:

  • Fire/Smoke Barrier
  • Sprinkler
  • Hazardous Areas
  • Means of Egress
  • Fire Alarm

While it does not appear that the disparity rates for the individual areas are not too extreme as a percentage of the whole (they seem to hover around a 7% rate), I think we can intuit that if the intent is to drive numbers of findings (is there anyone out there that doesn’t feel that this is the focus of the survey process at the moment?), then these are a really good place to start. In sort of a variation of “let he who is without sin cast the first stone," it loops back to the general notion that no building is perfect and those imperfections have a tendency to manifest themselves in the noted areas (plus a few others). The other dynamic is the notion (and I believe we have touched on this once or twice in the past) that productivity/effectiveness is measured as a function of square footage, but the reality is that the physical environment is very much a 4-dimension undertaking (with the 4th dimension being building occupants – if you want to include time as a 5th dimension, please feel free to do so).

Soooo, I think we will continue to have our work cut out for us – I used to be able to measure trends across one cycle of the survey process (with each organization being surveyed once every 3 years), but with all the disruption brought about by COVID, what would typically work through the industry over the course of 3 years now seems to loop back on itself, etc. There will always be something to do, but now it seems like “done” is a lot less predictable…

About the Author: 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 also a contributing editor for Healthcare Safety Leader. Contact Steve at

Found in Categories: 
CMS, Environment and Facilities