Looking forward is looking back…

By Steve MacArthur, Hospital Safety Consultant

I don’t know about you, but when November kicks over into December, it tends to result in a more reflective outlook for me; perhaps it is the melancholy that sometimes accompanies the season (which I think I encountered fairly early on in life—mostly through “A Charlie Brown Christmas”—it gets to uplifting eventually, but it’s a fairly long haul for what is ostensibly a children’s program…but I digress. But if you want evidence, you might consider this: https://www.youtube.com/watch?v=_fh133ZO1AE ).

At any rate, one of the things upon which I was reflecting was this whole notion of the realignment and reduction of certain standards and performance elements as a function of their inclusion (or not) in the CMS Conditions of Participation (CoP) (we chatted about this earlier in the Fall).

It occurred to me that when this has happened in the past (and it’s been a little while, but I remember), certain “requirements” were dropped off, but some of those things—safety rounding as a specifically required element is the one that “pops” most in my mind’s eye—never really went away, mostly because, while not requirements, those things were essential to an effectively managed program.

I continue to hope for the “retirement” of the requirement for the written management plans—they are not required by the CoPs and, I would submit, are not particularly useful from an operations standpoint. To have programs for the physical environment functions is essential, as is the annual evaluation process—you’ve got to have a report card/scorecard/dashboard that provides organizational leadership a sense of how effective the programs are. But these written plans (which somehow end up being a re-summation of the standards, etc.) are very much less than essential (IMHO).

That said, as we see (or not) things start to shift in terms of what is required by standard, I would encourage you to pay close attention to what goes away, with the underlying understanding that sometimes mandatory ideas and practices may be replaced with vague expectations. This should never be about what is required but rather what you need to do (and say) to have an effective program. We’re not doing this because someone tells us to—we’re doing this because it’s an effective method for ensuring a safe, productive, and caring environment.

One last item before I sign-off for this week: I know that the management of waterborne pathogens remains a “hot button” topic for survey and it occurred to me that while we may very well have our “house in order,” we can receive patients from other facilities that might not have the same levels of attention or wherewithal to manage those risks. There continue to be outbreaks in communities all over the globe, and it never hurts to know what’s going on, so please check out the information on outbreaks from the good folks at HCInfo—the more information we possess, the more informed our decisions and strategies can be.

About the Author: Steve MacArthur is a senior consultant for the PES Division 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 stevemacsafetyspace@gmail.com.

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CMS, Environment and Facilities