Mac’s Safety Space: If you knew there was a problem in the physical environment, you would correct it

By Steve MacArthur, Hospital Safety Consultant

If you knew there was a problem in the physical environment, you would correct it.

Wouldn’t you?

When you think about it, it is a fairly simple equation—problem occurs, problem is identified, problem is corrected. But somehow, the gaps in that equation result in more than 50% of accreditation survey findings—and there’s no reason to think that that number is going anywhere but up (so to speak).

Having worked in healthcare for just more than 45 years (June 19, 1978 is when it all began—it also happens to be the day the first Garfield comic was published—coincidence?), I do remember a time when the sense of urgency and preparation regarding the physical environment actually resulted in a limited number of findings. And yes, I also recognize that the survey of the physical environment was a very different beastie than it is today, particularly in terms of competence, etc., but it seems to me that a great many of the findings that I see in survey reports (OK, most of the survey findings) would/could/should be managed through that simple equation noted above. And, somehow, that doesn’t really happen to the extent that serves us well during surveys.

Part of that is the dynamic of the perfect versus imperfect building (buildings are never more perfect than the moment before people enter), but that’s more or less the baseline consideration—“stuff” is going to happen. The thing is this “stuff” that keeps happening almost never happens completely unwitnessed; as an example, it’s like the door to the soiled utility room whose operation has somehow managed to gouge a hole in the wall behind it—or that same door that is tied back with string (or oxygen tubing—or wire…) You and I know that these are conditions that would result in a survey finding or two—but do the folks in the field not really understand that that is the case?

That said, there are any number of factors that can “influence” how forthcoming folks might be when it comes to dancing the fine line of compliance; more often than not, without guidance, convenience will upstage any regulatory requirement. But be on the lookout for:

  • Drawing “hard lines” without explanation (or at least “framing” the request in a way that leads folks to understand the benefits of compliance); I know that policing an absolute is the easiest approach, but if you don’t provide alternative strategies that truly work towards compliance, then it is nigh on impossible to sustain any improvements you might make in the moment. A good example is the classic door stop/wedge/unauthorized holdback device—there are a whole host of reasons why this is not a compliant practice (not the least of which is the practice being expressly prohibited), but if you don’t work through the reason for having to hold the door open, the “malpractice” will in all likelihood recur at some point. The individual to whom you initially communicated the “citation” might change jobs, leave the organization, etc. You want the “fix” to persist beyond the moment of instruction.
  • As an overarching conceit/concept, there is always the potential for the “unauthorized field modification”—patient rooms are converted to storage rooms (unbeknownst to the plant ops folks); patient bathtub or shower rooms get converted to storage (it’s been a very long time since I’ve seen a hospital with “enough” storage). Alcoves fall victim to combustible loading beyond what is allowed by code and regulation; stuff (just about anything) gets “parked” in front of electrical panels, zone shutoff valves, pull stations, fire extinguishers, eyewash equipment—the list of obstructed building safety equipment is seemingly endless. Or emergency equipment is installed behind a locked door or made completely inaccessible by its location. And don’t get me started on power strips and extension cords…

The management of the physical environment is a collaborative pursuit that starts at point of care/point of service and should stretch throughout the organization. I know if there are “enough” (there’s that word again—how much is enough) findings, it will generate a finding at the leadership level, but this is definitely a shared responsibility. The unfortunate thing about shared responsibilities is that sometimes (and far too often) we forget to share.

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