Mac’s Safety Space: The most frequently cited standards…

By Steve MacArthur, Hospital Safety Consultant

…become the most challenging requirements (we don’t have deficiencies, we have challenges and opportunities— they just call them deficiencies on survey reports, kind of like compliance clickbait).

So, we can finally close the book, so to speak, on survey year 2022 and, in so doing, ponder the forces that come into play to increase the degree(s) of difficulty when it comes to compliance. And, in case you hadn’t guessed, the forces that come into play in the (drum roll) physical environment.

In looking at the recently revealed Top 5 (, with the exception of issues relating to the safe and appropriate administration of medications (which, as it should happen, usually occurs in the environment – coincidence?), we’re pretty much looking at stuff that fits squarely into the physical environment portion of the process.

Admittedly, I’m stretching things a bit for the most frequently cited standard, which deals with intermediate and high-level disinfection of equipment, devices, and supplies, but in the absence of specific examples of what they’re citing, I can only rely on how I’ve seen things going sideways in this regard and there is much that crosses over into the monitoring of conditions and practices in the environment (expired product, expired or outdated test strips, issues with the pre-treatment of instruments as the await collection in soiled utility rooms, etc.)

The other things that are being cited: management of ligature risks—particularly as a function of how specifically the individual risks are identified in the official risk assessments (I’ll have something more to say about risk assessments in the not-too-distant future – I just don’t want to be too reiterative for those who have followed this space for a while); the general management of interior spaces (much as integrity of egress always use to figure in the most frequently cited standards, I think that as long as the focus of the entire survey team remains in the environment, there will always be “imperfections” to be seen and cited); and, the management of ventilation in critical areas.

Again, in the absence of specific examples, as a process with many, many, many moving parts (some mechanical, some human), ventilation is likely to continue to be a frequently identified opportunity (FIOs, if you will).

So, what does one do to be better prepared? Well, a couple of things spring to mind.

Ligature risk assessments: In general, annual reviews can suffice, but it might be useful to bring fresh eyes into the mix when you revisit assessments—folks who are new to your organization, folks external to your organization, even folks who are unfamiliar with the environment in which you are assessing risk. One of the truisms of this whole endeavor is that every surveyor (much like every person) has a different perspective based on what they’ve seen, learned, etc. And everyone assimilates those elements differently—you want to “mock” as many different outlooks as you can when it comes down to the assessment of risk. It’s almost a case of identifying everything as a risk and then addressing each in turn—a pain to be sure, but it is a methodology that will place you on the most solid footing.

Disinfection and sterilization: Presumably, your organization has been collecting data through rounding, tracer activities, etc., so you should be able to identify where your problem locales are likely to be. There very clearly has been an increase in all sorts of findings as the survey process moves more definitively into the ambulatory care environment—more opportunities than ever to stub one’s metaphorical toe. Our surveyor friends have a very clear understanding of that dynamic and are focusing their energies on where the findings are (go figure!)

Ventilation: As to the ventilation stuff, again, you should have a sense of where the trouble spots are likely to be— make a list of those spots and make sure that as soon as word goes out that Elvis is in the building for the survey, have someone check those potential problem areas. Even if something has been behaving itself recently, bad habits sometimes return at the worst possible moment, so at least you’ll have a shot at making the corrective action before it gets cited. It’s not a guarantee, but it certainly increases the likelihood for success!

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