Mac’s Safety Space: People are people, so why should it be…

By Steve MacArthur, Hospital Safety Consultant

As folks who have been following this space for a while will understand, most of the “coverage” tends to be more TJC/CMS-centric than not, with the odd sprinkles of OSHA, etc. That’s mostly because of how the accreditation “market” is distributed among accreditation organizations (AOs), along with there not being a ton of intel as to what’s being cited by other AOs. My intuition tells me that the focus for the accreditors with smaller market shares is very similar to our friends in Chicago (after all, the physical environment is the physical environment is the physical environment), but it’s generally instructive to see things in the flesh, so to speak. So, this week we are focusing on recent doings with the Accreditation Commission for Health Care (ACHC), who’ve been around since 1994 (you may remember them as HFAP -, based on the information contained in their publication “The Surveyor,” which you can find here: .

In looking over the materials relating to the physical environment (and to the surprise of almost no one), I see issues relating to:

  • The integrity of the ceiling barrier (gaps; missing escutcheons; chipped, cracked or missing tiles, etc.)
  • Ventilation, light and temperature controls (air pressure relationships; adoption of the humidity categorical waiver without having documented a risk assessment; policies that don’t include a standardized approach to dealing with conditions that go out of range; failing to have a solid process for monitoring temperature and humidity for sterile storage during “off” hours and weekends)
  • Issues with eyewash stations and emergency showers (failing to provide appropriately accessible eyewash equipment for occupational exposure to corrosive or caustic chemicals, including the test of emergency generator batteries; installing emergency eyewash equipment that was not truly in compliance with the ANSI standard; failing to test eyewash equipment weekly, etc.)
  • Management of infection control risks in the environment (rusty stuff, particularly in procedural areas; corrugated cardboard in areas where it probably isn’t wise; storage of “clean, but not sterilized” materials with sterilized materials; dust; no standardized approach to disinfectant dilution rates; tears in mattresses; chips, stains, etc. in vertical and horizontal surfaces; failure to adhere to pre-construction risk mitigation strategies, particularly as it relates to barriers)
  • Issues with general safety (obstructed building emergency equipment – pull stations, fire extinguishers, electrical panels, shutoff valves; ice build-up in walk-in freezers)

And so on.

As I am fond of saying, buildings are never more perfect than the moment before you let people inside and then it’s a constant battle to keep things on an even keel in the environment (the corollary is that squalor happens incrementally).

When you look at the list of conditions above, I think we can conclude that there is really no good reason for any of this stuff to be “available” for identification during a survey. Pretty much any of it should be visible to the occupants of the space in which the conditions are found, but somehow, over time, the conditions acquire a cloak of invisibility, thus our charge becomes one of providing line staff with the ability to “see” these invisible items. It’s really not so much a question of looking “for” something, but rather a question of looking “at” everything.

One has to assume (and yes, I know what happens when one does that, but this is the exception that proves the rule) that there is something “wrong” in every space (which, I suppose, is the opposite of being innocent before proven guilty—every space is deficient until proven otherwise). With the headlong rush of the past three years, the “edges” have gotten really blurry—and that’s clearly where the fruit is for the regulators. It’s typically not the crazy, hair on fire, big ticket stuff – it’s death by a thousand cuts, my friends, and we just need to do a better job at providing first aid to these conditions before they “fall out” during survey.

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