Mac’s Safety Space: Pondering imponderables – CMS versus the physical environment

By Steve MacArthur, Hospital Safety Consultant

Just so you know, as I am at the ASHE Conference in San Antonio this week (hope I got to see many of you there), as well as coming back from two weeks of vacation, I am penning this particular missive to you just shy of mid-July. I suppose if something crazy-important “drops” at the beginning of August, you may not see this until after the ASHE conference has come and gone, but this seemed like a good summary topic for summery thoughts.

So, jumping back a little in time, I did want to loop back to the physical environment “problem list” identified in CMS’ most recent assessment of the survey effectiveness of the various accreditation organizations (AOs) just to, if you will, tie a bow around specific physical environment items (I try to refrain from acronym-izing physical environment to PE—makes me think too much of high school gym calisthenics, hoop-jumping and rope-climbing) identified as being the most problematic.

As with many of (well, truthfully, most of) the environmental deficiency lists, there is a certain degree of commonality that pervades (not to get too biblical, but it was noted a very long time ago that there is nothing new under the sun; not to get too pop-cultural, we can run with same as it ever was). At any rate, the top 10 list covers the period of time October 2019 through September 2020, so the data set is likely to be a little on the smaller side. But, in looking at the list, I don’t know that the sample size, regardless of its size, is going to have a significant impact on what was (and can be) found “on any given day.”

I don’t think there’s anything here that we have yet to discuss in this forum, but if folks have specific questions about their own “house,” is a really swell way to reach out and ask questions.

The top 10 list:

  • Sprinkler systems
  • Means of egress
  • Electrical
  • Doors
  • Fire alarms
  • Hazardous areas
  • Fire/smoke barriers
  • Essential electrical systems
  • Flammable and combustible storage
  • Emergency lighting

If data spelunking is your thing, you might find many hours of the day lost by visiting, a website maintained by the Association of Health Care Journalists and containing a searchable archive of survey reports. You can search by term or by state; I would advise refraining from too global a search term (searching for “life safety” and not reducing the search grid to the state level seems to grind things to a halt). But checking these terms as a function of your home state (or, indeed, someone else’s home state) should provide some interesting reading. There are any number of rabbit holes that can be visited—over and over again!

That said, I am still having something of a struggle in figuring out which specific types of physical environment conditions and practices are resulting in condition-level findings that were not identified during surveys by the various accreditation organizations. Empirically, we know that the behavioral health and surgical environments are the areas “enjoying” the greatest level of scrutiny, so maybe that’s where the gaps of significance can be found, though, again, what are the AOs missing that are being picked up in the 60-day re-surveys?

I suppose some of that (and maybe the numbers are “big” enough to reflect all of the disparities) is due to the fact that your organization is likely going to look—and perform—differently in 60 days’ time.  I suppose another component is the reality that every surveyor sees things a little differently from every other surveyor—there is naught that can be done for it. I don’t know, maybe AI can somehow level the survey playing field by standardizing the approaches (and interpretations). I guess we’ll have to wait and see…

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

Found in Categories: 
CMS, Environment of Care, Life Safety