Mac's Safety Space: Additional training may not bode well if you’re managing the environment

By Steve MacArthur, Hospital Safety Consultant

Maybe I’m just a “nervous Nellie,” but there were one or two takeaways from the recent CMS approval of our friends from Chicago (isn’t it nice to have friends in Chicago!?!) to continue accrediting critical access hospitals that gave me pause. In the approval notice, there is a list of several items beyond a review of standards to ensure alignment with the Conditions of Participation (CoP) and among that list are the following items:

  • Revising The Joint Commission’s surveyor guide to ensure a comprehensive review of environmental safety and life safety requirements are performed.
  • Provide additional training and education to surveyors on procedures related to investigation of “immediate jeopardy” situations in accordance with appendix Q-section VI of the SOM.

Now there may be those among the audience that wonder how much more “invasive” can the physical environment survey process become—and I fear that the items above represent an excellent (tongue firmly in cheek) starting point for an even greater attention to the physical environment. Certainly, we can point very clearly to the increased role of the clinical survey team members as a function of generating physical environment findings and it appears that this may represent even more focus during tracer activities.

While you can check the entire list for yourself by using the link above, I will note one additional condition of the approval: Providing training and education to surveyors related to the use of open-ended questions during staff interviews to elicit information.

There always seems to be something of an ebb and flow when it comes to surveyor interactions with frontline staff as a function of the practical application of “gotcha” questions—sometimes the surveyor(s) manage to find someone early in the onboarding process who might not be as “crisp” in their response as someone more “seasoned”—that’s always going to be a potential survey vulnerability (which is why it is a good idea to get frontline staff used to answering questions from well-dressed strangers).  I hope I’m wrong about this…

One quick closing item that came up on the radar this week, specifically for those of you that provide home care services through your organization. Starting with CoP section §484.102(b)(1), CMS requires individual plans for each home health patient during a natural or man-made disaster and those plans must be included as part of the comprehensive patient assessment. So what that becomes in the hands of one of the accreditation organizations is this: The home health organization’s plan for providing care must include written procedures that require a documented emergency preparedness plan for each patient that is based on the patient’s priority level, is individualized to the patient’s needs, and is reviewed and confirmed with patients and family or caregivers.

Also in the mix is a prioritization of patients by risk in order to facilitate the rapid triage of patients according to their need of services, particularly those at high-risk (which makes sense from a practical planning standpoint). 

The reason I’m posting this is that I really hadn’t bumped into this as a specific “requirement;” again, from a practical planning standpoint, I think it makes sense, but not sure how well known this is, so I figured it would be worth sharing—keep an eye on the home care plans (probably worth considering how one would integrate this into one’s general Emergency Management planning activities).

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