Mac's Safety Space: Tambourines and elephants are playing in the band…

By Steve MacArthur, Hospital Safety Consultant

As has been made fairly clear over time, when the regulatory survey folks come a-knock, knock, knockin’ on your door, they tend to focus on what is new to the mix (which, I suppose, underlines a sense that you have a good grasp of the standards and performance elements that have been dogging untold generations, but that may be a bit of an overreach).

At any rate, if you are accredited by our friends from Chicago, then you should have completed the first go-round of the workplace analysis (including an investigation of organizational workplace violence incidents) relative to the management of workplace violence risks in your organization. Which likely means that folks being survey between now and whenever will be asked to produce the work product of that analysis, including an accounting of the actions taken to mitigate or resolve the workplace violence risks identified in the analysis.

And, particularly now that “initial compliance” is very much a measurable undertaking, it’s a pretty good bet that this has the potential for becoming a hot button survey issue if you don’t have your ducks in a row. At the very least, as you’re probably putting the bow on the annual evaluation of your EC program right about now, I think it makes perfect sense to highlight the analysis—and the roadmap for moving forward—in the annual evaluation.

At some point, this is one that’s going to have/need a very clear path of communication to the top of your organization—this is much too important an undertaking to compartmentalize at the EC Committee level. There are cultural paradigms that will need to be shifted in order to make improvements and leadership participation is an essential component.

One of the other elements of the go-forward aspect is the whole notion of “best practices.” I’ve been at this for far too long to think that there is a “one-size-fit- all” solution to any of this, but I know there are lot of folks devoting time and energy to trying to support the folks in the field. To that end, you might check out the CDC workplace violence education materials for nurses and other healthcare workers. It does fly in the face of staying away from a cookie cutter approach to education, but (at least in the short term), you can point to this as being from a credible source—and a source that has done a lot of the lifting to get things started.

My suggestion would be to ask some of the folks in your organization to check out the course and provide feedback. It’s not going to be perfect for everybody, but it might be just the thing to get the ball rolling.

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