Maybe these maps and legends have been misunderstood…

By Steve MacArthur, Hospital Safety Consultant

Just in case you’ve not yet run across the latest edition of EC News, I wanted to highlight a couple of items that might be useful as we close out survey year 2022 and embark upon the 2023 open season on the environment.

  • For those of you that might have (or might have considered) a risk assessment that identified a less frequent than weekly testing process for your emergency eyewash equipment, the Chicagoans have officially declared that a non-starter and that weekly testing is the requirement based on the 2014 edition of ANSI Z-358.1. The article indicates that there was an update to the FAQ regarding eyewash stations, which appears to be the case, but there’s no specific mention of the frequency of testing. I suspect that the update focuses on using the 2014 edition of Z-358.1 as opposed to the 2009, but perhaps it might have been more helpful to have included the testing frequency as a specific piece of information. Of course, that might be entirely dependent on one’s definition of helpful…
  • We already discussed the “new” safety briefing component of the survey, so no big news on that front; I suspect that this will take an evolutionary path as we head through 2023—stay tuned!
  • Some clarifications regarding the water management plan requirements, including a note that the basic diagram of your water systems is just that—a basic diagram; I would definitely refer you to the water system diagram in the CDC toolkit as a template. Also, it is important to have a proactive process for managing stagnant water in your facility—in something of an oxymoron, stagnancy can move around, so you need to have a way of keeping tabs on areas. As we continue to struggle with the realities of staffing challenges, the opening and closing of services might become a sticking point when it comes to managing the risks associated with waterborne pathogens. There’s also mention of the need to evaluate the patient populations served (some are more susceptible to waterborne pathogens than others—your IC folks will have a good sense of that), as well as the difference between monitoring and testing—and what is required by our friends and what is not (monitoring is specifically required; testing not so much, but that doesn’t mean that your state doesn’t require testing, either as a routine thing or as a response to an outbreak). Monitoring temperature, chlorine or disinfectant levels, inspecting for stagnant water—those would be considered required types of activities (your program should identify the critical control measures that need to be monitored).
  • Relative to the maintenance of furnishings and equipment, there’s been a clarifying addition to the requirement that shifts the focus a little to “non-medical equipment” (I suspect that this might be the result of surveyors trying to cite issues that might better be captured under the infection control or equipment management standards), so we’re (apparently) talking about ice machines (which I would have thought would fit under the maintenance of infection control utility systems equipment), non-medication-related fridges, and washing machines/dryers (clean those lint filters!). Examples of furnishings are waiting room chairs and countertops (I don’t think that’s revelatory, but who knows).
  • Introduction of the 2022 edition of the FGI Guidelines and certain pieces therein; I just looked quickly at some of the stuff that’s included and (for sure) am hoping that the next issue of Perspectives will include (at least) a summary of the 2022 FGI stuff. I think I will work on pulling together a wee bit of analysis on this topic for next week (I think this is going to require a little bit of thought before I open my yap).
  • Finally (for the moment), there’s a pretty extensive surgical fire risk assessment tool; the interesting thing is that, for all intents and purposes, the risk assessment—which is from a JCR publication—is behind a paywall, so if you subscribe to EC News, you can access the tool, otherwise you have to purchase the JCR publication. I guess they can do what they want with their “intellectual property”, but I still find it curious (that’s the most benign term I can think of to describe my sense of this) that this information is not disseminated freely to accredited organizations (or maybe it is—I’m not an accredited organization, so this may be accessible to others). Ah well, everybody gets to make their own way in the world, so I guess this is just another example of that.

See you next time…

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