One of these things is not like the other years: Your accreditation top tunes

Actually, that title is a bit misleading because, truth be told, the most frequently cited conditions in the physical environment as collated by our friends from Chicago over the past year or so are pretty much the ones they’ve been for as far back as I can remember (which is far enough). The one item (sort of) missing involves the consideration of safety risks in the management of behavioral health patients. As a formerly (lots of formerly at the moment, I suppose) National Patient Safety Goal (soon to be morphing into National Performance Goal), this was included in the summary of clinical “opportunities” and, at No. 14 of 15 items, fairly far down the list of most frequents. Unfortunately, the slides to which I have access don’t necessarily provide a lot of data about how often these items are being cited, though I believe that there is fair indication that the number of physical environment findings is still out-stripping the number of non-physical environment (you might use the term “clinical” as a descriptor, though some of the infection control stuff leans a little bit into the physical environment). There is some detail as to how the findings in each “bucket” manifest themselves, nothing of which is in any way surprising to me, but that might be par for the course.

In the interest of space, I’m going to break these out into three posts. I’m also going to minimize the standards numbers, etc. into a sort of short hand—if you can’t figure out what’s what, please feel free to reach out to me at stevemacsafetyspace@gmail.com and I will be happy to walk you through the numbers. So, my plan here is to identify what our friends have been finding, and, adding any thoughts about what I’ve seen in the field that might represent a potential vulnerability.

Suicide-Safe Environmental Risk Assessment (N.15.1.1.1)

• Unidentified or unmitigated ligature risks
• Inadequate implementation or documentation of mitigation strategies
• Presence of contraband or unsafe items in patient areas

I don’t know that I’ve seen anything different, though I honestly don’t run into too many legitimately unmitigated ligature risks (sometimes the mitigation strategy is a bit squishy particularly if the mitigation relies on anything less than 1:1 observation of high-risk patients). That said, I think we need to expand the notion of “suicide-safe” to include anything in the environment that could be used to harm self or others. Hopefully, that’s already the practice, but a comprehensive risk assessment needs to include any and all potential for harm.

Interior Spaces are Safe and Suitable (E.2.6.12)

• Ceiling and wall damage
• Emergency pull cord accessibility (aka “don’t wrap the call cord”)
• Unsecured sharps and equipment

I think I would also include any damage to surfaces (chipped laminate, etc.) or anything that represents a “non-intact” surface (and yes, I’m looking at you, rusty fixture). That said, I am not surprised that this is the top of the heap for the environment. I have never (ever!) been to a place where I couldn’t find a divot in a surface somewhere—that’s why I continue to (and will continue to continue to) stress the importance of the folks at point of care/point of service. Damage happens accidentally, but it typically is not invisible. This is the stuff we have to get folks to “see” and report. It’s the only way that you can stay ahead of this (unless someone invents a self-mending surface—wouldn’t that be awesome?).

Utility System Control Labels (E.2.5.19)

• Spare/energized breakers labeled incorrectly
• Missing or inaccurate panel schedules/labels
• Unlabeled utility shutoff valves

For you folks who don’t have an electrician on staff, this can be tough to manage. I can’t tell you the number of places over the years in which I found a spare circuit breaker in the “on” position. How much of a “deal” that condition is, is something of an unknown quantity, but right now, you need to work with folks to ensure that they’re checking the panels anytime they’re in an electrical room. Knowing what’s on and might need to be shut off is an important consideration in the event of an emergency.

When it comes to missing panel schedules and shutoff valves, in my experience, those issues are significantly rarer.

Clean/Odor-free Environment (E.2.6.1.20)

• Dust and debris accumulation
• Soiling and residue on equipment and surfaces
• Infection control and sanitation concerns

I worked in environmental services too long not to know how to look for cleaning “opportunities.” When you find these opportunities, you need to talk to the folks in the area(s) responsible for cleaning to figure out what the barriers might be. My experience has been that the folks doing the cleaning want to do a good job. Asking them what’s preventing them from doing so is an excellent start to adopting a sustainable approach to cleaning. For instance, the classic example is having a snake pit of power cords in a staff station area or a space between pieces of equipment that is so narrow, you’d need to hire Inspector Gadget to be able to reach in between or in back of it. Quick note about residue: disinfectant tends not to dry without leaving some sort of residue. Make sure the cleaning folks can reach the totality of the surface they are disinfecting—I can always tell when someone can’t reach.

Non-High Risk Utility Systems Inspection, Testing & Maintenance (E.2.5.5.6)

• Blocked or obstructed electrical panels and equipment
• Open or uncovered electrical junction boxes
• Unlocked or accessible electrical panels

This is kind of a mixed bag of conditions relating to various electrical fixtures. I’ve been to any number of places in which the original design of the facility resulted in the presence of electrical panels in areas where you would not want them: in staff stations, in staff break areas, in kitchens, in medication prep rooms, in stretcher alcoves (which makes them so much less useful). I suspect that the only real way to “stay ahead of the sheriff” for electrical panels is to know which ones are your greatest vulnerability and when the survey team arrives at the front door, give a designated person electrical panel clearance duty for the duration. (I euphemistically refer to this as having an Elvis plan—when Elvis is “in the building,” this is the plan.)

Having an open or uncovered junction box is an issue I have very rarely not seen at least once during my visit to any facility. Yet everybody who monkeys around with a junction box understands that they are supposed to be covered. And, in case you were wondering, for the purposes of compliance, it doesn’t matter what voltage is being run through the box—if it’s a junction box, it needs a cover.

Okay, that takes us through the top 5 most frequently cited standards/performance elements. Again, no surprises, no trickiness (so to speak); these are representative of stuff that you can find pretty much any day in any facility anywhere. I guess the question becomes how much resource do you want to apply to proactively managing the conditions noted above (and those to come).

About the Author: Steve MacArthur is a safety consultant with The Chartis Group. 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 an advisory board member for Accreditation and Quality Compliance Center. Contact Steve at stevemacsafetyspace@gmail.com.