Where there’s smoke…

By Steve MacArthur, Hospital Safety Consultant

In the January 2023 issue of Perspectives, our friends in Chicago have unveiled the first results of their efforts to “retire” standards and performance elements that aren’t supported by code and/or regulation, etc. If you don’t happen to have ready access to your organization’s issue of Perspectives, you can find the overarching discussion (and links to the changes for the specific accreditation programs) here: https://www.jointcommission.org/standards/prepublication-standards/the-joint-commission-retires-select-accreditation-requirements/.

As I might have mentioned once or twice in the past (pretty much any time that there’s a review of standards with the intent of reducing the regulatory burden), my fervent hope was for the requirements regarding the maintenance of written management plans for the care environment functions (safety, security, hazardous materials & wastes, fire safety, medical equipment, utilities systems) to be quietly laid to rest.

I’ve been hacking at this part of the regulatory iceberg for a very long time and, particularly as there is no code or regulation that requires one to have these management plans, the programmatic value of this approach, from a practical standpoint, makes very little sense to me. I’m pretty confident that everyone within the sight of my words has an organized (and hopefully, effective) process for managing the risks associated with each of the noted functions—and those processes are not, in any significant way, enhanced or otherwise improved by the written plans.

You can probably tell by the tone of the preceding paragraphs that the written management plans are still with us (they are), but there were a couple of retirees that do impact the physical environment:

  • Written policy prohibiting smoking: I’m guessing this one was retired because local/state regulations pretty much cover the management of smoking; I suppose one benefit might be the avoidance of a survey finding if there’s a stray butt floating around, but that’s probably as far as that goes.
  • Automatic fire extinguishing requirements relating to NFPA 101-2012 18/19.4.2: This relates to automatic sprinklers in high-rise buildings, which renders superfluous the performance element that’s retiring.
  • Education of staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible: This one relates to the safety goal on clinical alarm safety and, to be honest, I’m not really sure why it’s going away, but maybe there’s enough to the process(es) required by the instructions for use (IFU) of the various alarm systems to negate the need for this as a specific requirement. That said, I would think that educating folks to the purpose and proper operation of any system/equipment/etc. is a fundamental component of ensuring end-user competence, so maybe that’s the thought behind the removal.

At any rate, not quite the earth-shaking results for which I had hoped (it’s beginning to look like I’ll be retiring before the management plans…), but incremental change is still change. Here’s hoping 2023 continues to decrease the burden (adopting a relentlessly optimistic outlook…)

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 stevemacsafetyspace@gmail.com.