Who are your subject matter experts?
Who are your subject matter experts and who confirms the validity of a finding?
It seems to me that I’ve been looking at a lot of survey findings lately and there appears to be a strong undercurrent of findings that might or might not represent actual deficiencies in the physical environment. And a lot of those findings are capped by the words (or something similar) “the finding was confirmed by the department manager” or some other similarly titled individual. And it always makes me wonder how (or to what degree) the individual being identified is qualified/competent, etc. to confirm that the finding is correct/accurate? I suspect, in the moment, that, in an abundance of survey etiquette, the department manager is electing not to challenge the surveyor. Sometimes the conditions revolve around eyewash stations or stickers (or not having stickers) on medical equipment or other practices that I tend to think of as being in the gray part of the compliance spectrum—and very much subject to interpretation. Now, if had the time and resources to fully inform line staff and managers of the intricacies of managing the physical environment, I could see the legitimacy of “the finding was confirmed" as a closing statement. But if the finding isn’t confirmed by someone within the organization who is legitimately a subject matter expert on whatever subject is in play, how worthy is that confirmation?
My thought on this is that we have to establish something akin to the “phone a friend” popularized on a certain game show for when something is identified by a surveyor that is not clearly (and I mean clearly) recognizable as an environmental deficiency. Not the stained ceiling tile, not the dust on some surface, not the damaged laminate; these are the types of conditions with which folks should be sufficiently familiar to be able to put in a work order to correct (which might beg the question as to why they had not done so prior to the survey, but, hey, sometimes stuff happens). But what if a surveyor says, “I see no evidence that this piece of equipment received its annual check for accuracy.” Empirically, I guess you would have to agree that the statement is accurate on the face of it, but where is the standard that says how that evidence is to be presented? Isn’t it likely that someone in clinical engineering/biomed might be able to furnish an informed position on the accuracy of the statement regarding the accuracy check? Not every piece of equipment is subject to an accuracy check, and not every activity of which a piece of equipment might be subject is going to be called out on a sticker, etc.
We have to get folks comfortable with reaching out for clarification, additional information, etc. Maybe you manage it through your incident command center, which, naturally, you are using to manage the survey process, so why not this part. Any question that comes up should be answerable in as definitive a manner as possible. Maybe the finding is accurate, and the piece of equipment was missed—it happens. But maybe, the piece of equipment has been maintained in top-notch fashion, and who’s more likely to know that: a department manager or someone responsible for managing the inspection, testing, and maintenance of the equipment? I know who I would ask first.
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.