May 2010 Vol. 18, No. 5 - HCPro: Providing Information to the … · · 2010-03-24It’s risky...

Think beyond D icons for your EC documentationIt’s risky just to stick with required records

You might be surprised to hear how many EC ele-

ments of performance (EP) appear to require documen-

tation even though they aren’t designated with a D icon.

Briefings on Hospital Safety has identified more

than 30 EPs in the EC chapter for which paperwork would

seem to be the only way to demonstrate compliance, even

without a direct requirement for documentation.

EC.02.05.07, which sets provisions for inspecting, test-

ing, and maintaining emergency power systems, offers a

good example of this dilemma.

EP 4 requires hospitals to test their generators 12 times

per year, and the EP has a D icon next to it.

Under EP 9, hospitals must institute interim measures

if any emergency power test fails. There is no D icon next

to this EP, yet it’s almost impossible to believe a surveyor

wouldn’t want to see paperwork showing what interim

steps you’ve assessed.

“A lot of times [Joint Commission officials] leave it

up to surveyors to interpret,” says consultant Marcia

Trenn, president of the Trenn Group in North Kings-

town, RI.

The list on pp. 4–5 details formally required docu-

mentation noted in EPs for the EC standards and also

identifies EPs that seem to imply necessary paperwork,

although to be clear, this is our assessment and not The

Joint Commission’s.

An important point to note is that EC documentation

may be available from sources on which you already rely.

> continued on p. 2

May 2010 Vol. 18, No. 5

IN THIS ISSUE

p. 6 H1N1 violationsWashington’s state OSHA agency fined a hospital $8,000 for alleged violations of required H1N1 protection measures for healthcare workers.

p. 7 Hospital Safety Center Symposium previewA likely way for Joint Commission surveyors to gauge your facility’s ability to respond during escalating disaster scenarios is to initiate tabletop exercises.

p. 8 Discipline tacticsSafety officers must be prepared to approach employees in an appropriate way when they ignore OSHA requirements.

p. 12 Tip of the monthThe FDA has alerted hospitals that a specific model of StatSpin® centrifuges has an alleged defect that could result in injuries to workers and others.

All subscribers can read our full list of official

and implied documentation requirements in

not only the EC standards, but also the life safe-

ty and emergency management standards. Log on to www.

hospitalsafetycenter.com and click the Special Reports link in

the left column. If you don’t have a username or password,

contact our customer service center at 800/650-6787.

“My consultative advice is to make use of the means

of documentation that already exist—minutes, evalua-

tions, etc.,” says Steven MacArthur, safety consultant

at The Greeley Company, a division of HCPro, Inc., in

Marblehead, MA, and the contributing editor for Brief-

ings on Hospital Safety.

MacArthur will also be appearing at the 4th Annual

Hospital Safety Center Symposium May 6–7 in Las Vegas

(go to www.hospitalsafetycenter.com for more details).

It’s how you manage risks that counts

One of the most prominent EC requirements, the

risk assessment process, resides in EC.02.01.01. EPs

1 and 3 require hospitals to assess safety and security

risks and take action to minimize the hazards. Neither

EP has a D icon.

Page 2 www.hospitalsafetycenter.com May 2010

© 2010 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

Instead, the bigger point from The Joint Commission’s

perspective is whether you’re managing risks properly,

which you may be able to gauge through hazard surveil-

lance results, safety committee meeting minutes, and per-

formance improvement efforts.

“If you have effective surveillance [and] occurrence

reporting processes, then those processes become all the

documentation you need, if you use it correctly,” says

MacArthur.

When talking to clients, “the question I ask is what

got better in the management of the care environment

over the last 12 months, to which I then follow with:

How do you know?” he says. “The bottom line is you

have to have a way of knowing where you are in terms

of compliance, because if you don’t know or indeed

cannot articulate that knowledge, you can’t be sure that

your program is doing what it’s supposed to.”

Proving staff competencies for safety

Staff competencies under EC.03.01.01 revolve

around employees being able to demonstrate or de-

scribe various aspects of eliminating or responding to

EC risks. There are no D icons for any of the EPs under

EC.03.01.01.

If surveyors attempt to verify staff member com-

petency, it would be a difficult chore without backup

paperwork.

“How do you prove competencies?” Trenn says.

“There’s normally a post-test that says, ‘Yes, I had that

training.’ ”

An alternative approach would be to use other activi-

ties to measure staff competency, such as fire drills and

hazard surveillance rounds, MacArthur says.

“There are no rules about what you can and can’t ask

during those activities,” he says. “My personal philosophy

has been you need to take advantage of every moment of

face time you get with frontline staff.”

For example, you could add a line to your fire drill

assessment form that prompts you to ask participants

Trenn compares risk assessment results to those of

a hazard vulnerability analysis (HVA) under the emer-

gency management standards. “To me, a risk assess-

ment is just like an HVA for a facility, so unless you put

it on paper, you just don’t have [proof of your work],”

she says.

Don’t be fooled into thinking that documenting a risk as-

sessment is merely just to prove you did one, MacArthur

says.

EC documentation < continued from p. 1

Editorial Advisory Board Briefings on Hospital Safety

Group Publisher: Emily Sheahan, [email protected]

Senior Managing Editor: Scott Wallask, [email protected]

Contributing Editor: Steven MacArthur, Safety Consultant, The Greeley

Company, Marblehead, MA,

[email protected]

Barbara Bisset, PhD, MS, MPH, RNExecutive Director Emergency Services Institute/WakeMed Raleigh, NC

Steven BryantVice President/Managing DirectorThe Greeley Company Marblehead, MA

Joseph Cocciardi, PhD, MS, CSP, CIHCocciardi & Associates Mechanicsburg, PA

Elizabeth Di Giacomo-Geffers, RN, MPH, CSHAHealthcare ConsultantDi Giacomo-Geffers and Associates Trabuco Canyon, CA

Zach Goldfarb, EMT-P, CHSP, CEMPresidentIncident Management Solutions, Inc. East Meadow, NY

Ray W. Moughalian, BS, CHFRMPrincipalSaf-T-Man Methuen, MA

John L. Murray Jr., CHMM, CSP, CIHSafety DirectorBaystate Health Springfield, MA

Paul Penn, MS, CHEM, CHSPEnMagine/HAZMAT for Healthcare Diamond Springs, CA

Dalton Sawyer, MS, CHEPDirector, Emergency Preparedness and Continuity PlanningUNC Health CareChapel Hill, NC

Steve SchultzCorp. E&O Safety DirectorCape Fear Valley Health System Fayetteville, NC

Barry D. Watkins, MBA, MHA, CHSPSenior EC SpecialistCorporate Safety Carolinas HealthCare System Charlotte, NC

Kenneth S. Weinberg, PhDPresidentSafdoc Systems, LLC Stoughton, MA

Earl Williams, HSPSafety SpecialistBroMenn Healthcare Bloomington, IL

Pier-George Zanoni, PE, CSP, CIHZLH Consulting St. Johns, MI

Briefings on Hospital Safety (ISSN: 1076-5972 [print]; 1535-6817 [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: Regular $299/year or $538/two years; Platinum $499/year; back issues are available at $25 each. • Briefings on Hospital Safety, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encour-aged, no part of this publication may be reproduced, in any form or by any means, outside the subscriber’s facility, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occa-sionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BHS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

May 2010 www.hospitalsafetycenter.com Page 3


D icon that requires organizations to document this

inspection.

In fact, George Mills, FASHE, CHFM, CEM, senior

engineer at The Joint Commission, told Joint Commis-

sion Resources’ Environment of Care News that documenta-

tion, even if not mandated, can prove ILSM compliance.

“When implementing any of these ILSMs, organi-

zations should document when and how they imple-

mented the measures,” Mills said in the July 2009

issue. “Although only EP 12—inspect and test tempo-

rary systems monthly—requires documentation, docu-

menting implementation efforts associated with any of

the [ILSMs] would illustrate compliance during an in-

ternal review or Joint Commission survey.”

Now to be clear, Environment of Care News does not

carry the weight of official Joint Commission standards,

so Mills’ views in this case are only suggestions. How-

ever, his thinking is clear to interpret, and it is likely he

repeats the same advice to surveyors. n

about other safety issues, such as how to find a material

safety data sheet for a particular chemical.

Construction and investigations crop up

The following are other areas where documentation

is not required but implied:

➤ EC.02.06.05. During construction or renovation,

EP 2 wants hospitals to conduct pre-construction

risk assessments for air quality, infection control,

utilities, noise, vibration, and other hazards. The

pre-construction assessment is prime ground for

documentation to show your deliberations to sur-

veyors or other regulators, Trenn says.

➤ EC.04.01.01. For example, EPs 3 and 5 require hos-

pitals to report and investigate injuries to patients

while in the hospital and incidents of property dam-

age. To Trenn, both of these mandates are no-brain-

ers for documentation even if it’s not required by

The Joint Commission. She recommends that safety

committees complete quarterly reports about patient

injuries and property damage, and then track that in-

formation against prior quarter and the same quarter

year-to-year.

➤ EC.04.01.05. Performance improvement results must

be reported by the hospital to people who analyze

EC issues, such as the safety committee, according

to EP 3. Could such a report detailing these results

be given verbally? Sure, it’s possible, but we’ve all

heard Joint Commission officials say, “If it’s not doc-

umented, it didn’t happen.” But perhaps the safe-

ty committee noting receipt of this verbal report in

meeting minutes would pass muster with surveyors.

Dilemma goes beyond the EC standards

The life safety and emergency management chapters

also have examples of implied documentation.

LS.01.02.01 sets up interim life safety measures

(ILSM), but only a few of the individual ILSMs require

documentation.

EP 4, for example, discusses inspecting exits daily if

a life safety violation exists in the area, yet there is no



Sampling of official vs. implied EC documentation rulesEditor’s note: The following list outlines formal and possi-

bly implied recordkeeping requirements for many of The Joint

Commission’s EC standards. Official documentation mandates

are noted by a D icon. Those elements of performance (EP)

marked as “implied” requirements below have been selected

by Briefings on Hospital Safety for your consideration,

but don’t necessarily represent the view The Joint Commission

would take.

EC.01.01.01—Minimizing EC risks

➤ EP 1 (implied): Identifying a person to manage

safety risks

➤ EP 2 (implied): Identifying a person to intervene

when safety risks threaten life or health

➤ EP 3 (D icon): Having a written plan for managing

environmental safety


security


hazardous materials and waste


fire safety


medical equipment


utilities

EC.02.01.01—Managing safety and security

risks

➤ EP 1 (implied)—Identifying safety and security

risks

➤ EP 3 (implied)—Minimizing safety and security

risks

➤ EP 9 (D icon)—Having written procedures to follow

during a security incident

EC.02.01.03—Prohibiting smoking

➤ EP 1 (D icon)—Developing a written policy that pro-

hibits smoking

EC.02.02.01—Managing hazardous materials

and waste risks

➤ EP 1 (D icon)—Having a written inventory of hazard-

ous materials and waste on site


during a hazardous materials or waste spill

➤ EP 10 (implied)—Monitoring levels of hazardous gases

➤ EP 11 (D icon)—Maintaining required permits and

licenses for hazardous materials and waste

EC.02.03.01—Managing fire safety risks

➤ EP 9 (D icon)—Having a written fire response plan

EC.02.03.03—Conducting fire drills

➤ EP 5 (D icon)—Critiquing fire drills

EC.02.03.05—Inspecting, testing, and main-

taining fire protection equipment

➤ All 20 EPs have D icons for various equipment

EC.02.04.01—Managing medical equipment risks

➤ EP 2 (D icon)—Maintaining a written inventory of

all medical equipment or selected medical equipment

by risk

➤ EP 3 (D icon)—Identifying inspection, testing, and

maintenance activities for medical equipment

➤ EP 4 (D icon)— Identifying inspection, testing, and

maintenance frequencies for medical equipment


during medical equipment failures


taining medical equipment

➤ EP 1 (implied)—Performing functional checks on

equipment before initial use

➤ EP 2 (D icon)—Inspecting, testing, and maintaining

life support equipment


non–life support equipment



➤ EP 6 (D icon)—Performing tests on automatic trans-

fer switches

➤ EP 7 (D icon)—Performing four-hour tests on

generators

➤ EP 9 (implied)—Carrying out interim measures

when an emergency power system fails

➤ EP 10 (implied)—Performing retests after repairs


taining medical gas and vacuum systems

➤ EP 1 (D icon)—Performing tests on medical gas systems

➤ EP 2 (D icon)—Performing tests on piped medical gas

and vacuum systems when modified

EC.02.06.01—Maintaining a safe and functional

environment

➤ EP 13 (implied)—Maintaining suitable ventilation,

temperature, and humidity levels

EC.02.06.05—Reducing risks during demolition,

construction, and renovation

➤ EP 2 (implied)—Conducting a pre-construction risk

assessment

➤ EP 3 (implied)—Minimizing risks during demolition,

construction, and renovation

EC.03.01.01—Ensuring staff members and

licensed independent practitioners are familiar

with safety responsibilities

➤ EP 1 (implied)—Describing or demonstrating ways to

minimize EC risks

➤ EP 2 (implied)—Describing or demonstrating actions

to take during an EC incident

➤ EP 3 (implied)—Describing or demonstrating how to

report EC risks

Editor’s note: To see our full list of documentation concerns

for the EC standards, as well as those for the life safety and

emergency management standards, please log on to www.

hospitalsafetycenter.com and click the Special Reports link

in the left column. n

➤ EP 4 (D icon)—Testing and maintaining sterilizers

➤ EP 5 (D icon)—Testing and maintaining hemodialy-

sis water

➤ EP 14 (D icon)—Inspecting, testing, and calibrating

nuclear medicine equipment

EC.02.05.01—Managing utility risks

➤ EP 2 (D icon)—Maintaining a written inventory of

all utility components or selected utility components

by risk

➤ EP 3 (D icon)—Identifying inspection and maintenance

activities for utility components

➤ EP 4 (D icon)—Identifying inspection, testing, and

maintenance intervals for utility components

➤ EP 6 (implied)—Providing appropriate air pressures

and exchange rates in ventilation systems designed

to control airborne contaminants

➤ EP 7 (D icon)—Mapping utility distribution


during utility disruptions


taining utility systems

➤ EP 1 (D icon)—Testing utility components


life support utility components


infection control utility components


non–life support utility components


taining emergency power systems

➤ EP 1 (D icon)—Performing 30-second tests on bat-

tery-powered lights

➤ EP 2 (D icon)—Performing 90-minute tests on bat-

tery-powered lights

➤ EP 3 (D icon)—Performing tests on stored emergency

power supply systems

➤ EP 4 (D icon)—Performing 30-minute tests on

generators



When federal OSHA issued its compliance directive in

November 2009 regarding healthcare worker protection

against H1N1, many worried that the requirement for

N95 respirators was nearly impossible to comply with,

given supply shortages.

OSHA indicated that when respirators were not com-

mercially available, an employer would be considered

compliant if a “good faith effort” had been made to ac-

quire N95s. Part of that effort included documenting at-

tempts to order respirators and including the Centers for

Disease Control and Prevention’s (CDC) H1N1 prevention

guidelines in the facility’s respiratory protection plan.

State cites hospital $8K

For those who were unsure how officials would en-

force this directive, the state OSHA agency in Washing-

ton gave an early lesson.

On January 29, Sacred Heart Medical Center in Spo-

kane, WA, received a citation and an $8,000 fine from

the state Department of Labor and Industries’ (L&I) Divi-

sion of Occupational Safety and Health for failing to ad-

here to state and national H1N1 safety standards.

According to the Washington State Nurses Association

(WSNA), L&I found the facility to be in violation in eight

instances, and cited the following alleged problems:

➤ Inadequate written respiratory protection plan

➤ Inadequate respirator fit testing and training

➤ No provision for men with facial hair, which affects a

respirator’s seal around the face

Union prompts investigation

At presstime in mid-March, Sacred Heart had not re-

turned requests for comment.

The WSNA may have played a role in the citations, as

the organization and affiliated labor union filed a com-

plaint with the state against Sacred Heart for allegedly

failing to provide proper equipment after hearing from

multiple nurses that the appropriate safety and infection

control measures were not in place.

“As the exclusive bargaining representative, that’s

what we do,” says Christine Himmelsbach, RN, assis-

tant executive director of labor relations at the WSNA.

“We protect workplace safety and took appropriate ac-

tion by actually filing the complaint.”

It was difficult to quickly obtain H1N1 supplies, but

many facilities successfully reacted to the OSHA direc-

tive, Himmelsbach says.

“I think when the flu season first began, it certainly

was a challenge, and yes indeed, we did see across the

state that it was a common problem that people were

trying to react to the need for the proper equipment and

have proper programs in place and it all happened very

quickly,” Himmelsbach says. “Many of the hospitals re-

sponded appropriately, and in the case of Sacred Heart,

they did not.”

However, the citation led to reevaluation of the facili-

ty’s program, she says. Equipment was made available and

employees felt they were protected from the H1N1 virus.

Other hospitals should take notice

After OSHA released its H1N1 compliance directive,

there was debate over whether N95s were actually nec-

essary, as the CDC suggested. Many wondered whether

surgical masks, typically used for patients with seasonal

influenza, would suffice.

The Washington citation will put healthcare facilities

on notice that failure to follow CDC guidelines to protect

employees against H1N1 could result in OSHA fines.

“It certainly sent a huge message in my opinion that

this is a serious matter,” says Himmelsbach.

According to Himmelsbach, the WSNA purchased a

large supply of N95 respirators prior to the inspection,

and provided them to the nurses at Sacred Heart.

“I’m sure the hospital’s claim [is] that it’s a very

lengthy process and very complicated to go through the

fit testing,” Himmelsbach says. “I also think too there

might have been issues stockpiling the supplies that

they did have.” n

State OSHA agency fines hospital for alleged H1N1 slips



We all know that The Joint Commission expects your

disaster drills to feature escalating scenarios that tax the

ability of staff members to respond.

This mandate falls under EM.03.01.03, element of per-

formance 3. But how do surveyors check this provision?

For starters, surveyors should review past drill and

actual emergency event critiques to see whether any

of those situations pushed the envelope in terms of re-

sponse and what lessons hospitals learned, says Joseph

Cappiello, BSN, MA, chair of Cappiello & Associates in

Elmhurst, IL.

But a more likely way for surveyors to gauge your fa-

cility’s ability to respond during escalating scenarios is to

initiate tabletop exercises, says Cappiello, who will be a

featured speaker at the 4th Annual Hospital Safety Cen-

ter Symposium, which takes place May 6–7 in Las Vegas

(go to www.hospitalsafetycenter.com for more details). At

the symposium, Cappiello will discuss business recovery

strategies as part of hospital emergency preparedness.

There’s no guarantee of a tabletop

A surveyor could request a tabletop exercise during

your emergency management session, although based

on reports we’ve received from the field, there are many

hospitals that aren’t asked to carry out a tabletop.

In some cases, that decision may rest on a surveyor’s

comfort with emergency management. For example, a

nurse with an infection control background is going to

spend time digging deep into infection prevention prac-

tices because that is what he or she knows best.

Meanwhile, a physician surveyor who is an obstetri-

cian may be more apt to focus his or her review on oper-

ating rooms and labor and delivery units—not necessarily

emergency management planning, Cappiello says.

Nonetheless, if a surveyor requests a tabletop, a like-

ly source for scenario ideas will be the hospital’s hazard

vulnerability analysis (HVA), which is mandated under

EC.01.01.01.

Don’t focus all energy on the top HVA risk

Savvy surveyors may not conduct a tabletop of your

top-rated disaster scenario from the HVA, but instead

perhaps test your No. 2 or 3 rated risk, Cappiello says.

Good surveyors won’t necessarily use the No. 1 HVA

scenario because there’s an assumption that hospitals

have spent time preparing for their No. 1 event, he says.

A good tip is to practice your lower-ranked HVA risks

during emergency exercises once you have your No. 1

risk down cold. Besides, continually exercising the same

scenario will not keep staff interest high.

“You’ve got to prepare for other kinds of things” if you

expect to increase flexibility through your staff training,

Cappiello says.

Emergency planner can’t be the only voice

Another way surveyors can check for your facility’s abil-

ity to adapt to escalating situations is to limit the amount

of time an emergency management coordinator partici-

pates in either the emergency management review session

or a tabletop.

Some surveyors “won’t let the emergency manager

take the floor and be the only one who talks,” Cappiello

says. “Some will even tell the emergency manager, ‘Just

be still.’ ”

With that approach, other members of the emer-

gency preparedness team will be forced to participate,

which will give surveyors a better sense of how well-

thought-out an emergency operations plan truly is

and how knowledgeable staff at all levels understand

their roles. n

Hospital Safety Center Symposium preview

HVA events will let surveyors test your flexibility

Platinum subscribers to the Hospital Safety

Center can use our hazard vulnerability anal-

ysis tool to help identify disaster risks. Log on

to www.hospitalsafetycenter.com and look for the Risk As-

sessment Workstations heading in the left column.



Unless safety officers work in a medical facility with

perfectly compliant employees, they’ll be forced into

the unenviable but inevitable job of confronting an

employee who is not adhering to OSHA worker safety

regulations.

On most occasions, safety managers encounter an in-

nocent mistake or a one-time offense that is easily cor-

rectable. On other

occasions, how-

ever, persistent or

especially hard-

headed employees

will demonstrate

consistent noncompliance because of inconvenience or

simply out of sheer stubbornness.

In either case, safety officers must be prepared to ap-

proach employees in an appropriate way that is ben-

eficial to the safety of the healthcare worker and the

overall adherence to OSHA regulations and best prac-

tices within the facility. Finding that approach, however,

can be challenging.

Note widespread PPE problems

Two of the most common OSHA safety violations are

phlebotomists biting the tip of the index finger off of gloves

to better feel for a patient’s vein and physicians not wear-

ing required personal protective equipment (PPE) during

procedures, says Kathy Rooker, safety officer and own-

er of Columbus Healthcare & Safety Consultants in Canal

Winchester, OH.

Incision and draining procedures are frequent ac-

tivities during which PPE is ignored because physicians

don’t think they need the required gloves, mask, gog-

gles, and impervious gown when performing such sim-

ple tasks.

However, Rooker has seen instances in which pus has

sprayed into a doctor’s mouth or eyes.

“I just try to tell them what the consequences are if

they don’t wear it, and is it really worth them taking

the risk?” Rooker says. “I hear, ‘Oh, I’m going to look

ridiculous,’ and I say, ‘Yeah, but you’ll be alive.’ ”

One-on-one may be effective

There are a few recommended practices to which safety

officers should adhere when discussing OSHA violations

with employees.

It’s rarely effective to raise one’s voice to a healthcare

worker or call out a physician in front of his or her peers,

says Rooker.

Instead, it is better to take physicians aside and explain

any errors or meet with them individually to explain

OSHA requirements.

“I would sit down with them one-on-one, and I will

usually bring with me statistics on hepatitis B, hepatitis

C, and HIV and say, ‘Look at the statistics. Look what

could happen to you by not using a safety needle if this

person were infected,’ ” Rooker says. “And that’s a real

eye-opener sometimes.”

(See the related story on p. 9 for more hints on bet-

ter ways to approach discipline and tactics to avoid.)

Stand your middle ground

At times, compromise works best, especially with

concerns over the comfort of wearing PPE, says Terry

Jo Gile, MT(ASCP), MA Ed, president of Safety

Lady, LLC, a lab safety consulting firm in North Fort

Myers, FL.

Gile says she worked with one facility where the gowns

were making employees too hot and uncomfortable, so

staff members were allowed to cut holes in the back and

under the arms.

Ideas on how to discipline workers for OSHA violations


Center can read a safety and health inspec-

tion checklist that will help maintain OSHA

compliance. Log on to www.hospitalsafetycenter.com and

search for the number 72028.

At times, compromise

works best, especially with

concerns over the comfort

of wearing PPE, says Terry

Jo Gile, MT(ASCP), MA Ed.



“[OSHA says] you have to have the front covered; it

doesn’t say anything about the back,” Gile says. “You do

what you’ve got to do. You need the employees, so you

have to make them comfortable.”

Maintain clear disciplinary records

There is the possibility that a one-on-one consulta-

tion is not enough to elicit consistent compliance or that

a blatant offender will continue to ignore OSHA safety

protocols. In these cases, employers will turn to their es-

tablished disciplinary policies. Most corrective action pro-

cedures begin with one or two verbal warnings, followed

by a written warning, suspension, and finally termination.

“Usually, it never gets past the written warning because

they know that goes into their [file],” Gile says of employ-

ees who don’t obey safety rules.

It’s important to note that in most facilities, disciplin-

ary action should be handled by the employee’s supervi-

sor, not necessarily the safety officer. The safety officer

may be involved with consultation, but he or she should

not assume the role of the bad cop who monitors the

entire staff.

Should a situation escalate, further actions—includ-

ing suspensions or minimizing salary increases—may

be more successful if verbal or written warnings are not

sufficient.

For this reason, it is important to document all instanc-

es of training, infractions, warnings, consultations, and

educational opportunities. For example, if an employee

won’t wear protective gloves when required and the hos-

pital has issued written warnings, such documentation

can be presented to an OSHA inspector should the in-

spector raise concerns, Gile says.

Still, as many are aware, it’s uncommon for OSHA

to find the hospital completely void of responsibility if

safety policies are routinely violated by employees, so

watch for patterns in worker noncompliance and dig

into bigger root causes. n

Steps to take—and avoid—with discipline

Do:

➤ Develop a disciplinary action plan

➤ Take an employee aside when you notice an infraction

➤ Investigate why a violation occurred

➤ Ask open-ended questions about an incident (e.g., “How

many times have you done this job without personal pro-

tective equipment and why?”)

➤ Ask the employee whether there is something you can

do to make compliance easier

➤ Issue a verbal warning, if appropriate, and document it

➤ Explain that the safety measures are in place for the em-

ployee’s own personal safety and describe what could

happen without these measures

➤ Cite specific OSHA or Joint Commission standards and

explain how a citation could affect the facility

➤ Cite specific healthcare worker injury or illness statistics

➤ Explain the disciplinary process, if necessary

➤ Focus on how safety measures will benefit an employee’s

day-to-day duties and improve patient safety

➤ Provide anecdotes that may be influential

➤ Hold your ground on the importance of regulations or

policies

Don’t:

➤ Yell or scream at an employee

➤ Embarrass an employee in front of his or her coworkers

or patients

➤ Immediately issue a written warning or suspension upon

the first infraction

➤ Simply ignore requests for education or new product

consideration

➤ Initiate the disciplinary process if you are not the em-

ployee’s supervisor

➤ Ignore infractions because the employee is defensive or

hard-headed

Sources: Terry Jo Gile, MT(ASCP), MA Ed, president of Safety Lady,

LLC, in North Fort Myers, FL, and Kathy Rooker, safety officer and

owner of Columbus Healthcare & Safety Consultants in Canal

Winchester, OH.



In this month’s Healthcare Security Alert

Don’t forget to read the latest Healthcare Security

Alert—available exclusively online at the Hospital Safe-

ty Center—to learn about best approaches for keeping

employees safe from workplace violence and teaching

them how to recognize early warning signs from problem

patients.

All subscribers have access to Healthcare Security

Alert by logging on to www.hospitalsafetycenter.com and

looking in the left-hand column. Years’ worth of archives

are also available.

If you don’t have a username and password, call cus-

tomer service at 800/650-6787.

HCPro’s new resource, Emergency Operations Plan Tem-

plate, contains advice and sample language on build-

ing an emergency operations plan that meets the intent

of The Joint Commission’s emergency management

standards.

The fully customizable template also includes a dozen

appendixes and annexes, including one that discusses

isolation plans, which we include below:

Subject: Isolation plan and procedure

Purpose: In order to contain airborne contaminants

beyond the normal

scope of this facil-

ity, engineering

shall take the ap-

propriate steps to secure a safe environment for patients

and staff members requiring cohorting patients on an

entire nursing unit under negative air isolation.

Please note that the facilities management department

should be consulted to designate and develop the health-

care entity units capable of 100% exhaust/negative air.

References: Joint Commission standards EM.02.01.01,

element of performance (EP) 8 (implementing response

procedures related to patient care during an actual

emergency) and EM.02.02.11, EPs 2 (describing how the

hospital will manage various patient care activities) and

8 (describing how the hospital will track patients’ clinical

information).

Procedures: ED unit isolation

If the ED is to be used as the designated isolation unit,

the ED charge nurse and/or nursing supervisor must de-

termine the location to relocate patients. Once this has

been determined and patients are relocated, the follow-

ing actions should be taken:

➤ The engineering department should close the ED by

installing temporary partitions across the corridor and

post signs limiting entrance to authorized personnel

only. Doors to the ED and the temporary partition

must remain in place during the isolation procedure.

➤ The engineering department should verify negative

air by using a differential pressure gauge.

➤ The engineering department should turn on isolation

exhaust fan at the control. Verify fan start and nega-

tive air by observing isolation systems from the build-

ing automation systems.

➤ The engineering department should close ED entrance

doors and post signs indicating that ED doors must

remain closed.

➤ The engineering department should measure and re-

cord the air pressure in relation to adjacent corridors

using the differential pressure gauge.

➤ Central supply should move the emergency supply

cart to the unit.

New resource excerpt

Sample unit isolation plan for emergency response

HCPro’s Emergency Operations

Plan Template is fully

customizable.

Contact Senior Managing Editor Scott Wallask

Telephone 781/639-1872, Ext. 3119

E-mail [email protected]

Questions? Comments? Ideas?



➤ Environmental services should deliver one waste cart

and linen cart inside the unit for waste disposal and

linen disposal.

➤ The engineering department should place a 55-gal.,

open-top drum inside the unit for waste disposal.

The drum shall be labeled appropriately, identifying

the waste.

➤ The engineering department should lock and se-

cure both linen and waste chutes, covering them

with plastic and duct tape. Shut down the pneu-

matic tube station and cover it with plastic and

duct tape.


cord the air pressure differential across the door using

a digital manometer.

Nursing unit isolation

If a nursing unit is to be used as the designated isola-

tion unit, the following actions should be taken:

➤ The engineering department should close the unit

by installing temporary partitions across the corri-

dor and post signs limiting entrance to authorized

personnel only. Doors to the unit and the temporary

partition must remain in place during the isolation

procedure.

➤ The engineering department should turn on nega-

tive air control. Verify the isolation fan start from the

building automation system and differential-pressure

gauge.

➤ The engineering department should verify negative air

by using a differential pressure gauge.

➤ Central supply should move emergency supply cart

to the unit.

➤ The engineering department should lock and secure

linen and waste chutes, covering them with plastic

and duct tape.

➤ Environmental services shall deliver one waste cart

and linen cart inside the unit for waste disposal and

linen disposal.

➤ The engineering department should place a 55-gal.,

open-top drum inside the unit for waste disposal.

The drum shall be labeled appropriately, identifying

the waste.

➤ The engineering department should shut down the

pneumatic tube station by turning off the power located

at the unit and covering it with plastic and duct tape.


cord the air-pressure differential across the door us-

ing a digital manometer. n

Editor’s note: For more information about the Emergency

Operations Plan Template, go to www.hcmarketplace.com/

prod-7973 or call our customer service center at 800/650-6787.

Another opportunity for us to bring the news to you

One of the great things about the Twitter social network-

ing site is that it saves you valuable time by delivering news

and advice directly to you—rather than you having to search

for this information on your own.

If you haven’t had a chance yet to test drive Twitter,

check it out for yourself with our posts at www.twitter.com/

hospitalsafety.

For those unfamiliar with Twitter, at its core is the ability

for users to post short, 140-character updates—known as

“tweets”—about what they’re doing.

You can keep track of other people’s tweets you’re interest-

ed in (i.e., folks you’re “following”) and also see who’s read-

ing your tweets (i.e., who your “followers” are). You need to

be registered with Twitter to follow someone’s tweets.

Recent tweets from us include updates from our Mac’s

Safety Space blog, the latest developments from The Joint

Commission, and emergency management implications of

a hospital firing nurses who called in during a blizzard.


Center can download a presentation on chemi-

cal incident scenarios that will help you develop

related disaster exercises. Log on to www.hospitalsafetycenter.

com, go the Regulatory Compliance Database, and look in

the What’s New box.



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Tip of the month

FDA warns of StatSpin centrifuge problems

Company already alerted distributors

StatSpin’s Web page doesn’t mention the recall. The

FDA said the company issued a letter to distributors on

February 3 about the centrifuge problems.

You can contact StatSpin about the recall by phone at

800/782-8774, Ext. 6123.

“When users return the recalled units, an upgrade

kit will be installed to upgrade the unit,” according to the

FDA. “If users have a trained technical repair person to in-

stall the upgrade kit, the company will send an upgrade

kit with instructions.”

Joint Commission surveyors could ask about the Stat-

Spin recall, so be sure you have documentation of what-

ever actions you take.

Standard EC.02.01.01, element of performance 11, re-

quires organizations to respond to product notices and

recalls. Distributing recall information to all affected de-

partments is an important aspect that surveyors may ask

you about.

The FDA has qualified this safety recall as Class I,

which is the most serious type of recall and involves

situations with the risk of serious injuries or death.

To read the FDA’s full alert, go to www.fda.gov and

search for the term “StatSpin recall” without quote

marks. n

The FDA has alerted hospitals that a specific model of

StatSpin® centrifuges has an alleged defect that could re-

sult in injuries.

The centrifuges have been recalled by StatSpin, Inc.,

of Westwood, MA, which does business under the name

Iris Sample Processing.

If you haven’t already, bring this topic up at your

next safety committee or biomedical engineering com-

mittee meeting.

Loose pieces could pose a danger

According to the FDA and manufacturer, the rotor

of the centrifuge could break off and separate from the

motor and strike a microswitch so it fails to shut down

the centrifuge.

The loose rotor could also strike the lid of the device’s

housing and possibly eject pieces of the rotor from the

centrifuge.

“These pieces may cause serious physical injury to by-

standers and may expose them to bloodborne infectious

microorganisms,” the FDA said in its February 26 alert.

The affected centrifuges are StatSpin Express 4, Model

#510, serial numbers 00100 through 001679. They were

manufactured and distributed from November 2007

through January 2010.

Telling the disgruntled from the dangerousUnderstand when patients are a threat

Medical facilities, by nature, attract a wide variety of

people, many of whom might be scared, anxious, under

the influence of drugs or alcohol, or mentally unstable.

Many of these facilities have no metal detectors and no

police officers—you can walk right in and have a seat.

Unfortunately, if you’re a healthcare provider, this

high-risk atmosphere is where you work day in and day

out. Staff members at many medical facilities, from phy-

sician offices to large hospitals, become used to deal-

ing with people who may be rude, agitated, or acting

strangely. It can become just another part of the job,

just another day.

Unfortunately, in the case of Dennis Sandlin, MD, it

wasn't just another day. Sandlin was allegedly shot and

killed by a patient he saw earlier in the day at a rural

medical clinic in Cornettsville, KY, December 8, 2009.

The patient, John Combs, was seen by Sandlin earlier in

the day but left after refusing to provide a urine sample

in order to receive prescription narcotics. A report that

followed an investigation by the Occupational Safety

and Health program, overseen by the Kentucky Labor

Cabinet, indicated that the patient allegedly told staff

members he would be back.

The incident highlights the risk medical profession-

als face every day and the need for staff members to rec-

ognize a dangerous situation and take threats seriously,

says Bill Abney, of TRACE Fire, Safety & Risk Manage-

ment Consultants, LTD, in Richmond, KY, who spoke at

a symposium in Hazard, KY, held in response to Sandlin’s

death.

“There’s no silver bullet to address this issue,” says

Abney. “If you look down at the [security] risk factors

for businesses, certainly healthcare fits—it’s community-

based, offers a service or has goods that are high value,

and is in such close proximity with the people.”

Abney says training for all healthcare staff members is

especially important because of the nature of treating pa-

tients. He notes that healthcare providers must be in close

quarters with patients and are often alone with them,

which makes it even more critical to educate staff not

only about a workplace violence plan, but when to start

implementing it.

“You have to really sit down and determine what

you’re going to consider workplace violence,” says Abney.

“Is it a threat when someone tries to intimidate you? Or is

it when physical violence occurs?”

He says it’s essential to remember that security profes-

sionals are more likely to already know when to inter-

vene and start implementing a course of action, but staff

members may not. It’s vital to pass on that information

to frontline staff members, making it clear when staff

members should call security or local law enforcement.

Teach staff to recognize a threat

Most well-trained security experts understand that the

longer a potential issue is allowed to continue, the more

likely it is that violence will occur. Frontline staff mem-

bers are often told to call security when there is an issue,

but a better definition of what constitutes an issue may

be necessary.

“We can no longer take threats as idle threats,” says

Fredrick Roll, MA, HCPA-F, CPP, president and prin-

cipal consultant at Healthcare Security Consultants, Inc.,

and Roll Enterprises, Inc., in Frederick, CO. “You need to

call security or law enforcement right away.”

Telling staff to err on the side of caution is critical, says

Roll. However, he adds that security should be cognizant

that ultimately, the human element can get in the way.

> continued on p. 2

May 2010 Vol. 6, No. 5

Page 2 Healthcare Security Alert May 2010


Dangerous < continued from p. 1

“What often happens is people sense something is

wrong, but they don’t do anything about it, or they are

afraid to do something about it because the patient might

complain about them to someone else,” says Roll.

Greeters and receptionists can be particularly useful

in identifying something going awry; however, if they’re

not trained appropriately, they can’t help.

“We sacrifice that person out there in a lot of cases.

In EDs, for example, we’ve got a lot of protection for

the nurses and the doctors in the treatment area, and

then there’s the lonely receptionist sitting out in the

middle of the waiting area by him- or herself at 2:00 or

3:00 in the morning,” Roll says, noting that such staff-

ers would most likely welcome de-escalation training

to feel more comfortable in handling a situation before

help arrives. “At least they’d be able to identify when

something is beginning to escalate and know what to

do and how to get help.”

That is not to say physicians and other healthcare

providers aren’t at risk. They should know, especially

when treating a patient in a private room, to stay be-

tween the patient and the door, says Abney. If the pa-

tient is under the influence, security or possibly local

law enforcement should already be aware of the situa-

tion, in accordance to a facility’s specific workplace vio-

lence plan.

Simply understanding what a threat is can be com-

plex. When a staffer is unsure, security or law enforcement

should be called. In the meantime, Abney says it might be

useful to train staff members to listen carefully to what a

disgruntled patient is saying to help determine the threat.

“If a person is giving you an out by using such key

phrases as ‘If you don’t …’ then typically, it’s just an at-

tempt to intimidate staff,” says Abney. But when patients

show no sign of compromise, they are likely to hurt them-

selves or others, he says. “You have to be listening very

carefully to what they say.”

To de-escalate the situation until help arrives, staff

should know that it’s important to attend to disgruntled

patients, giving them attention and letting them know

you are trying to help and that you are not ignoring them.

“At the time that they perceive they’re no longer of any

value to you, that’s when it escalates to the next point,”

says Abney. Although this technique is not 100% proven

to work, it’s a good tool for frontline staff to have, he says.

Customize your planning and training

Eastern Kentucky has had many incidents of medica-

tion-seeking behavior. It’s a well-known problem, accord-

ing to Karen Engle, executive director of UNITE, which

works to rid communities of illegal drug use. UNITE spon-

sored the Symposium for Medical Professionals after re-

ceiving numerous calls from the medical community in

response to Sandlin’s death.

The symposium hosted about 375 physicians, nurses,

and other healthcare professionals from physician offices,

clinics, and hospitals. Engle calls prescription drug abuse

an epidemic in eastern Kentucky—something Abney says

local healthcare facilities must acknowledge when de-

veloping workplace violence plans. He urges facilities

throughout the country to understand local patterns of

drug-seeking behavior.

Staff members should know whether there is a com-

mon drug abuse problem in the area, which drug is most

widely used, what the side effects look like, etc.

Russ Colling, MS, CHPA, CPPHealthcare Security ConsultantColling and Kramer Salida, CO

Steven C. Dettman, BS, CHPADirector, Security and Visitor Support Services Mayo Clinic Hospital Phoenix, AZ

Linda Glasson, CHPA Security ConsultantSuffolk, VA

Steven MacArthurSafety ConsultantThe Greeley Company Marblehead, MA

Anthony N. Potter, CHE, CHPA-F, CPP, FAAFSMarket Director of Public SafetyNovant Health Winston-Salem, NC

Fredrick G. Roll, MA, CHPA-F, CPP President and Principal ConsultantHealthcare Security Consultants, Inc., and Roll Enterprises, Inc. Frederick, CO

Group Publisher: Emily Sheahan, [email protected]

Associate Editor: Tami Swartz, [email protected]

Editorial Advisory Board Healthcare Security Alert

May 2010 Healthcare Security Alert Page 3


and neighboring facilities are posting similar policies. You

don’t want your facility to be the only one around without

a posted policy, he cautions.

CCTV cameras should be hooked up in a visible area

near the front entrance of the clinic or hospital to help

deter people from entering for the wrong reasons, says

Roll. The treatment areas should be separated from the

waiting area, and the receptionist ideally should be physi-

cally separated from the wait area.

“Panic buttons should also be strategically placed

throughout clinics or EDs,” and staff should know ex-

actly what happens when they’re pressed, he adds.

Facilities might also be interested in creating a better

way to track people in your facility, says Roll.

Many large hospitals believe there’s no good way to

track who is in the building, but it doesn’t necessarily

have to be a free-for-all. Roll says some hospitals stop

visitors as they enter the facility and hand them a color-

coded pass.

“If you are there to visit a victim of violence, then

you get a red pass, and it has to be cleared with the pa-

tient and the patient’s caregiver to make sure that it’s

all right. Then security is contacted and will escort the

visitor to the room,” says Roll. Passes are color coded

depending on which area of the facility the person is

visiting. “Then you train your staff to call security or re-

direct any visitors who have the wrong colored pass in

any area.”

Roll says although there might always be some people

who dislike being stopped, security can work with the PR

office to let the public know that the protection the prac-

tice offers outweighs the inconvenience. n

“We as a healthcare community have not tracked the

violence. If you don’t know where your problems are,

what time of day [they’re likely to happen], or what type

of person the problems are going to come from, you’re in

trouble,” says Abney. “If methamphetamines are a prob-

lem in your area, then you would want to train your staff

about what an addict might look like and the actions they

may exhibit,” says Abney. “Make sure that your training

is site-specific. There’s no such thing as just a boilerplate

plan. If it’s not site-specific, you may be giving false secu-

rity to your staff.”

If you can’t get away from the problem, you just have

to mitigate it and provide the best healthcare you can,

says Abney, who notes the problem isn’t just Kentucky’s.

“Emergency rooms have been seeing a rise [in drug seek-

ers] across the country for the last 10 or 12 years; it’s just

escalating so fast.”

Certain healthcare settings may want to drug screen

patients who request pain medication. Staff members

should also know to alert security when a patient shows

up under the influence of drugs and alcohol, and learn

to notice patients who get nervous or fidgety in the

waiting room.

Create a safe environment

Educating staff and customizing your plan to your re-

gion can help you react to potential threats once they are

sitting in your waiting area. But Abney and Roll advocate

preventing potentially dangerous people from entering

your facility in the first place.

You can start at the entrance. If you are a clinic that

does not keep any narcotics, post that information on your

door. If you do, but have a policy that first-time patients

will not receive a medication prescription, that should

also be posted. Any safeguards you have against drug-

seeking behavior should be advertised at the entrance of

the facility.

“You would be surprised how many people will just

turn around and leave,” says Abney, who says this ac-

tion will help stop your facility from becoming a magnet

for drug seekers, especially if you’re in a high-risk area

If it’s been more than six months

since you purchased or renewed your

subscription to BHS, be sure to check

your envelope for your renewal notice or call customer

service at 800/650-6787. Renew your subscription early

to lock in the current price.

Don’t miss your next issue!


Page 4 Healthcare Security Alert May 2010

Editor’s note: Healthcare Security

Alert provides expert answers to your se-

curity questions. Steven MacArthur,

safety consultant at The Greeley Company,

a division of HCPro, Inc., in Marblehead,

MA, answers this month’s queries. If you have a security

question for one of our experts, e-mail Associate Editor Tami

Swartz at [email protected].

Ask yourself these questions as you create your in-

ventory. They should help you assess whether an up-

grade of some sort is necessary.

What do regulations say about handcuff use?

Handcuffs are a very dicey thing to undertake at

this point in hospitals.

The position of the Centers for Medicare & Med-

icaid Services (CMS) is really one of ensuring that

handcuffs are only used for forensic/criminal pur-

poses. Check out the full details in CMS’ Interpretive

Guidelines (section 482.13[e] of the State Operations

Manual).

If you’re using handcuffs to hold someone you

found breaking into offices, then that’s outside of the

scope of CMS interest. But if handcuffs are used on a

patient, there are likely to be fines and the increased

potential for a full-scale CMS survey.

There is a delicate balance that needs to be main-

tained on this, so any of you using handcuffs must be

careful as you move forward, especially when defin-

ing and educating the security officers about the rules

of engagement. Security officers have to be absolutely

clear about the whens and when-nots. n

Editor’s note: If you’d like more tips on security and other

safety-related topics, visit Mac’s Safety Space at http://blogs.

hcpro.com/hospitalsafety.

Questions of the month

How do I assess my hospital security camera system?

Contact Associate EditorTami Swartz

Telephone 781/639-1872, Ext. 3165

E-mail [email protected]

Questions? Comments? Ideas?

How do I assess my hospital security camera

system?

It’s important to know whether your security

camera system is working correctly and giving

you the results you expect. One way of going about it

would be to create an inventory, by location, of the de-

vices you have now—cameras, digital video recorders,

etc.—and look at each location as a function of what

type and quality of image you would need if you had

to respond to some sort of event.

Ask yourself the following questions when perform-

ing your assessment:

➤ Is it necessary for the picture to be in color, or

would a high-resolution black-and-white image

be sufficient?

➤ Are there locations for which you might not

know right away that something had happened?

In such cases, you would want to have a system

with the ability to review and retrieve images

fairly quickly. (I have sat for far too many hours

watching a blurry VCR tape trying to find a useful

image.)

➤ Is a static image sufficient, or would you be best

served by having the capability to pan, tilt, and

zoom the image?

➤ Can you make use of your IT network?

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