Believe in better—A sunsetting of the focus on the physical environment

This is rather more of an aspirational post (i.e., a rant) this week as the evidence from the field shows no sign that the unsettling depths of physical environment findings are likely to decrease any time soon. At risk of sounding like an elderly neighbor telling the kids to stay off their lawn, I keep looping back to the notion of whether the accreditation survey of the physical environment actually leads to improvements in the effectiveness of how organizations manage the care environment. Or, perhaps more correctly, whether the accreditation survey process is supposed to help organizations improve the management of the physical environment.

I’ve been at this for a long time, and I must confess that some of the areas of focus mystify me from the perspective of this whole undertaking as a performance improvement activity. And a lot of that has to do with how the applicability of whichever code (and whichever edition of whichever code) comes into play in the hands of a surveyor. The Life Safety Code, as a reference, at least gives us a clear delineation between new and existing facilities, but the introduction of NFPA 99 as an “official” part of the canon (it was always in the mix but gained headliner status when CMS officially adopted the 2012 edition in 2016) results in a different applicability because it boils down to whether the building that’s being surveyed is a “healthcare facility” or not. And, as we’ve come to know (and love), healthcare facilities come in all shapes, sizes, degree of antiquity, etc.

Nominally, that means (meant?) that anything that was in place before the official adoption date in July 2016 would not have to comply with the specifics of the 2012 edition of NFPA 99 until there were significant enough renovation, etc. activities to warrant the upgrade. But lately, I’ve come across some findings in which a facility was designed, approved, and constructed between 2012–2014, but found to be out of compliance with an edition of NFPA 99 that had not yet been adopted (that being the 2012 edition).

I also know that when it comes to compliance, the simplest approach is to deal in absolutes, mostly because absolutes are the easiest thing to police. Think about all the risks to be managed that, over time, have become absolutes—storing stuff under the sink, uncovered clean linen carts, cardboard boxes on the floor. (OK, we’ll just put them on an ugly old wooden pallet that never gets moved or cleaned.) But those absolutes end up driving more findings in the environment and driving less in the way of materially improving the management of the environment. Any given day, one can do a walkabout at any hospital anywhere and find things that need repair or replacement –and do that takes time. As I like to say, squalor happens incrementally – if you don’t have an effective process to identify those things that need repair or replacement, then you won’t have an effective means of correcting those things you identify. But it’s always going to take some element of time – I don’t know of too many organizations that have the resources (and I will include access to the areas that need attention as a resource – perhaps the most important of all) to be able to instantly correct those pesky wear and tear issues. And if those wear and tear issues get away from the process, then surveys, etc. should identify that an effective process is lacking.

But, even in the face of all that, one has to hold on to the notion that the care environment can be appropriately managed (notice the use of “appropriately” as opposed to “perfectly”) – we have to believe in better – or what’s the point?

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.