Can you manage behaviors through a policy?
Happy New Year! I wish for each of you a year full of exceptional compliance and further embracing of the management of the physical environment as a shared responsibility—together we can make this work!
One of the truisms of the compliance biz is that it is very difficult to argue your way out of a finding if that finding is the result of your organization failing to comply with its own policy/practice. And, when playing the role of a persnickety surveyor and engaged in a review of written policies, I tend to look for those instances in which the likelihood of absolute consistent compliance is somewhere south of 100%. I suppose the analogue to this is the use of absolutes in policies; as has been mentioned once or twice in the past, absolutes are the easiest thing to police, but can back compliance into a corner, so to speak. Again, when I’m reviewing policies, I’m always looking for those self-imposed requirements that are oh-so-difficult to pull off operationally. A classic example is under-sink storage. Somewhere there is a sink with stuff under it (usually flower vases, sometimes other things), but if the policy says “nothing stored under the sink” then nothing is all that should be found, or it will generate a finding. As a related note, The Joint Commission’s FAQ on the topic tells you all you need to know about working this one through (and if your bingo card had “risk assessment” on it, you could be a winner).
All that said, as we embark upon the new year, I would encourage you (as you start your review of policies, perhaps as part of the annual evaluation process) to look carefully for those compliance “corners” that don’t provide enough operational flexibility. And, as you’re rounding and encounter compliance gaps, ask the question: is there a way that we can support operational efficiencies while maintaining compliance with any applicable code, standard, or regulation? Use compliance gaps as an opportunity to provide education to the folks at point of care/point of service. Help them understand why it’s important and not just a “because I said so” requirement. Maybe you’ll convince some folks to embrace the challenge of compliance—what could be a better way to start 2025!
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.