Mac’s Safety Space: What is required by code or regulation…

…versus what is required in order to keep patients safe.

As I think has been established (for pretty much all time), when it comes to the vehicle of compliance (particularly as a function of sustainability), the color palette is very much an infinite set of shady grayness (or gray shadiness – your choice!).

Starting with the physical environment portion of the Conditions of Participation, the actual requirements (such as they are) are really more like an umbrella that is to be used in any weather conditions—or any risk conditions, under which the management of risk can be customized (so you only have to do what you need to). So, we set off on this journey with all the best intentions—relying on learned resources, things that are spelled out more succinctly in professional codes, basing our strategies on the instructions for use (IFU) provided by manufacturers, and so on.

But then we have to wait for the survey interaction with a surveyor who knows something about our organization(s), but certainly not everything, to determine if the choices that have been made measure up to the expectations of surveyors (and, as more and more folks are experiencing, the gaps between what is and what is expected can be a great deal wider than anticipated).

But sometimes the gaps manifest themselves outside of the survey process.

With that in mind, I would encourage you to check out a recent article in Health Facilities Management, that outlines the steps taken in response to several cases of healthcare-acquired infections (HAI) in cardiac surgical patients at a hospital. The HAIs ended up being traced to bacteria in ice and water machines on a patient unit, with the likely source being the municipal water supply (I don’t want to give away the whole story).

The “kicker” is that the ice and water machines in question were being maintained in accordance with the manufacturers’ IFU, but it was determined that the recommended process was not enough to prevent a biofilm on the internal components of the machines. Certainly one of the “lessons” is that ice machines and/or water machines are, essentially, a one-size-fit- all proposition and are not necessarily “ready-to-use” in an environment in which you have immunocompromised patients.

As has frequently become the case over time as a function of the risk assessment process, it becomes a question of do you stop the assessment when you’ve done enough or do you have to push beyond that to the land of “more than enough.” Recent survey results would seem to indicate that, for the big-ticket items—particularly those that reflect on the management of patient safety, there is a clear intent on the minds of the regulators that enough isn’t really enough anymore (kind of makes my head hurt a little bit).

I absolutely understand that the focus has to be on infections acquired during hospital stays—they cause too much harm and have to be considered “preventable,” so it might not be a bad time to reflect on the general question—how do we know that what we are doing is effective? Compliance with a standard or regulation might not be enough.

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.