Are you threatening me? Do I look like I'm threatening you?

One of the more precipitous aspects of the survey process is the invocation of an immediate threat to health or safety. This would the moment of a survey in which your entire world turns into manure.

Hopefully, such a plight will never darken the hallowed halls of your organization, but there is some indication that this problem has been occurring more frequently of late, so it seemed a good opportunity to cast a little light into this shadowy corner of accreditation lore.

Basically, the ball starts rolling when surveyors believe that they have encountered a situation that has, or may potentially have, a serious effect on someone’s health or safety, and thus requires immediate action to remedy the condition.

The survey comes to a screeching halt, your CEO gets to hear the fabulous news, Joint Commission headquarters near Chicago gets a call, even “appropriate government authorities” are in the loop—it’s all just too lovely. Of course, the impact on your accreditation status can be swift and painful, too. I’ll take root canals for $1,000 please, Alex.

Then there are the things you have to do to get out from underneath this damnation:

• Take immediate action to completely remedy the situation
• Prepare a thorough and credible root cause analysis
• Adopt systems changes that prevent future recurrence of the problem

There are a number of conditions I’ve heard about in the environment of care that have resulted in the invocation of an immediate threat to life and safety. I’ll get into them in my next posting.

Stay safe,

Steve Mac.

smacarthur@greeley.com