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Posted At : December 5, 2008 3:45 PM
| Posted By : Steve MacArthur
Related Categories:
Security
If I may continue on the topic of security officers getting pulled into the role of caregivers . . .
Time and again, I have seen security directors bemoaning the positions they find themselves in: patient watches spread all over an ED, multiple patients being assigned to a single officer (because that’s all that is available), and entire shifts of security officers tied up in the ED watching patients. The litany of, at best, untenable situations in which security staffs find themselves continues to grow.
And again, this is not a knock on security officers, who are generally very well-educated and competent in their role as security officers. But they are not educated as caregivers, and I believe that when we are looking at best care for these patients, caregivers are indeed what is needed (and not just sitters).
These patients are in crisis, and this thought of security keeping an eye on them just doesn’t translate into appropriate care. I’ve worked with security staffs over many years of my healthcare career and I can say with all honesty, if I had a family member in crisis, I would want them to be observed by someone competent in the whole range of potential issues, not just “making sure they don’t get up off the bed” or “making sure they don’t get out of the room.”
During those tense moments of crisis, security absolutely should be involved, but once the situation is under control, the patient should be handed off to a caregiver.
Posted At : December 3, 2008 2:06 PM
| Posted By : Steve MacArthur
Related Categories:
Security
Howdy blogspotters!
There was an article in The Boston Globe in November regarding the rise of incidents involving combative patients in Massachusetts emergency rooms that I thought was worth bringing to your attention, primarily (as I see it) because you are either already experiencing this phenomenon or you will be. I don't think there's anybody involved in healthcare safety and security who will remain unscathed on this one (a little hyperbolically apocalyptic you might say, but I don't think so).
Over the course of my career (more years than it's comfortable to consider), I've had the opportunity to observe the arc of patient behaviors in the direction of, shall we say, more aggressive actions. I think there's been a great deal of societal shifting that's resulted in this (people with virtually any reserves of patience are becoming a bygone artifact), as well as a diminution of the services provided to those folks who might be considered at greatest risk (from a psychological/medical standpoint).
As with the rise of the various and sundry healthcare plans that end up encouraging (for want of a better word) patients to seek out EDs to manage whatever might be ailing them, the hospital emergency room has become a fulcrum of acuities, symptoms, (sometimes unrealistic) expectations, attitudes, preconceptions, impatience, and so on. It seems that EDs have become much like vacuums in that no matter how big they are, there's always enough "stuff" to fill them.
In looking at the above-noted article, I cannot help but reflect on what I think is the defining (or perhaps overarching would be le mot juste) question: Are we managing this condition/situation/patient population to the best of our abilities? Or more to the point: Is this what good, quality care is about?
In many instances, the answer is a resounding "no"! The Globe article referenced (and I'm interpolating a bit here) the thought that one of the causative factors is the lower profile of security staff as a function of efforts to be more customer-service oriented, and to be honest, I have a hard time thinking that that is anything but a red herring.
My experience has been (almost uniformly) that security’s ability to respond to crisis situations is almost completely mitigated because they are tasked to take over the management of the “at risk” behavioral health patients (which would also include those addictive personalities).
In hospital after hospital, I see a continuing rise in the use of security officers to “watch” patients. Now I have no quibble for the most part with the need for these patients to be provided some sort of oversight. From a care as well as a liability standpoint, we have no real choice to do otherwise.
What I do continue to take issue with is the use of what is generally a very finite resource (security staff) to function, even if only at a de minimus level, as caregivers.
More on this next time . . .
Posted At : December 2, 2008 10:52 AM
| Posted By : Steve MacArthur
Related Categories:
Security
A while back I was conversing with someone at an organization about the use of handcuffs and pepper foam by security officers.
Handcuffs are tricky because of the forensic restraint issue. I don't know of too many, if any, security forces in my travels who use cuffs that have not received special police designation from the locals. If you’re considering handcuff use, my suggestion would be to canvas some of the other hospitals in your area to see if they're using cuffs.
As for pepper foam, I know from personal experience at the hospital where I first started working that the local police would never allow security services, contracted or otherwise, to carry pepper foam. Depending on where you’re located, your state or police might require pepper foam carriers to have a firearms identification card issued by an agency. You definitely need to tread very carefully on this one.
Someone on HCPro’s Patient Safety Talk listserv recently asked about using alcohol-based hand sanitizers in psych units.
The key here is whether the results of your organization's risk assessment indicate that you can safely place the dispensers in that particular care environment. A psych patient population is absolutely unique to a given organization, and when it comes to matters of safety as a function of medical condition/diagnosis, you really need to use that uniqueness (uniquity?) as the basis of the evaluation.
Also, consider these concerns:
- What product do you use? Foam-based products might be a little safer in a psych application than a liquid.
- How is the psych environment configured? Is there a safer way to install the dispensers?
Particularly with the likely scrutiny of this type of a thing as a function of The Joint Commission’s National Patient Safety Goals, there will be any number of folks who will take issue with whatever you end up doing. The psych safety zealots will condemn you for using the alcohol-based hand rubs and the infection control zealots will chastise you for not using the product.
I'd work the process through and base the decision on what will work for your patient population.
Hi everyone, it's Scott Wallask logging on today.
I just wanted to remind all Hospital Safety Center subscribers that the latest issue of Briefings on Hospital Safety is available online.
You can check out the following articles:
- An overview of the challenges coming in The Joint Commission's new life safety chapter
- Why one hospital endured a tough CMS review following two patient suicides
- How moving patients to new buildings offered two hospitals chances to fine-tune their evacuation plans
If you're not a subscriber to the Hospital Safety Center and want to learn more, click here.
Posted At : October 2, 2008 4:56 PM
| Posted By : Steve MacArthur
Related Categories:
Security
A story getting some attention up here in Massachusetts has to do with an apparition of the Virgin Mary on a window pane of an office building at Mercy Medical Center in Springfield.
Brushing aside religious discussions, to me an interesting aspect is that 500 people showed up on hospital property on Wednesday to view the image, which is on a window of an unoccupied office, according to The Republican of Springfield.
Think about the following security-related concerns that have cropped up Mercy Medical, and how they might apply to more urgent incidents:
- Police have been called in to direct traffic in the area
- Hospital security officers have worked to corral the onlookers to one end of the facility’s parking lot
- Gatherers have placed flowers and votive candles at a makeshift shrine near the entrance
As you’d expect in this type of situation, the crowd has been peaceful. But if a throng was more unruly, 500 people outside the hospital would present challenges to any security department, particularly if police couldn’t immediately assist.
Back in 2003, another Massachusetts medical facility, Milton Hospital, had to deal with 25,000 unexpected visitors over a two-week period after it, too, became home to an window apparition of Mary.
That hospital had to exert some unusual tactics, such as asking onlookers to only come between 5:30 p.m. and 8:30 p.m. each day to view the image. During “non-viewing” hours, the hospital put a tarp over the window containing the likeness. The facility also had to hire extra security officers.
How would you deal with hundreds of onlookers outside your hospital?
Someone asked me about whether clean and dirty utility rooms need to be locked. The short answer is no, a clean utility room does not have to be locked, at least in terms of a regulatory requirement.
The longer answer is the overriding expectation that organizations will, as a function of the safety and security risk assessment process, identify those areas in which access and egress must be controlled due to the nature of the contents, accessibility of contents, etc.
A soiled utility room is somewhat similar in that, again, the risk assessment process would come into play. However, the risk assessment process will probably have to go a little bit further due to the fact that there are sometimes regulatory requirements at the state or local level that must be taken into consideration, as well as taking into account patient populations, etc.
For instance, in Massachusetts, the state public health regulations require soiled utility rooms to be locked. I don't necessarily agree with this--I think that if the soiled utility room is in active use for disposal of contaminated materials, having to unlock a door to access the room increases the exposure risk for staff.
In that light, I have been able to negotiate with state inspectors that the risk of intrusion by unauthorized persons is very small compared to the increased risk of an exposure or spill while trying to access the locked soiled utility room.
That said, there are environments--behavioral health units, pediatrics units, maybe maternity (if there's a fair amount of sibling visitation)--in which the risk of unauthorized intrusion is sufficient to go with securing the soiled utility room (and maybe even the clean utility room--almost certainly with behavioral health).
The first step is to document the decision making process. That way, if the question arises during survey, you will be able to discuss the process and how you reached the decisions that you made, including any interventions.
Let’s talk for a moment about what I like to call “safe-curity”--in other words, the combining of safety and security functions into EC.02.01.01 in the 2009 Joint Commission (formerly JCAHO) standards.
The safety and security risk assessment processes (which includes appropriately managing the risk in the EC) have been folded into EP 3. This will continue to be the general duty clause section of the EC standards; anything surveyors see that they don’t like becomes fodder.
Folks are going to have to be very diligent in documenting the decision-making process when identifying risk strategies. For instance, there is a nonbinding ANSI standard that requires the testing of eyewash stations on a weekly basis; however, if any organization chooses to test at a lesser frequency, it must have a documented risk assessment supporting that decision, otherwise a citation can occur.
I can see similar risk exposures relative to under-sink storage, management of crash carts, handling IV solutions, and all that.
I recently chatted with someone about items you need to monitor in the EC.
There are myriad activities, primarily represented through the "C" elements of performance (EPs) in the EC chapter, that revolve around the "care and feeding" of the care environment--medical equipment, life safety equipment, emergency power equipment, conduction of safety rounds, and the like.
A solid EC program is going to have a process for monitoring compliance with all these "have to" elements, just to ensure that the EC program’s baseline competencies, if you will, are in place and functioning appropriately.
Beyond the activities and processes that you "have to do," things get a whole lot grayer in very short order.
The key standard for the rest of the monitoring expectations is EC.9.10 (the hospital monitors conditions in the environment). These expectations are pretty much a function of the risk management process in the care environment. There are six EPs involved in EC.9.10, pretty much divided into constant activities and periodic (at least annually) evaluations of the whole kit and caboodle.
More on this topic in my next post . . .
Did you hear that great sighing sound earlier? In all candor, I have to tell you that I was one of those sighers.
(Is “sighers” a word? Probably not, but the blogosphere can’t rest on such formalities).
The other shoe has dropped, and The Joint Commission 2009 standards changes have (finally!) been posted on the Web.
The question then becomes: Celebration or commiseration? What do we do?
For the moment, it appears that a moderately restrained celebration will suffice. The key words indicating the disposition of the current standards I noted in reviewing the materials are the following:
- Retention--No change in the applicable EP, i.e., the song remains the same.
- Consolidation--A slight change, a blending, if you will, of risk management activities under a general umbrella. For instance, all the safety education elements are now living in one happy house, EC.03.01.01, and, perhaps most controversially, the safety and security standards have become one under EC.02.01.01.
- Split--EPs previously containing multiple component requirements are broken down into the individual components. For instance, EC.3.10, EP #3 under the 2008 standards speaks to the risk management of chemicals, which has been further broken out in the 2009 standards under EC.02.02.01 to reflect the risk management of hazardous chemicals, radiation equipment and lasers, and hazardous gases and vapors.
As near as I can tell (and this has pretty much been the indication as this initiative has rolled out), there are no new requirements, per se. What appears to be changing is more a function of how EPs could be scored during a survey, especially those (banana) splits.
In my client work, I have often compared the current survey process’ arrival at “jeopardy” as not so much death by a sucking chest wound, but more death by a thousand cuts--and the Swiss survey knife appears to have grown a couple more blades. While my obsessive-compulsive disorder has not yet resulted in my counting up the number of EPs in play, rest assured I will.
There is a fundamental constant that every time The Joint Commission deck gets shuffled, there is a likelihood of some resulting confusion, not only in the EC community at large, but also in the surveyor community.
Hi everyone --
It's Scott Wallask at HCPro logging in.
Just a quick FYI, The Joint Commission has posted its 2009 standards, including the revised EC and new life safety and emergency management chapters:
I'm sure Steve Mac will have more to say on this soon on the blog.
Meanwhile, I'd also like to mention that HCPro has an upcoming seminar on September 5 that will dig into all these new standard changes prior to January 1 effective date.
Thanks...Scott W.
Posted At : June 30, 2008 10:01 AM
| Posted By : Steve MacArthur
Related Categories:
Security
I was talking about photography policies and hospital security last week in the blog, and a related concern is media actions during a big news story.
Unfortunately, due to immediate media saturation of almost any event, it is frequently (and to my mind, rightly so) a primary concern of organizations to develop an approach/policy for the management of photography, not only within the walls of the hospital, but also on the grounds of the hospital.
My experience has been that hospitals need to maintain a very strict line on the media, as any precedent-setting "permission" to the media (even for pleasant circumstances) can make it that much more challenging when the media breaches the hospital as they pursue a story that might be considerably less flattering to the hospital.
Thus, it is important to determine ahead of time how much access can be granted, regardless of the situation, and how that access would be managed (preferably in the form of some sort of neutral ground, but that's not always possible).
Yet another interesting risk assessment strategy is to identify a severity score for an unprotected risk, then using a matrix format, identify the interventions you've implemented to manage the risk and determine a score for the "protected" risk.
This works really well with security stuff because of the wide variety of interventions that can come into play (CCTV, access control, panic alarms, alarms, security presence, etc.).
Posted At : June 25, 2008 12:59 PM
| Posted By : Administrator
Related Categories:
Security
I was asked by a grad student last week about hospitals establishing photography policies in light of HIPAA concerns.
There’s a balancing act between maintaining an open care environment (people generally like to take pictures of newborns and other happy events) and the privacy of other patients in the hospital.
That said, fortunately, the types of allowable photo opportunities inside a hospital are pretty limited to those happy moments and so can be isolated to a fair degree. In so doing, it becomes fairly simple to identify those photographic pursuits that would be prohibited.
In the case of photography without permission, it's more a case of regular privacy and, for all intents and purposes, customer relations as opposed to a HIPAA issue. HIPAA, at its fundamental core focuses on “protected health information,” or PHI.
In the first years of HIPAA, there was a lot of angst about what this meant --for instance, some hospitals went to the extreme of not providing any information about patients over the phone, even to verify the patient was actually a patient!
Lately, things have reached more of an even keel as the definition of PHI becomes clearer. Basically PHI involves any information that specifically identifies the patient and his or her diagnosis. If you don't have both elements in place, then you don't have PHI, and if there is no unauthorized release of that combo, there’s no HIPAA violation.
I saw a question on HCPro’s Patient Safety Talk listserv last week asking about whether The Joint Commission requires fencing around exterior generators.
There is no specific requirement in the EC standards regarding the means by which you would secure your generator and any associated equipment, pipes, etc. That said, there are a number of ways that you could be cited if a surveyor believes your security measures for the generator are inadequate, including provisions under:
- The emergency power Sentinel Event Alert
- The maintenance and care of the generators as a function of your utility systems management program
- Safety and/or security risk assessments
My recommendation would be to conduct a security risk assessment, identify any applicable vulnerabilities to things like vandalism, and then carry out strategies for appropriately managing the identified risks.
It may be that your organization decides some strategies make good sense from an operational reliability standpoint and some may not. So long as you document the decision process (with a dash of ongoing monitoring to ensure the chosen strategies are indeed effective), then you should be in good stead during survey.
I caught wind of some recent Joint Commission survey notes, including what came up during an emergency management tracer.
In discussing the organization's preparations for the six critical areas, the surveyor asked if the organization had ever conducted a lockdown drill. Then, upon an affirmative response from the hospital, the surveyor asked about the results of the most recent lockdown drill.
(By the way, in this era of ever-increasing demands for escalating drill scenarios, lockdowns are a nifty way to change the dynamic of even the most basic exercises. And if you're feeling really lucky, try including the lockdown with minimal warning to staff at large--and don't forget to take pictures!)
Then the surveyor asked a kind of interesting question in follow-up: Where does the organization get the manpower to implement lockdown procedures?
I'm not quite sure what prompted the question specifically, but sometimes the ways of the surveyor are many and varied. This issue actually dribbles over a bit into EC.4.16, which requires you to manage staff roles and responsibilities during responsibilities.
Now, for some organizations, staffing a lockdown might be the most simple of tasks, but I'd wager that, depending on the type of event, you might not want to "waste" your designated security resources to implement the lockdown.
In which case, you need a reliable and well-stocked resource pantry, a.k.a. the manpower pool. And also ideally a plan. A poorly handled lockdown, even during a drill, can be a customer service nightmare. "What do you mean I can't come in to see my sick mother?"
Something to think about . . .
How long will you have to mobilize on the first day of your Joint Commission (formerly JCAHO) survey? Presuming that your organization has someone monitoring your Joint Commission extranet site on a regular basis, then how early are they looking? How long will it take for the word to reach you, whoever you might be?
This is a point where one of those nasty little cliches comes into its own: You only have one chance to make a good first impression, and the sooner you can "get to it," the better.
Try to take advantage of some pro-activity as well because setting the stage is key. For example, make sure that there's a process for neatening up those high-profile public restrooms early in the day. Even surveyors have to take a break, and you don't want them to walk into the proverbial pigsty.
Also, ask your security staff on the overnight shifts to keep an eye out for law enforcement officers with a patient in tow. Make sure that the officers at least receive some sort of briefing as to the ways and means of your organization. A number of folks have had success with cobbling together a little brochure to hand out to forensic staff (and contractors, too) to provide them with a broad-stroke overview of your processes.
For some reason, surveyors seem to be attracted to forensic/law enforcement officers, so ensure the experience is a positive one for all involved. You and your HR department (that Joint Commission EP lives in HR standards) will be glad you did.
Posted At : March 6, 2008 4:01 PM
| Posted By : Steve MacArthur
Related Categories:
Security
There was a question on our Safety Talk discussion group today about whether there is a regulation that mandates a pharmacy must have a stand-alone locking system, or whether it can be part of a bigger system.
I've seen some different configurations of systems, and the question also brought to mind a condition I found recently during a consulting engagement. And it also brings to mind that most favorite of subjects, the risk assessment.
In the hospital where I grew up, the folks in the pharmacy were always very insular when it came to their security systems. Every aspect was managed by them, through them, etc., with absolutely no interface whatsoever with the organization at large.
I admit that at first I was a little tweaked by that, but over time I came to realize that pharmacy is an enormous undertaking and the fewer fingers in that pie, the better the likely outcome. During today's discussion on Safety Talk, some folks cited state-level requirements, which should definitely be the starting point for this stuff. But what about those instances in which the state-level guidance is non-existent or just plain not helpful?
Why then you'd do a risk assessment, which kind of leads me back to the initial question of whether the pharmacy's access system should be stand-alone.
Ultimately, I think the decision point is a determination of how impregnable your general access system would be and if there is a chance that someone could violate the pharmacy through the general system. You need to determine your comfort level with how "remote" that chance might be. If that chance exists to a degree, then you need to make sure that there is sufficient "separation" to ensure appropriate security levels.
To take the example in a slightly different direction, recently I visited a hospital in which the "brains" of their infant security system were in a cabinet (albeit a locked one) in a soiled utility room. There were no other defenses other than the locked cabinet--the utility room was unlocked, there were no cameras or other monitoring devices, etc.
Now, we can absolutely stipulate that there is no specific Joint Commission requirement for this one. But the question sort of becomes: Is this really the way we want to set this up?
I know that sometimes you need to go with what your infrastructure can support, but at other times you just have to say, "We've got to find a better way of doing this."
So the question you have to ask yourself--besides, "Do you feel lucky, punk?"--amounts to whether this is the best we can do (whatever "this" might happen to be). And, you know the answer you'd be looking for...
I was corresponding with a plant operations manager recently about using thumb tacks on bulletin boards in patient care corridors.
Because there are no standards-based requirements for bulletin boards, you can pretty much do whatever you feel is a safe practice--which, of course, invokes the mighty risk assessment.
There are one or two concerns you might want to consider along the way:
- The likelihood that a person could use thumb tacks as weapons
- The possibility that someone could ingest the thumb tacks
Don't just think of this in terms of suicidal patients--you might want to extend consideration beyond that patient population and include visitors. And how about pediatric patients? They might be an "at risk" population for mischief.
The other possible issue relates more to the amount of postings on the bulletin boards. Some surveyors have been known to pick on generously configured bulletin boards for increasing the combustible load. In fact, I've witnessed George Mills of The Joint Commission (formerly JCAHO) push the issue a little bit during a survey.
You may end up deciding that the best way to manage the whole thing is to have enclosed bulletin boards with some sort of security hardware. That way the tacks are out of harm's way and the combustible load aspect becomes a non-issue.
I was asked about whether there are any national standards that specify the contents of employee ID badges, and there are none that I know of.
Certainly The Joint Commission requires each organization to identify (as appropriate) "patients, staff, and other people entering the hospital's facilities" (EC.2.10, EP #5), which, of course, leaves each organization the determination of "as appropriate."
That said, you probably want to check your state public health regulations--frequently there are specific pieces of information that they require you to have available to patients via the ID badge (various name components, licensure, etc.). Also, as an added incentive, since the state folks are the ones usually tasked with CMS validation activities, it's probably a good idea to make sure that you're on their page.
Posted At : September 17, 2007 3:10 PM
| Posted By : Steve MacArthur
Related Categories:
Security
As an aside, I saw a documentary not that long ago about security advances in facial and body recognition technology. John Cleese of Monty Python fame was prominently featured.
Regular video footage, though useful, can be defeated via disguise, which is my point with this Cleesian digression. Just remember this little cautionary tale if your security department uses video to monitor suspicious people.
Even though you can't depend on pictures as an absolute identifier (more on identification technology in the future, with a special guest), it is worth checking the video images during your drills to make sure that you're getting the quality (angles, clarity, etc.) that will keep you out of hot water when your boss wants to “go to the videotape.”
Posted At : September 5, 2007 10:06 AM
| Posted By : Steve MacArthur
Related Categories:
OSHA, Security
There’s been a fair amount of media coverage relative to workplace violence in general and healthcare in particular. As safety professionals, we clearly have an obligation to enact whatever prudent measures are necessary to appropriately manage the risks associated with potential for violence in our workplaces.
Since we’ve already talked a bit about risk assessments in general (and by the way, there’s a pretty good assessment form regarding violence and aggression available here), I want to talk a little bit about one of the interventions that seems to be gaining a bit of popularity—the use of armed security officers.
Somehow in the midst of all my work-related activities, I managed to miss the event in Houston in April in which a father was Tasered by a hospital security officer while holding a newborn (use this link to check out the latest on the story, including video footage of the discharge of the Taser).
Even before I saw the footage, I have to admit that I was rather horrified at the description of the event. From a risk management and general liability standpoint, I’m just not keen on aggressively pursuing someone holding an infant (though it appears there was some indication that the father in this case was attempting to leave with the infant in some sort of custody dispute).
I’m seeing the use of armed security officers in hospitals much more frequently, and I am always curious about how well-defined the rules of engagement might be, whether they include the use of lethal force, what education has been provided, how are competencies assessed, etc.
Now you might want to call me a yellow-bellied, Massachusetts liberal type, but I’m really curious about how folks feel about this particular event. Clearly, there are opinions to be had by a great many people, some of whom will probably be involved in the pending lawsuit, but purely as a function of process, what’s up here?
If you were to use this case as a training example, how would you characterize this officer’s actions as a learning experience? Are their improvement opportunities to be had and, if so, what are they? I can’t help but think that The Joint Commission might have similar questions to ask the folks at the Houston hospital in question. If you were in a surveyor’s shoes, what would you say?
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