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Newly published FAQs shed light on common confusions


June 1, 2009

The Joint Commission discusses locked soiled utility rooms, among other topics

In the spirit of its 2009 standards offering greater clarification to help hospital compliance, The Joint Commission has issued dozens of new FAQs, many of which address the EC and emergency management provisions.

Although it’s not spelled out in every FAQ, between the lines, The Joint Commission (formerly JCAHO) wants hospitals to show how their risk assessments justify not adopting recognized best practices if facilities choose alternative approaches, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

Examples of such best practices include conducting infant abduction drills and prohibiting electric fans in patient rooms.

Although these best practices are not defined in the standards, surveyors can review the content of the FAQs as though they are part of the standards—so your risk assessment data must be solid if you’re not using best practices noted throughout the FAQs, says MacArthur, who is also a contributing editor to Briefings on Hospital Safety.

“They’re giving us a laundry list of the types of things that come up during surveys [for which] there isn’t a specific requirement,” MacArthur says. “Anything that comes up on an FAQ is, for all intents, surveyable.”

To read the full slate of FAQs online, go to www. jointcommission.org/Standards/FAQs.

Locked versus unlocked utility rooms

One interesting FAQ addresses soiled utility rooms. Some hospitals lock these rooms for infection control purposes. However, The Joint Commission doesn’t require this step, nor is there anything about this measure in the 2000 Life Safety Code®.

Locking soiled utility rooms may increase staff members’ exposure to bloodborne pathogens by forcing workers to manipulate a locked door when they have an armful of waste or soiled linen to dispose of in the room, MacArthur says.

As an example of competing priorities in the risk assessment process, the FAQ states that locking soiled utility rooms may prevent exposures to patients, especially in behavioral health, geriatric, and pediatric settings, who inadvertently enter those rooms.

Although there are specific patient populations you should be attentive to in this regard, MacArthur hasn’t heard of many instances in which people have taken items from utility rooms in nonbehavioral patient care units, citing some facilities’ fears of IV drug abusers looking for needles.

“But if you think that because of the local culture you have a risk of somebody coming in and hooking a needle box, that’s something you need to take into consideration,” he says. “It’s all part of the risk assessment.”

Along the same lines, check out the FAQ dealing with ID badges, says Cameron Bruce, PE, CSP, president of Cameron Bruce Associates in Orinda, CA.

The Joint Commission requires that “the organization identifies individuals entering its facilities,” which defers to your hospital’s policy. Local provisions may require photo badges for all staff members, including physicians, Bruce says. Make sure that your policies take these rules into account.

Keeping MSDS data ready to go

Two FAQs deal with material safety data sheets (MSDS) and their implementation. One clarifies rules stating that MSDSs are needed not only for chemicals, as required by state or federal law, but also for consumer products (e.g., turpentine) when a hospital’s risk assessment determines exposure rates are greater than that of “normal consumer use.”

The second MSDS FAQ recommends hospitals keep at least one hard copy of appropriate MSDS data. The unstated message of the FAQ is that paper copies be kept in case computers go down in a power outage or other emergency, MacArthur says.

OSHA’s hazard communication standard (1910.1200) requires hospitals to ensure that staff members have access to the appropriate MSDS, should a situation immediately warrant it.

Annual tracking of disaster inventories

In the emergency management realm, an FAQ on maintaining supplies during a disaster response states: “Tracking assets and inventory for a year is recommended in order to accurately ascertain what the capabilities are for the organization.”

Does that mean your hospital must track supplies for one year—a potentially arduous, time-consuming task—or risk scrutiny with surveyors?

Once again, the answer is in the information your risk assessment yields.

“I think [surveyors] are going to be looking for evidence that you know what your supplies are,” says Bruce. Your materials management colleagues might be able to help you assess what resources you’ll need as part of your 96-hour deliberations.

“I don’t know that you have to do exactly what The Joint Commission says [in the FAQ], but you need to show them some kind of assessment or report,” says Bruce.

In the absence of compelling performance data regarding your emergency supply inventory—and until hospitals learn more about how this FAQ is being surveyed—the recommendation in the FAQ is going to be a tough one to ignore, MacArthur says.

Other areas to watch

Double-check your EC and emergency planning compliance against the following items tucked away in the FAQs:

  • When community agencies won’t participate in your emergency planning activities—The Joint Commission requires hospitals to reach out to these agencies—document your communication (e.g., letters, meeting minutes, and e-mails) to prove to surveyors that you did your part. Due diligence may include a hospital administrator communicating with a top municipal executive to explain the importance of working together.
  • “No smoking” signs are not required on doors of rooms where oxygen is being administered if you are a smoke-free campus. Strictly enforce this policy and have signs outlining the policy posted prominently at all major entrances. The FAQ cites the exception under paragraph 8-6.4.2 in the 1999 edition of NFPA 99, Healthcare Facilities.
  • Joint Commission standards don’t prohibit electric fans in patient rooms or laboratories, but many hospitals ban them for numerous reasons, including tripping dangers, fire risks, and infection control—fans blow microorganisms and dust around, the theory goes. The FAQ states that if patients use fans, it may indicate a ventilation or temperature control issue for facilities crews to examine.

That last aspect is the most interesting part of the fan FAQ, MacArthur says. If surveyors see fans in use, he says, they may look at how a hospital manages its heating and cooling systems, which may be another risk assessment to investigate.

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