It’s almost impossible to push back when you are not compliant with your own policy

Hospital Safety Insider, June 21, 2018

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Editor's note: This was originally published on Steve MacArthur's blog, Mac's Safety Space.

I’d like to start off this week with an interesting (and hopefully instructive) tale from the field.

I was doing some work recently at an organization that is facing down its final six months of survey window. This was my first visit to the facility and I was working on getting a sense of the place as well as identifying the usual list of survey vulnerabilities.

As we’ve discussed before, one of the things that’s always in the mix, particularly with the gang from Chicago, is the care and feeding of emergency eyewash stations. This particular organization has adopted the strategy of having folks at the department level perform the weekly testing, a sensible approach from my standpoint. I think the most important piece of the weekly testing is helping to ensure that folks who might actually need the eyewash in an emergency actually know how the darn thing works.

The documentation form had two columns, one for the date and one for the signature of the person doing the test. The sheet did not, however, have any instructions on it, which prompted me to inquire as to how folks would know what -- and why -- they are checking, since the purpose is not just to run the water. The response to my inquiry was rather noncommittal, which is not that unusual, so I continued to collect data relative to the process.

So, over the course of the facility tour, we found a couple of eyewashes with missing caps and no clear indication on the testing form that this had been identified as an issue. OK, not crazily unusual, but pointing towards a process that could use some tweaking. A couple of eyewashes with obstructed access provided a little more data.

Then we made our way to the kitchen. No real compliance issues with the eyewash itself, but I noted that they were checking the eyewash station on a daily basis and recording the temperature at that same frequency. Now, the ANSI standard does not require daily verification of eyewash flushing fluid temperature, so I asked about this particular practice (BTW, nowhere else had we seen this practice, at least not yet) and was informed that another hospital in the region had been cited for not doing the daily temp checks. I have not been able to verify that this was an actual survey finding, but sometimes believing is enough to cause trouble.

And then we headed over to the lab, and ran into a similar practice (they were just verifying the temps during the weekly test) and the feedback there was that a College of American Pathologists (CAP) surveyor had told them a story about an individual who had suffered eye damage because the low-temperature water from the eyewash interacted with a chemical. This was not written up as a finding but was relayed as an anecdotal recommendation.

The “funny” thing about all this is that each of the eyewash stations in question are equipped with mixing valves, which pretty much mitigates the need for daily or weekly temperature checks (you want to check the temp when you’re doing the annual preventative maintenance activity). But the more telling/unfortunate aspect of this is that, independent of each other, these folks had unilaterally adopted a process modification that was not in keeping with the rest of the organization (it has been said, and this is generally true, that you get more credit for being consistently wrong than inconsistently right).

Now, one of the big truisms of the survey process is that is almost impossible to push back when you are not compliant with your own policy/practice. And while I absolutely appreciate wanting to “do the right thing," particularly when the survey window is closing, it is of critical importance to discuss any changes with the folks responsible for the EOC program. While I pride myself on not telling folks that they have to do something that is not specifically required by code or regulation, some of the regulatory survey folks don’t share that reticence.

The other potential dynamic for these “mythical” requirements is when a surveyor tells an organization something that doesn’t show up in the actual report. I run into this all the time. They may look at the finding in the report, but what they sometimes react to is what the surveyor said. Compliance has way more than 50 shades of whatever color you care to designate and what works or worked somewhere else doesn’t always work everywhere. So, folks make these changes without knowing what is actually required and end up increasing the potential for a survey finding.

And healthcare isn’t the only pursuit in which incomplete communications (or making sure that communications are as complete as they can be) can have an impact.

At the moment, I am reading “An Astronaut’s Guide to Life on Earth," by Colonel Chris Hadfield. (This, apparently, is going to be the summer for reading astronaut memoirs, be that as it may.) I came across a passage in which Col. Hadfield describes a debriefing following a practice spacewalk in which one of the instructors noted that while Col. Hadfield has a “very clear and authoritative manner," he encouraged the folks participating in the debriefing to not be “lulled into a feeling of complete confidence that he’s right.” As soon as I saw that, I was able to tie it back to the management of surveyors who speak in a “very clear and authoritative manner” and sometimes turn out not to be worthy of complete confidence that the surveyor is correct.

If you are doing something that, in good faith and to the extent of your knowledge, is the “right thing” and somebody -- even me! -- comes along and says you’re not doing that right, never be afraid to ask to see where it says that in the code/regulation, etc. (BTW, I’m not giving you permission to be obnoxious about it!) Surveyors and consultants see a lot of stuff, and sometimes compliance becomes a fixed idea or process in their head, but that doesn’t mean it’s then only way. And if you hear something that makes you think you have a vulnerability (something you’ve heard through that pesky grapevine), talk it out before you make any changes. That gives everyone in your organization a fighting chance at compliance.

As a final note, if you’ve forgotten about Col. Hadfield’s most notable performance (beyond the astronaut thing), check out this YouTube video.

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