SDS Accreditation Update

Standards focus on risk assessment

Falls NPSG applies only to hospital-based programs

One way to make sure your outpatient surgery program is covering all of its bases to prevent patient falls is to carefully review accreditation standards and National Safety Patient Goals, says Jeanne Linda, RHIT, CPMSM, CPHQ, director of medical staff services and quality review at San Leandro (CA) Surgery Center.

Although her center is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC), Linda also reviews the Joint Commission on the Accreditation of Healthcare Organizations' National Patient Safety Goals, especially the goal related to prevention of patient falls (Goal 9).

Although Goal 9 of the NPSGs applies only to outpatient surgery programs surveyed under hospital standards, there are standards that require ambulatory and office-based surgery centers to look carefully at assessing patients' risk for falls, says Virginia McCollum, RN, MSN, associate director of the standards and interpretation group at Joint Commission. "Standard EC.1.10 requires managers to assess the safety risks to patients. An organization should assess a patient's risk for falling during the initial assessment," she says. Evaluate the patient's age, medications, and the patient or family member's reports of previous falls, she suggests.

Look carefully at the physical environment of your facility as well, suggests McCollum. "Hallways should be at least 44 inches wide, and floors should not be slippery," she points out. Bathrooms should be designed to follow the guidelines set by the American for Disabilities Act, McCollum adds. "Hand bars, emergency call lights, and railings on the beds are all important," she says.

Surgery programs are responsible for the safety of patients outside their doors even if they do not own the building, McCollum says. Because surveyors trace a patient's entire trip through the visit to the surgery program, the condition and location of the parking lot, the patient drop-off area, sidewalks, hallways, stairs, and elevators will be evaluated, she adds. "Work with the owner of the building to make sure that all safety requirements are met," McCollum suggests. Make sure that the building owner knows to check for cracks in the sidewalk, uneven pavement in the parking lot, and icy patches during the winter, she adds.

Monitor incidents and evaluate reasons for falls on an ongoing basis, suggests McCollum. "Once you've evaluated the reasons for falls, be sure to develop and implement plans to reduce the risk of future falls," she adds.

It is best to be proactive, says Linda. "Even one fall can be devastating to the patient, the staff, and the facility," she says.


  • Joint Commission on Accreditation of Healthcare Organizations' web site has a frequently asked question section related to the patient falls' National Safety Patient Goal. While this goal applies only to hospital-based programs, it offers guidance on development of a falls prevention program and suggests resources. Web: Under "Patient Safety" on top navigational bar, click on "National Patient Safety Goals." Under "2006 Resources," look for "Frequently Asked Questions." Choose "Goal 9."
  • The National Guideline Clearinghouse offers research and clinical practice guidelines on a range of health care issues. Go to and type "falls prevention program" in the search box. More than 60 guidelines appear, including: Guideline for the Prevention of Falls in Older Persons. American Academy of Orthopaedic Surgeons — Medical Specialty Society, American Geriatrics Society — Medical Specialty Society, British Geriatrics Society — Medical Specialty Society. 2001 May. Nine pages. NGC:002199.