Spa services can bring hidden risks if not assessed

By Marva West Tan, RN, ARM, FASHRM
Risk Management Consultant
MW Tan Communications
Marietta, GA

A claimant alleged that she had developed a severely infected finger that required surgical drainage and intravenous antibiotics following a manicure with dirty implements at a beauty salon located on the hospital campus. The plaintiff named the hospital, the salon manager, and the nail technician as defendants. Investigation of the claim revealed that the managing cosmetologist, an independent contractor, had not verified current licensure of the uninsured nail technician and that there was no consistent method for disinfecting nail implements between clients. The hospital risk manager had not conducted a risk assessment of the on-site beauty salon, which was new to the hospital facility, before the salon opened.

An unlikely claim for a hospital? Perhaps not for long, as hospitals seek to expand profitability by adding spa services, such as massage therapy, aromatherapy, reflexology, manicures and pedicures, to their wellness program. Even hospitals that do not undertake a full hospital-based spa program may arrange for a cosmetologist to come on site and provide beauty salon services in a hospital-owned space.

Besides adding another revenue stream to hospital services, spa services have other benefits such as meeting patient demand for a full range of complementary/alternative medicine techniques, supplementing a holistic wellness program, and increasing patient satisfaction through stress reduction and improved self-image.

Hospitals with long-term care services may find that offering full or partial spa services enhances the quality of life for their residents. Spa services not only pamper patients, but also may offer clinical benefit. For example, early research indicates that massage therapy may be useful in treating depression, chronic pain, immune and autoimmune conditions, and improving weight gain in pre-term infants.

As with any new service, the addition of spa services to the hospital setting introduces new risks as well as benefits.

Conduct risk assessments of all new services

Ideally, the risk manager should conduct a risk assessment of every new clinical service so that risks are identified and addressed before the services are implemented. Promote these prospective risk assessments as a valuable service provided by the risk management department. Develop good rapport with senior management, department heads and clinical chairman so that you will be kept informed of any new services that are being contemplated. If you hear about a possible new service, discover who is on the planning group and ask if you can participate in the planning process. Seek advice from your manager on the best way to become involved in new program risk assessment within your environment.

If you achieve access to evaluate risks of a planned new service, do some research about the proposed service to learn the terminology, relevant national associations, major risks and claims history or adverse events in other settings, if possible. Develop an organized approach to assessing risks of new services and programs using risk management principles. Consider professional and general liability factors, operational issues, construction risk, employment liability, compliance issues and financial risks.

The American Society of Healthcare Risk Management’s Self-Assessment Tool for Risk Management Programs & Functions, 2nd Edition, Appendix D, contains an extensive list of risk factors to consider when evaluating loss potential that could be used as the basis for your own checklist. Be supportive to the planning process by suggesting strategies to address any identified risks rather than only pointing out the possible liabilities of the new service.

Major risks of spa services

Initially, assessing the risks involved in providing massages and manicures may seem very different from the usual world of hospital risk management. But, on reflection, spa risk factors fall into familiar categories, including the few areas discussed below.

Financial risk

A 2001-2002 Health Forum/American Hospital Association Complementary and Alternative Med-icine (CAM) Survey of 502 hospitals with CAM services found that the greatest obstacles to successful implementation of CAM services were physician resistance, budgetary constraints, lack of internal expertise and credentialing. Spa services are likely to face similar obstacles to "breaking even" unless marketing clearly promotes the clinical links that differentiate hospital-based spa services from commercial spas in the community. Physician resistance to spa services may be reduced by education about the growing patient demand for expanded CAM services and the emerging body of research literature addressing the value of selected spa services. Some medical services, such as dermatology, plastic surgery or physical medicine, may be interested in forging closer clinical links with spa services.


Credential all spa therapists and technicians using a formal system similar to the allied health or CAM practitioner process. At a minimum, verify licensure and conduct a background and reference check. If your state does not license or regulate a specific category of spa worker, national associations, such as the American Massage Therapy Association, can provide guidance on expected levels of training, education, experience, and skills. Some therapists, such as massage therapists, may have completed a national certification such as the one offered by the National Certification Board of Massage Therapists and Bodywork.

Delineate privileges if therapists will offer specific clinical treatments such as manual lymph drainage for post-mastectomy arm edema. Check credentials even if salon staff will be independent contractors working in hospital-owned space. Don’t learn from a claim that an independent technician working in your hospital has a felony theft or sexual assault record.

Confidentiality and privacy

Stress the importance of patient confidentiality and privacy for all spa staff. Gossiping with clients at the beauty salon takes on different implications when the salon or spa is hospital-based. All staff must protect the privacy of the physical person as well as patient/resident clinical information.

Because patients undergoing some services may be partially or completely unclothed, insist on staff maintaining appropriate boundaries to avoid allegations of sexual misconduct. The American Massage Therapy Association has a code of ethics addressing these issues.

Infection control

Spa services involve considerable direct contact with patients, which increase the risk of hospital-acquired infections. Stress careful hand washing and maintenance of good infection control practices regarding linens, solutions, equipment and water therapies. Contact your local board of cosmetology regarding sanitation methods. Check out fire safety implications before recommending alcohol-based hand rubs in the spa area. Involve your infection control practitioner in review of the planned spa programs.

Fire safety

Because flammable liquids, such as nail polish and remover, and electrical equipment, such as hair dryers, will be intensively used in spas or salons, conduct a careful fire safety inspection of planned use and storage of flammable materials and electrical appliances. Involve the safety officer or your local fire department.

Policies and procedures

Develop appropriate policies and procedures for spa services, such as whether a general physician order or approval is adequate or whether in certain clinical situations, such as pedicures for a diabetic patient, services require a specific physician order. Spell out who will provide supervision and the supervisor’s responsibilities.

Supervision may be a foreign concept to therapists or cosmetologists accustomed to working on their own. Orient all staff, including employees and independent contractors, about what to do in case of a patient/resident emergency.

Word marketing materials carefully

Insurance risks

Identify professional and general liability risks and determine how to address these risks. If the hospital does not provide liability coverage for spa staff and premises, require proof of valid insurance in adequate limits from the salon manager and each therapist or technician.

If there are any contracted spa or salon services, have the hospital attorney review the contract. Assure that any indemnification clauses are favorable to the hospital. Try to reduce the risk of "apparent agency" claims by making it clear to the community and patients that the spa or salon staff are independent contractors. Post appropriate signage in the hospital spa or salon area. Word spa marketing materials carefully to avoid taking on unnecessary liability. For example, avoid use of words such as "the hospital’s" skilled spa staff.

To sum up, be sure you follow these four steps if there is a spa service within your organization, or if one is planned:

1. Market the risk management program so that you will be viewed as a valuable resource for the planning process.

2. Don’t be intimidated by an unfamiliar clinical service or new technology.

3. Apply risk management fundamentals to developing the assessment plan.

4. Tap into available resources, such as national association web sites, professional literature, other risk managers and practitioners working in the proposed field in another facility.