ED Accreditation Update

Environment of care: Joint Commission wants to know how well your emergency department protects itself

Security and safety of patients and staff considered hot button’ topic among standards for EDs

A hospital invests hundreds of thousands of dollars to install a state-of-the-art security system, but administrators resist conducting drills to educate employees on how to respond, because they’re afraid of sending a message to the community that the hospital is not secure.

A nurse in a busy emergency department (ED) is entering information in a patient’s electronic record when she’s called away on another patient matter. She walks away, leaving the record open and visible on her computer monitor.

Each of the above examples illustrates a threat to an ED’s security — the first highlights a potential risk to the safety of employees and patients, and the second shows a break in keeping records secure.

Security is the "hot button" topic in the area of environment of care these days, according to Steve Wilder, CHSP, of Sorensen, Wilder, and Associates, a consulting agency in Bradley, IL.

Environment of care is the accreditation focus area that requires a hospital to provide a "safe, functional, supportive, and effective environment for patients, staff members, and others who may be in the hospital. Safety, security, equipment maintenance, aesthetics, privacy, access, and physical layout of the facility fall under the umbrella of the environment of care standard.

The Joint Commission on Accreditation of Healthcare Organizations specifies that the environment of care consists of three basic components: buildings, equipment, and people.

Leslie Furlow, PhD, RN, C-FNP, president of AchieveMentors management consulting firm in Tolar, TX, says the element of safety that must be considered under environment of care consists of reducing environmental hazards; preventing accidents; maintaining security; and emergency preparedness.

Furlow further breaks down those components into eight elements:

• Signage

• Access

• Space, size, and configuration

• Physical layout

• Patient flow

• Privacy

• Safety

• Aesthetics

"The Joint Commission is getting much [stronger] in its interest in EDs’ ability to protect themselves," says Wilder. "One of the big concerns is terrorism, obviously. Hospitals are vulnerable targets. The basic concern is, How do we bring in the people who need to be here, and keep out the people who don’t?’ "

The first thing surveyors look at when entering an ED is its physical layout and how access is controlled, Wilder says.

As security concerns have grown, hospitals and EDs have been challenged to make their existing facilities — that in many cases were designed and built during a time when access to a hospital was wide-open — secure yet accessible.

According to Mike Bundy, System Director for Safety, Security, and Emergency Management for Wellmont Health Systems in Kingsport, TN, living up to what you say your facility is going to do is critical when surveyors arrive.

"If you don’t say your ED is a sensitive area, you don’t have the [access control requirements] to meet," Bundy says. "But we’re a Level I trauma center, so any surveyor is going to think that our trauma suites are sensitive areas."

Britt Berek, Associate Director for Standards Interpretation for the Joint Commission, says establishing and maintaining security in the ED can be frustrating, because there are so many issues to consider.

"The ED and the [hospital] nursery are two areas you think of when you talk about security issues." Berek says. "If you’re going to [examine your hospital] for security issues, the ED is where you’re going to wind up."

Wilder says hospitals historically have been reluctant to lock down their EDs.

"They don’t want to give the impression that it’s not safe," he observes.

Security measures to control access range from installing bar gates that prevent access from the ED to other areas of the hospital, to using staff as human gatekeepers to monitor and control access to and from the ED.

Bundy says the two largest hospitals in the Wellmont system, Holston Valley Hospital and Medical Center in Kingsport, TN, and Bristol Regional Medical Center in Bristol, TN, have different security demands than the smaller hospitals in the system.

Patient volume and the risk analysis associated with the community vary from facility to facility, he says. So while armed security guards may be present in the ED in some situations that involve higher risk (e.g., if a victim of a gang shooting is brought into the ED), during times of low patient volume and lower risk (e.g., 10 a.m. on a weekday), there may be no security staff present at all.

Wellmont uses barcode-activated controls to limit entry into the sensitive areas of the ED. Egress from the ED is restricted only under certain conditions, and must comply with Life Safety Codes.

"Security in the ED [can be] problematic," says Berek. "You are trying to make it accessible 24 hours a day, but also to make it inaccessible, in a way, 24 hours a day.

Furthermore, some technology that works well in other locations (e.g., metal detectors) isn’t practical in the health care setting, Berek says.

Wilder points out that hospitals that use personnel for security, rather than relying on technology, seek to establish "an atmosphere of Come in. We’re here to serve your needs, but we are employing a security guard to make sure you’re safe.’"

Further challenging hospitals, Wilder says, is the fact that some environment of care standards are seen as being somewhat ambiguous. For example, environment of care standard EC.1.20 states, "The hospital maintains a safe environment of care." Such standards may be open to broad interpretation, Wilder says.

"Add to that the fact that most of the [Joint Commission] surveyors who are looking at security issues have had no background in health care safety and security," he adds. "There is so much conflict between safety issues and facility management issues, that hospitals now are spending more time to prepare for the environment of care survey than for anything else.

"The environment of care standards are the toughest to be in compliance with now."

Bundy says the ED may be one of the easier departments in a hospital in which to maintain constant compliance with environment of care standards pertaining to security, however.

"We are getting tested every day," he points out. "If you are not ready to control access to your ED, it is going to cause you operations problems on a daily basis. For example, if you can’t keep 30 rowdy visitors out of patients’ rooms in the ED, it’s going to cause problems, and you’re going to know that immediately.

"Our ED is tested every night after 9 p.m., especially on weekends," Bundy says, referring to high-volume times for the ED. "That’s my survey."

Wilder said it’s easy for hospitals to forget that the three components of environment of care — people, equipment, and buildings — are intertwined.

A suggestion Wilder makes to clients is to use the P2T2 formula: people, programming, training, and technology.

"Written programs, training programs, people, and technology all are important, but you have to have all of them in order for the system to work, he says. "We see hospitals that have written programs that are superb, and that have spent thousands of dollars on security technology, but their people aren’t trained to use it, or they’re not staffed adequately."

Hospitals, and EDs in particular, are having to re-educate themselves and accept that EDs can no longer afford to be the wide-open doors to the hospital that they once were.

Wilder says many seasoned ED staff are having to get used to a new way of looking at security.

"No one used to force us to be cognizant of security. No one enforced information [records] security. Now, we have to control access to the ED," he points out. "We have to pay attention to information security. You can’t leave a patient’s confidential information up on an unattended computer screen. You can’t leave charts lying around."

When it comes to terrorism threats against hospitals, one mistake Wilder says he sees rural hospitals make is to assume that, because they are smaller and in more remote locations, that they are immune from terrorist attack, when just the opposite may be true.

"If you look at an inner city hospital, if one comes under attack, you have several others close by that can care for the community," he points out. "But in a rural community, the one hospital might be the only one for 20 miles, and if you take it out, the community vulnerability goes up proportionally."

The Joint Commission has posted a pre-publication edition of the newly revised 2004 standards, including a "crosswalk" that compares the 2003 standards to the 2004 standards, on its web site. The pre-publication edition will be posted online until the official accreditation manuals are published in the fall.

Berek says accredited organizations should keep in mind that the changes to the standards manual are largely organizational and do not change the standards themselves.

"The standards review task force took out some redundancies and also shuffled some of the standards to other parts of the manual," Berek states. "We tried to not change the standards per se; we reorganized and renumbered some things, so some requirements may be in other chapters, and people need to be aware of that." 


For more information on the Joint Commission’s standard for environment of care, contact:

Steve Wilder, CHSP, Senior Partner, Sorensen, Wilder and Associates, 596 North Van Buren Avenue, Bradley, IL 60915. Telephone (800) 568-2931. E-mail: swa@swa4safety.com.

Britt Berek, Associate Director for Standards Interpretation, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5900. Fax: (630) 792-5005. E-mail bberek@jcaho.org.

Leslie Furlow, PhD, RN, C-FNP, President, AchieveMentors Inc., P.O. Box 185, 200 N. Oak Lane, Tolar, TX 76476. Telephone: (254) 834-3333; toll-free: (877) 331-4321. Fax: (254) 835-4993. E-mail leslie@achievementors.com. Web: www.achievementors.com.

Mike Bundy, System Director for Safety, Security, and Emergency Management for Wellmont Health Systems, 130 Ravine Road, Kingsport, TN 37662. Telephone: (423) 224-4000. E-mail michael_n_bundy@wellmont.org.

Pre-publication Edition of 2004 Standards are available for viewing at www.jcaho.org. Click on "accredited organizations," then "hospitals," "standards," and "environment of care." Crosswalk charts that compare current standards with new standards also are featured on the site.