Try hazards walk-through to meet safety standards

Familiarizes risk manager, alerts staff

To detect and minimize safety hazards and comply with accreditation standards for safety, Franciscan Skemp Medical Center in LaCrosse, WI, conducts a monthly walk-through hazard surveillance.

The walk-throughs are part of a comprehensive safety policy implemented at Franciscan Skemp, says Saverna Stemper, RN, risk manager and safety officer.

Like many risk managers, Skemp recently has had "safety officer" added to her title and responsibilities. Prior to July 1995, Stemper was risk manager and safety officer for St. Francis Medical Center's acute care, outpatient, same-day surgery, rehabilitation, and hospice services. A merger last summer created Franciscan Skemp Healthcare, and Stemper found her risk management and safety responsibilities expanded, with a focus that includes three hospitals, regional clinics, and nursing homes.

The safety committee is charged with managing the hospital's environment-of-care functions, Stemper says. "The development of a policy was vital to the success of our safety effort, because the policy outlines the purpose, goals and objectives, authority, and procedures for the safety committee and its subcommittees."

Besides establishing monthly walk-throughs, the hazard surveillance policy outlines the formal appeals process for questioned or disputed findings, Stemper explains.

The Franciscan Skemp Medical Center safety committee is composed of administrators, clinicians, and staff from ancillary and support service areas of the hospital.

The hazard surveillance subcommittee is also multidisciplinary, composed of the hospital epidemiologist, a representative from electronic services, an environmental services staff member, a clinician, and the risk manager/safety officer.

Making the subcommittee multidisciplinary ensures that more than one perspective is present when a safety variance or deficiency is identified, says Stemper. "It also ensures that recommendations for improvement will be based on the expertise of people who are well-informed in a number of environment-of-care areas."

Readying for the Joint Commission

During the monthly walk-throughs, the surveillance team checks compliance with the environment-of-care standards, which helps the medical center prepare for the semiannual hospitalwide hazard surveillance surveys required by the Joint Commission on Accreditation of Healthcare Agencies, based in Oakbrook Terrace, IL.

The monthly walk-throughs are beneficial because they give the hazard surveillance team a hands-on feel for the overall safety climate of the facility, Stemper says. They are also useful to the department directors, because they give the departments ample time to correct any safety variances prior to the Joint Commission survey.

Unlike the monthly walk-throughs, the semiannual survey is done in the department, by a department member. "It's a thorough survey, but it is not as consistent as the ones conducted by the hazard surveillance team," said Stemper. "The hazard surveillance team has a formal survey process that remains consistent throughout the organization and across departments."

As risk manager/safety officer, Stemper usu-ally takes the leadership role in the walk-through survey process. She sets up the inspection dates and coordinates the inspection activities. She will likely oversee the data collection and reporting process, follow up on recommendations, and act as the "point person" for staff throughout the inspection.

Department directors are notified two to four weeks before a walk-through survey. The director or a designee is always invited to participate in the walk-through. Including the department director ensures collaboration, signifies an institutional commitment to high-quality patient care, and raises staff awareness of the function and authority of the hazard surveillance team, Stemper says.

Department directors are also given the checklist that will be used during the surveillance. The checklist is based on the Joint Commission standards outlined for each of eight environment-of-care components (safety, security, hazardous materials and wastes, emergency preparedness, life safety, medical equipment, utilities systems, and space). (See a summary of the Joint Commis-sion's environment-of-care standards, p. 15.)

The same checklist is used throughout the hospital, although some departments have specific modifications for their areas (for example, fire safety standards may be different in patient care areas than in storage areas).

Following are some of the issues the Joint Commission addresses during a walk-through survey1:

1. Have hospital leaders planned for the space, equipment, and resources needed to support safely and effectively the services provided?

Are the planning and design consistent with the hospital's mission, vision, and values?

2. Are staff educated about the role of the environment in supporting patient care safely and effectively?

Are staff aware of the physical characteristics and process for monitoring and reporting on the health care environment?

3. Are standards developed to measure staff and hospital performance in managing and improving the environment of care?

4. Is an information collection and evaluation system being used to continuously measure, assess, and improve the status of the environment of care?

Checking staff work practices

The hazard surveillance team also looks at safe work practices, specifically how the staff perform their jobs in light of the environment-of-care components. The surveillance team checks to make sure staff use personal protection equipment when necessary, and that the materials and equipment the staff use in caring for patients are properly labeled, properly stored, and functional.

Stemper cites exposure control -- the disposal of hazardous materials and wastes -- as one aspect of safe practice inspection. "We check to make sure our staff know the proper use of needle boxes, red bags, and the procedures for removing hazardous materials and wastes," she explains.

"For example, we remove used needle containers when they are three-quarters full. If our staff are not aware of or do not meet this particular safety standard, both patients' and employees' safety could be compromised."

Handling safety deficiencies

During the walk-through surveys, one member of the hazard surveillance team serves as a recorder. The recorder notes the deficiencies and variances by listing them under one or more of the eight environment-of-care components.

The recorder documents the type of deficiency, the location, and the primary problem. For example, a ceiling-high stack of boxes blocking a sprinkler in a surgical storage area would be listed as: "Life safety component, surgical storage, boxes blocking ceiling sprinkler."

At the conclusion of the walk-through, a report is compiled and distributed to the department director, the hospital administration, and the director of plant engineering services.

"The report goes to the department director so the director can see what variances were noted," says Stemper. "The hospital administration's report serves to keep them informed of the hazard surveillance team's inspection efforts and any major deficiencies the team identifies. And the plant engineering report alerts this area to the future work orders that will arise as a result of the inspection."

After receiving the hazard surveillance team's report, the department director has 30 days to correct the deficiencies and sign off on the report. Requiring follow-through in writing helps to ensure compliance with the recommendations.

If the department director disputes the findings, he or she can appeal through a formal appeals process. If the safety committee upholds the original findings, it may ask the hospital administration to help determine an improvement plan for that particular area.

"Administrative involvement is especially important when financial expenditures are needed to make improvements in a certain area, and it assures that the variances will be addressed," Stemper explains.


1. Excerpted from the 1996 Comprehensive Accreditation Manual for Hospitals. (Oak Brook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1996), p. 139. *