Briefings on Hospital Safety, May 2017
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April 28, 2017
Joint Commission focuses on suicide prevention rules during surveys
A new focus on preventing patient deaths results in high scrutiny. Here’s what to expect and what to do
Patient injuries caused by self-harm and suicides have long been a problem with hospitals. With behavioral health patients becoming a more prevalent population in healthcare facilities, preventing suicides through thoughtful design has become a priority in most facilities.
It also is about to become more of a concern when it comes to meeting accreditation requirements, and you can expect Joint Commission surveyors to pay more attention to the way your facility helps to prevent suicides.
What will change?
Effective as of March 1, The Joint Commission has ordered its surveyors to immediately start placing more emphasis on the prevention of suicides in hospitals, and will start paying close attention especially to the assessment of potential ligature (hanging) injuries, suicide, and self-harm monitoring, especially in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.
According to Joint Commission literature, the added emphasis on suicide comes at a time of national concern about suicides in the nation’s hospitals, and is meant to be in coordination with the “Zero Suicide” campaign, an effort by several national outreach groups trying to eliminate suicide in healthcare facilities nationwide.
Suicide prevention is also second on the list of The Joint Commission’s Sentinel Event Alerts (SEA), and was the basis for SEA #56, which was issued in February 2016 as a way of bringing attention to the problem. According to that alert, suicide is the 10th leading cause of death, and claims more lives than traffic accidents and more than twice as many as homicides.
Furthermore, The Joint Commission says that care providers often do not detect the suicidal thoughts (i.e., suicide ideation) of individuals (including children and adolescents) who eventually die by suicide, even though most of them received healthcare services in the year prior to death, usually for reasons unrelated to suicide or mental health.
What can you expect?
Hospitals will, of course, have to adhere to the usual Environment of Care (EC) and Life Safety (LS) standards that they’ve always had to when it comes to preparing for surveys, but you can also expect increased scrutiny on standards that were introduced from last February’s Sentinel Alert, including the following:
- EC.02.06.01, which requires facilities to establish and maintain a safe, functional environment.
- National Patient Safety Goals (NPSG) NPSG.15.01.01, element of performance (EP) 1, which requires a risk assessment be conducted that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
- EP 2: Addressing immediate safety needs for patients and determining the most appropriate setting for treatment.
- EP 3: When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
- Provision of Care, Treatment, and Services (PC) PC.01.01.01, EP 24, which requires that if a patient is boarded while awaiting care for emotional illness and/or the effects of alcoholism or substance abuse (think about where you house patients that come in under the influence to sleep it off), the hospital does the following:
- Provides a location for the patient that is safe, monitored, and clear of items that the patient could use to harm himself or herself or others.
- Provides orientation and training to any clinical and nonclinical staff caring for such patients in effective and safe care, treatment, and services (e.g., medication protocols, de-escalation techniques).
- Conducts assessments and reassessments, and provides care consistent with the patient’s identified needs.
- PC.01.02.0, which requires hospitals to assess and reassess patients.
- PC.01.02.13, which requires hospitals to assess the need of patients who receive treatment for emotional and behavioral disorders.
- PC.04.01.01, which addresses patient needs for continuing care, treatment, and services after discharge or transfer.
- Provision of Care, Treatment, and Services (PC) PC.04.01.01, which governs the hospital’s process that addresses the patient needs for continuing care, treatment, or services after discharge or transfer.
- Care, Treatment, and Services (CTS) CTS.02.01.01, which addresses screening procedures for the early detection of risk of imminent harm to self or others.
- Environment of Care (EC) EC.02.01.01, which addresses the organization’s management of general safety and security risks.
In addition, The Joint Commission has indicated in written literature that during surveys, observations of ligature or self-harm risks will be documented, and may issue an Immediate Threat to Life citation in the worst-case scenarios while on-site (Hospital leadership would be notified immediately). Any violations would be written up by surveyors as a Requirement for Improvement (RFI). You and your staff should be able to show evidence or proof of the following to a surveyor that can answer the following questions:
- Has your facility previously identified these risks?
- What is your facility’s plans for removing these risks?
- What’s your organization’s environmental risk assessment process?
In addition, you can expect that surveyors will assess and scrutinize the following situations in your hospital:
- Any plans or policies on mitigation of harm posed by risks while removal of any violations found takes place
- Adequate staffing to support these mitigation plans
- Patient suicide risk assessment processes
- Action plans, as well as policies and practices related to patients identified at risk
- Ensuring staff awareness of a patient’s level of risk
- The organization’s internal processes for improvement, including:
- History of patient safety events and the process for root cause analysis of these events
- Process for monitoring compliance with its policies
- Actions taken when noncompliance was identified
What can you do?
You’re probably asking yourself, “What can I do to make my facility safer?” and you wouldn’t be alone. While many newer facilities are being built with patient treatment areas outfitted to handle the intricate needs of behavioral health patients and other at-risk patients considered high suicide risks, older facilities are struggling to retrofit their existing buildings at lower cost, while trying to remain in compliance with accreditation standards.
Fortunately, there is plenty of advice out there. The Joint Commission recommends the Design Guide for the Built Environment of Behavioral Health Facilities, published by the Facilities Guidelines Institute (FGI), and there are also the design guidelines, published by the International Association of Healthcare Safety and Security (IAHSS), that has lots of information regarding helping prevent patient suicides and harm.
In the meantime, there are things you can do now to assess your facility, and take measure with your staff to help cut down on the risk. Experts say you should consider the following:
Decrease boarding times. Many safety experts say that long waits are major precursors to violence and anxiety among patients, especially to behavioral health patients, forensic patients, or any others prone to harming themselves or others. Anything you can do to cut current waiting times and keep boarding times down will help to decrease the risk of violence or suicidal behaviors.
“Sometimes at least half our ED psychiatric patients are being boarded, often for eight hours or more or even several days,” says Peter Charvat, MD, an ED physician at St. Cloud (Minnesota) Hospital. “We often get these patients transferred to us from outlying cities, psychiatrists in the community, and law enforcement. Many of the hospitals in our area don’t have the resources to handle these patients, so they are sent here.”
Make the environment friendly. Many hospitals are creating behavioral health units—and more patient treatment areas in general—that boast high ceilings, open areas, and large windows that allow more natural light to come in. The result? Friendly, therapeutic places that calm patients and give a greater overall feeling.
What you do will depend on your space and budget, but picture behavioral health units with “wander space,” to a group area to hang out and walk off their energy as opposed to sitting around. Some hospital waiting rooms are being designed with a living room feel, with even comfy furniture and fireplaces in some cases, as well as showers and video game areas to create a less-threatening environment for those who may be subjected to longer stays.
Design through the eyes of the suicidal. In 2013, Minnesota hospitals began redesigning patient rooms, when it was found that facilities there were seeing some of the highest national rates of suicides since the 1990s. As a result, facilities began floor-to-ceiling reviews of room designs, eliminating any features that patients could use to potentially harm themselves.
“Patients who are determined to harm themselves can do so by self-strangulation or by banging their heads on the floor or on a wall,’’ said Kathy Knight, vice president of behavioral services at University of Minnesota Medical Center-Fairview, in a report in the Star-Tribune of Minneapolis. “It’s very challenging to prevent suicide when there is a deep determination to die.”
In its psychiatric units, the hospital concentrated on patient bathrooms, which is where many suicide attempts take place (here’s your documentation as to your plan of attack, for the surveyors).
“There are no pinch points in the doors anymore,” Knight said in the Star-Tribune report. “We have breakaway shower heads. The handles on the faucets are modified. We don’t have door knobs. There really isn’t anything that we don’t constantly look at.”
Think about flexibility. If you have a behavioral health patient who needs a special room—and all your rooms are filled with equipment that they could potentially harm themselves with—they’ll have to wait until you can accommodate them, and that can lead to other problems. Why not redesign your rooms so that they can accommodate anyone?
To cut down on hazards, some facilities have begun designing “multi-modal rooms” that can be transformed depending on the needs of the patient being treated. Need a safe room for a behavioral health patient? Regular rooms are designed with medical equipment, oxygen tanks, IV pole, and other potentially harmful items behind a sliding “garage door” that can be pulled down and secured.
Lower surfaces. Although it can be pricey and difficult for older hospitals to renovate current spaces, newer construction is focusing on design elements that provide fewer opportunities for patients to harm themselves. "You want to design it in such a way that it makes it difficult to jump off higher areas," says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, N.C. Smith has served on a task force for construction and renovation for the IAHSS, which focuses on recommendations ranging from avoiding high parking decks to rooftop play areas (a hospital in North Carolina tried it).
“The people that create these spaces create what's called an attractive nuisance,” he says. “Just by the nature [of] how it’s designed, it has safety issues or people could easily commit suicide.”
Search everyone. Especially in a busy emergency room environment, it can be difficult to assess who will be a violence or a suicide risk, so many hospitals have developed procedures for screening patients as they are admitted. Clothes are removed; sharps, belts, and jewelry are inventoried; and purses and other belongings are placed somewhere safe. In the meantime, a nurse or other staff member asks some basic questions to ascertain each patient’s baseline mental status. Finally, a patient may be given a color-coded set of scrubs to dress in. “Does this mean you strip search everyone? Maybe not, but in some places a purple gown can ID someone as high risk,” Smith says.
Use checklists. Many physicians and hospitals swear by checklists to minimize mistakes in the surgical suite; now, some hospitals are adapting checklists to other areas, such as the behavioral care unit.
St. Cloud Hospital uses a checklist that gives staff a list of things to do when preparing a room for a new patient arrival. Tasks on the checklist include things like moving extra garbage cans into the bathroom, removing excess furniture and cords, taking down decorative crucifixes, and folding a room’s computer up into a wall when it’s not being used.
How a rolling OR stool cost a hospital $7 million
After a surgeon’s fall, one hospital in Georgia learned how expensive unsafe furniture can be
Mark Corbitt, MD, was finishing up a surgical case in operating room No. 5 at the South Georgia Medical Center in Valdosta, when he tried to sit down and write orders in the patient’s chart. As he transferred his weight onto a four-legged rolling stool, it slipped out from underneath him. He fell to the floor and struck his head.
Corbitt, who has since suffered repeated seizures and been diagnosed with trauma-induced epilepsy, sued the hospital. He accused the facility of failing to address a known safety hazard prior to the injury that ended his promising career on January 25, 2010. Precisely seven years later, a jury sided with him, finding the medical center at fault and issuing a $10 million verdict.
Since the jury determined that Corbitt himself should carry 30% of the blame for the incident, the judgment was apportioned to reflect the hospital’s 70% share in the liability, leaving the facility on the hook for $7 million.
“Unfortunately, this is yet another example of the growing trend of out-of-control jury verdicts,” said William R. Johnson, JD, a partner with the Moore Ingram Johnson & Steele law firm, in a statement. The defense team was correct, he added, to argue that Corbitt should be awarded nothing. (If the jury had saddled Corbitt with at least 50% of the blame, he would not have been entitled to collect damages under Georgia law.)
Rather than appeal the judgment, however, the Hospital Authority of Valdosta and Lowndes County voted in February to authorize a payment of $2.3 million, with an insurance company covering the remainder of the $7 million tab, as The Valdosta Daily Times reported.
The judgment serves as a stark reminder of just how expensive a simple piece of furniture can become when its presence in a medical setting is implicated in a personal injury case. More broadly, experts say the story points to a need for proactive vigilance in identifying and mitigating ergonomic risks.
At the center of Corbitt’s complaint were four casters attached to the bottom of the four-legged stool. Calling upon expert testimony to bolster his claims, the doctor argued that the stool rolled too easily across the OR floor, presenting a safety hazard.
“The hard, plastic caster wheels may have been perfectly suitable for use on a soft, carpeted flooring surface, but the casters were wholly unsafe and unsuitable for use on the hard, slick flooring surfaces present in Defendant’s operating rooms,” Corbitt stated in court documents. He alleged, furthermore, that South Georgia Medical Center bore sole responsibility for selecting and purchasing the stool, then making it available for use in an inappropriate setting.
Corbitt argued, based on scientific testing conducted by his team of experts, that a stool with hard plastic casters is “over 100 times more likely to roll out from under a user” than a stool with rubber wheels.
Corbitt pointed also to Caster City, a Las Vegas–based supplier of casters and wheels, for general guidance on flooring compatibility. The company’s website notes that hard wheels should be used on carpet, and soft wheels should be used on hard flooring. It includes a chart that juxtaposes seven types of casters with 11 flooring materials, using stoplight colors to code each of the 77 potential combinations: green for “good,” red for “not recommended,” or yellow for “possible,” contingent upon professional consultation.
Safety experts agreed that flooring compatibility should be a key consideration when deciding how to furnish a given medical setting.
“You need to make sure you get the correct type of caster for the job you’re trying to accommodate,” says Cindy Taylor, ARM, CSPHP, director of Workers’ Compensation and Ergonomics for UNC Health Care in Chapel Hill, North Carolina. Even in the absence of a specific regulation pertaining to rolling furniture, she says, OSHA, CMS, and The Joint Commission all expect that medical environments are kept safe for staff, patients, and visitors alike.
“For any environment, it is the responsibility of the safety professional to review data for trends and follow up on any incidents which could have been prevented,” Taylor says. “Identifying potential and existing workplace hazards and taking action to prevent these hazards should be number one for any safety professional.”
If workers report problems with a particular piece of equipment or furniture, efforts should be taken immediately to assess and address the problem, to prevent future mishaps. That’s where South Georgia Medical Center fell short, according to Corbitt’s complaint, which argued that a surgical technician had experienced and reported problems with the same type of stool involved in his fall. Corbitt complained that the technician’s report had not been passed along to the hospital’s safety director and that it did not result in a substantive investigation or corrective action prior to his injury.
Ergonomics and OSHA
Beyond casters alone, the big lesson to be taken from Corbitt’s lawsuit is that healthcare personnel need to be paying attention to ergonomics, says Dan Scungio, MT (ASCP), SLS, a lab safety officer for Sentara Healthcare, a multi-hospital system in Virginia. In older facilities, especially, there are numerous furniture arrangements that offer less-than-ideal working conditions, introducing the prospect of long-term or even immediate harm, he says.
“Some ergonomic injuries are slow, and you don’t realize that that’s happening until it’s too late, until you’re near retirement, until something permanent has happened and it’s not fixable or it has to be fixed by some sort of surgery or a brace or medication or anything like that,” Scungio says. “Or some of them, like this case in Georgia, are instant.”
For more than 30 years, OSHA has been wrestling with ergonomics issues, offering training and guidance along the way. In late 2000, after several years in the rulemaking process, the administration issued its Ergonomics Program standard, but the regulation was quickly repealed in 2001 when newly inaugurated President George W. Bush signed a congressional joint resolution into law, undoing the rule and barring OSHA from enacting anything substantially similar to it.
Elaine Chao, who served as Secretary of Labor during all eight years of Bush’s tenure in the White House and who now serves as Secretary of Transportation under President Donald Trump, explained later in 2001 that the Republican administration was looking for a way to better approach ergonomics in a manner that would promote worker wellness while also respecting differences across various workplaces and sectors of the economy.
“We want American workers to be safe, but we also want them to have jobs,” Chao said in a speech at George Mason University. “Placing unnecessarily onerous regulations on America’s employers won’t help American workers. It will only help put them out of work.”
Chao said she would instead seek “a reasonable middle ground” that protects workers and their livelihoods.
Even in the absence of a comprehensive rule devoted specifically to ergonomics, OSHA has held that the duty of employers to keep their workplaces generally “free from recognized hazards” includes ergonomic hazards. If an employer fails to make a good faith effort to reduce ergonomic hazards, OSHA could, therefore, issue a citation under the General Duty Clause.
Similarly, the statutes cited in Corbitt’s lawsuit pertain to general provisions of Georgia law, not to laws about specific furniture or flooring materials. This highlights once again that healthcare safety professionals must ensure their dedication to regulatory compliance comes coupled with a commitment to spot and proactively mitigate additional hazards as well.
Despite the successful application of general provisions of law, some contend that a specific ergonomics standard from OSHA could still be a worthwhile addition.
“I’m not always a fan of more rules and regulations,” Scungio says, “but a standard from OSHA would at least force employers to pay more attention to ergonomics when so many don’t.”
Look at ergonomics more broadly
Tamara James, MA, CPE, CSPHP, director of ergonomics for Duke Health and Duke University in Durham, North Carolina, says the Corbitt case should remind institutions to furnish their facilities as meticulously as they design and build them.
“We often see and hear of situations where furniture is specified without regard to the total environment, even without regard to the users, maybe, or how it’s used,” James says. “And that’s a classic situation, it sounds like, where the wrong casters were specified. You don’t put carpet casters on a linoleum floor, you just don’t.”
James, who launched Duke’s ergonomics program 24 years ago, joined forces with Duke Patient Care Ergonomics Coordinator Yeu-Li Yeung, OT/L, CPE, CSPHP, who has worked in the office 14 years, to offer several pointers for safety professionals looking to shore up their ergonomics initiatives:
Review voluntary standards. The American National Standards Institute (ANSI), for instance, publishes a variety of guidelines applying ergonomics principles in specific settings, and the ANSI–accredited Business & Institutional Furniture Manufacturers Association (BIFMA) produces safety and performance standards and guidelines for furniture. The ergonomics team at Cornell University is a great resource for tips and checklists, James adds. (Visit their website at www.ergo.human.cornell.edu.)
Consider all points of interface. When assessing whether to place a given piece of furniture in a given workspace, you should consider who will be using it and for what purposes.
“When we do evaluations, we always look at three things: how the person, the environment, and the task work together,” Yeung says, noting that it’s often easier to change the environment than it is to change the person or task. “The flow should make sense.”
James noted that assessing these “points of interface” should account for any expected movement of the furniture and any number of likely users.
“If that piece of furniture is going into a pediatrics clinic, you need to think about the fact that there’s going to be little kids climbing all over it and jumping on it,” she says. “What’s the impact of that?”
Test a sample. “If you’re going to buy something, then tell the vendor, ‘Bring one to me. Let me try it. Let me use it with my staff to make sure this is going to work,’ that’s really the only way you’re going to know,” James says. “I would never buy a mattress if I didn’t at least lay on it for a few seconds. It’s no different. You have to try this stuff because you can’t just order things online and expect them to work or just order them out of a catalog and expect them to work.”
Educate workers. Even if the environment is set up perfectly, there is still potential for individuals to misuse equipment or furniture, Yeung notes. This is where ongoing educational efforts can promote best practices among workers and continue reducing the likelihood of potentially expensive furniture misadventures.
For more on the Duke Ergonomics Division, including links to resources and exercises, visit www.safety.duke.edu/ergonomics.
Joint Commission: Leadership key in push for culture of safety
Solid leadership is central to promoting and sustaining a culture of safety in any healthcare organization, The Joint Commission said in its latest Sentinel Event Alert, published in March to remind leaders that it’s their job to identify and mitigate potential pitfalls on an organizational level.
People will err, and equipment will misfire, but a systemic approach to safety will aim to catch mistakes before they harm patients and, in the event of a negative outcome or a close call, see the situation as a learning opportunity, the alert states.
“Although this latest alert was in regard to patient safety, I do absolutely believe that leadership is central to developing a safety culture for patients, visitors, and staff,” says Cindy Taylor, ARM, CSPHP, director of Workers’ Compensation and Ergonomics for UNC Health Care in Chapel Hill, North Carolina. “If you do not have the support of leadership, you will not be able to create a safety culture.”
The alert, which updates and replaces a previous version issued in 2009, outlines actions leaders should take within their organizations to build trust, accountability, an eye for safety hazards, stronger systems, and means of assessment. First on the list is ensuring that the adverse-event reporting process is neither opaque nor focused solely on doling out punishments. This nonpunitive approach can increase error reporting, giving organizations more data points to analyze in the never-ending search for weak spots to be patched.
The alert calls for organizations to root out any intimidating behaviors that might discourage workers from reporting problems, and it encourages them to give special recognition to those who spot and report unsafe conditions. The document urges leaders to quantify the health of their safety culture and track it over time.
Steve MacArthur, a safety consultant for The Greeley Company in Danvers, Massachusetts, who co-authored The Hospital Safety Professional’s Handbook with Taylor, says he doesn’t see anything particularly novel in the latest alert.
“I guess it’s possible that this might light a fire under folks to move the ball forward with a little more quickness, but organizational culture does not turn on a dime,” MacArthur says. “The real focus of this is that it puts organizational leadership on the hook for making this happen.”
The paradox of strong leadership in this case is that you cannot force a cultural change. Leaders can explain and model safety procedures, but they cannot mandate safety culture, says Ken Weinberg, BA, MSc, PhD, consultant in environmental health, safety, and toxicology for SafDoc Systems LLC in Stoughton, Massachusetts.
“What develops a safety culture is getting people to understand how they can create a safe working environment for themselves,” Weinberg says.
The Joint Commission outlined 11 recommended actions and related resources in SEA 57, noting that the recommendations are designed to be implemented simultaneously, not in a particular order. They are as follows:
- Reporting systems should avoid secrecy and obsession with punishment. Anyone within your organization should be able to report any mishap, near miss, or unsafe situation without fearing reprisal or penalty for an honest error.
- Distinguish between mistakes made by individuals and those stemming from flawed systems. Treat individual errors as learning opportunities, while using tools like the Incident Decision Tree published by the UK’s National Patient Safety Agency to promote transparency in your accountability process.
- Model good behavior from the top. Organizational leaders must embody the respectful and engaged demeanor they expect from their staff.
- Communicate expectations. Every team member should be made aware of the safety policies that have been established and enforced.
- Praise those who speak up. To help dismantle the culture of fear that discourages staffers from reporting safety concerns, actively encourage those who spot problems and report them.
- Quantify your safety culture. Measure the health of an organization’s current safety culture using the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture.
- Study your own data. Survey results regarding safety culture within your organization could contain clues on where you might improve safety and/or quality. Break the d