Managing the risks in health care facilities

Risk assessment is the process of identifying hazards that could negatively affect the health care organization’s ability to provide a safe environment.

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When patients, visitors or staff come to a hospital, they expect the facility to be safe, and rightly so. Health care institutions employ staff whose sole purpose is to look after the safety of those on its premises; however, it is an impossible task for a small group of people and must be everyone’s job.

Hospitals are unique in the potential risks that could affect anyone on the property. Some patients are incapable of self-preservation in an emergency and are totally dependent on others. There are hazards relating to electricity, radiation, infection, water safety, medical gases, fire, cryogens and chemical exposures.

Additionally, there are security-related hazards such as workplace violence and criminal activity. Other hazards come when responding to internal or external emergencies. There also are occupational hazards such as skeletomuscular injuries when handling patients, needlesticks and slips, trips and falls.

Health care is a unique category within the Department of Labor’s Occupational Safety and Health Administration (OSHA), which shows a higher injury rate in health care than in any other private sector — 806,200 cases in 2020, according to OSHA's data.

Health care also has a set of unique requirements to support a safe and healthy environment for patients, visitors and staff.

Building a program

Being one of the key people responsible for supporting safety in an environment with so many hazards can seem daunting, especially to those who wear multiple hats. For example, a facilities manager is responsible for supporting the facility systems and procedures relating to life safety, fire safety, infection control, electrical safety, water safety, construction safety and security, to name a few.

They may also serve on other teams relating to infection control, as well as emergency management committees. Knowing what to do in an ever-changing environment is incredibly challenging. The key to providing a safe environment for patients, visitors and staff is developing a good program and getting others involved to build a culture of safety.

Four essential things are needed for a safety program to be effective:

• Knowing and supporting compliance with regulatory agencies.
• Using outside resources effectively.
• Using and developing tools for decision-making.
• Participating in continuing education.

Health care is one of the most regulated fields in the United States and the Centers for Medicare & Medicaid Services (CMS), state and local regulations are geared toward keeping hospitals safe. For example, a facilities manager at a Joint Commission-accredited hospital must make sure that 21 Environment of Care (EOC) standards with more than 200 elements of performance, 23 Life Safety standards with more than 160 elements of performance and thousands of other codes are met.

Regardless which accreditation agency is used, these standards provide a safe environment. For health care facilities managers, this is where to start. Being in good regulatory compliance is necessary to create a safe environment for patients, visitors and staff. Assistance is available from the following sources:

Outside resources. There are numerous outside resources available to help facilities managers achieve and maintain a high degree of safety throughout the organization. Organizations that are specific to health care can provide valuable information regarding various areas within a hospital. For example, the American Society for Health Care Engineering (ASHE) offers workshops and certifications for building contractors, health care facilities managers, environmental staff, mechanics and architects, with a major focus on hospital safety. Conferences and training classes are periodically provided by ASHE on a national level and by local and regional chapters. Also, ASHE has webinars to help answer code compliance questions called Just Ask ASHE.

ASHE Chapters serve as an affordable option for training and information. In addition, being a member of ASHE opens a multitude of resources and tools relating to everything from administration to construction management.

The American Hospital Association (AHA), of which ASHE is a professional membership group, also offers safety webinars and training.

While ASHE and AHA broadly cover many areas related to health care safety, some organizations cover specific areas. They include the International Association for Healthcare Security and Safety for security, the Association for the Health Care Environment for environmental services and the Association of Healthcare Emergency Preparedness Professionals for emergency preparedness managers.

Other valuable resources can be located through a hospital’s accreditation organization. The Joint Commission, DNV Healthcare USA Inc., CMS and others have resources for maintaining a safe facility. The National Safety Council and OSHA also are good resources. Additionally, the Centers for Disease Control and Prevention provides resources pertaining to infection control.

Mock surveys by third-party health care consultants can be a valuable tool to maintain a safe and compliant facility, provide another set of eyes to point out discrepancies and validate efforts. There also are life safety consultants who can assess life safety building conditions and documentation. Additionally, the local fire marshal can identify improvement opportunities pertaining to life safety.

Risk assessment tools. Risk assessment is the process of identifying hazards that could negatively affect the health care organization’s ability to provide a safe environment. They help identify opportunities and prompt measures, processes and controls to reduce the impact of these risks. To help, risk assessment tools can be applied to almost any risk or hazard. Several are available through ASHE’s website.

The risk assessment process aims to determine measures that should be implemented to mitigate those risks. For example, certain hazards or risks might determine the type of protective barriers needed on a construction project, such as an infection control risk assessment.

A hazard vulnerability analysis is a risk assessment tool used by health care organizations to take a systematic approach to identifying risks that are most likely to have an impact on a health care facility or the surrounding community.

A security assessment is commonly used in health care facilities to assess risks such as access and protection of sensitive areas. A ligature room assessment tool helps evaluate risks associated with behavioral health patients.

Risk assessment tools can range from simple to complex. A simple assessment can be written out or developed on an Excel spreadsheet, with numerical values assigned to pertinent items, which are weighed and added together to give a risk score. Preconstruction risk assessments for health care can be obtained through ASHE, AHA, The Joint Commission, the Center for Improvement in Healthcare Quality and other organizations. Managers also can search online for “risk assessment templates” to get free templates that can be tailored to fit their needs.

Continuing education. Regardless of a health care employee’s role, continuing education is necessary to keep up with evolving regulatory changes and safety trends.

A few years ago, for example, CMS made regulatory changes that required hospitals to develop better methods for safely maintaining their water systems to prevent potential waterborne contamination from affecting people in or around hospitals. Water management will most likely continue to evolve, requiring more complex systems and practices to maintain compliance and keep hospitals safe from waterborne contamination.

Being actively engaged with continuing education through professional associations helps keep those involved with hospital safety updated on the latest safety management changes, such as The Joint Commission’s new, revised workplace violence prevention requirements for behavioral health care.

Building a culture

It takes time to develop a culture of safety and it takes everyone to be engaged in safe practices and behaviors.

Most hospitals are short-staffed and find themselves taking on more responsibilities, which can affect safety. Shortcuts are taken, and safety risks go up. Needlesticks happen, fire doors get propped open and back strains occur, all of which are preventable.

However, many strategies can help build a culture of safety, including having a top-down mindset, providing practical training and conducting multidisciplinary EOC rounds.

Often, hospital staff look at safe practices as an inconvenience. The top-down mindset focuses on the reasons safety is important. Most facilities managers have used language like “because The Joint Commission says,” or “the fire marshal says.” Instead, health care facilities must move in a direction that stresses and informs others that it is the right thing to do for patients, visitors and staff. The language around safety needs to change to be something positive and beneficial, not something health care facilities staff have to do because someone else says so.

Practical training is another area that most hospitals could improve. New hires are rushed through orientation, which usually does not provide enough training time to cover all the information needed to do their jobs safely. Many hospitals use virtual training modules that the employee can accomplish at a convenient time, which is a good idea for compliance purposes, but it does not allow someone to ask questions or collaborate on various safety scenarios.

General and department-specific safety training can be supplemented through events like safety fairs and fun activities with games and prizes. Subject matter experts can answer questions regarding all aspects of safety, from security to needlestick prevention. Physical therapists could be present to demonstrate safe patient-handling techniques. Tools to aid in safe practices could be demonstrated.

Finally, EOC rounds should be a chance to solicit questions and provide hands-on training for staff. Safety fliers, scorecards and written articles could be distributed while rounding. Environmental rounding should be an enjoyable and collaborative event for everyone.

Multidisciplinary EOC rounds with subject matter experts consistently help maintain an eye on the state of the environment. They also provide opportunities to talk about keeping the facility safe and secure. Infection control practitioners can review and discuss handwashing and isolation practices, security staff can address ongoing issues within their area of expertise, clinical engineering can be sure equipment is in good working order, and facilities engineering can discuss how to evacuate patients. Together, the team can discuss or address most of the safety issues on the spot as well as have opportunities to promote safety.

A safe environment

Keeping hospitals safe for patients, visitors and staff is a daunting task that should be designed before a hospital is even built. Everyone needs to make sure the facility has the proper safety features and that training, follow-up, monitoring and corrective actions are performed.

Facilities managers should be sure their EOC chairs have expertise in their areas and use it to promote a safety culture on the campus.

Additionally, myriad resources and tools can be used to help evaluate and maintain facility safety.

Being compliant with applicable codes and standards, using tools, building a good program and focusing on shifting the culture will go a long way toward having a safe environment for everyone. 

Related article // Creating effective EOC committees

An environment of care (EOC) committee meeting should not be another gathering for the sake of having a meeting and checking a box. With a little effort, meetings can be streamlined and more effective.

The use of standardized reports for each section should cover only the information for the reporting period without having to repeat anything. For example, facilities managers should not have to review a semiannual documented test every month. They should just indicate “current” and move on. They should organize their reports using PowerPoint colored reports and charts when possible.

If an EOC committee is large and it becomes difficult to manage all the information from month to month, they should consider splitting up their meetings. For example, the chapter leads can meet every other month, and the entire committee could meet on the alternate months. If a facilities manager is the EOC chair, they should keep the meeting moving. They should set a time and stick to it.

The field has a greater tendency to hold virtual meetings since the COVID-19 pandemic. If possible, facilities managers should have meetings in person to achieve a higher level of interaction. They should make it fun by bringing snacks and drinks. They should encourage their team to share something they learned during the past month. They also should set some time to review EOC rounds (with photos if possible) and discuss the issues and solutions. They should always have some free time at the end of the meeting for open discussion and resolution of any open items.

The EOC committee members should be part of the EOC rounding team. It is important to have the subject matter experts in the field doing the rounding, answering questions and addressing issues when they come up. At the end of the year, facilities managers should be sure to highlight the work that has been accomplished and celebrate the wins. 

James Craig Ayers, MHA, CHFM, CHC, CHSP, CSMP, CPO, SASHE, is director of system engineering services at Memorial Hermann Southeast | Pearland in Houston. He can be reached at james.ayers@memorialhermann.org.