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Recent Publications

Risk Assessment and Management

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Are patients, hospital staff and the public protected in your hospital environment? What laws and regulations might the Compliance Office help to enforce to ensure protection from physical and material harm? This article will address these questions by examining two important compliance categories: Hospital Environmental Safety and Health, and Physical Security.

Environmental Health and Safety

While the hospital setting is one of healing and comfort, it also includes certain dangers. Hospitals contain hazardous chemicals, chemotherapeutic drugs, radioactive material and infectious matter, among other threatening items. For this reason, the Occupational Safety and Health Administration enforces laws and regulations to ensure protection against these exposures. In addition there are also dangers from fire and smoke that can be particularly perilous for vulnerable hospital patients. Life Safety Codes have been promulgated to address these problems and are enforced by the Environmental Protection Agency, and reviewed every three years by The Joint Commission. Some states and municipalities also have laws and regulations concerning hazardous material and fire safety.

In order to remediate the risks of Environmental Health and Safety, we recommend the Hospital Compliance Office, as part of its annual risk assessment, include the following topics:

  • Hazardous Exposure Control Plan
  • Engineering and Work Practice Controls
  • Personal Protective Equipment
  • Regulated Waste Containment
  • Post-Exposure Evaluation and Follow-Up
  • Fire and Safety Plan
  • Building Design, Fire Protection Features and Furnishings
  • Fire Drills and Fire Alarm Notifications
  • Maintenance of Fire-Safety Equipment and Building Features

While most of the work related to the above topics will be the responsibility of the Engineering Staff, Public Safety Staff, Patient Care Services, and others, the Compliance Office should ask questions during the annual risk assessment to ensure adequate remediation is actually occurring.

Hospital Physical Security

Patients, hospital staff and the public need to be protected from physical harm on both a day-to-day basis and in the event of an unusual circumstance, such as a natural viral epidemic, bioterrorism attack or major accident. The day to day events would include possible harm from robbery, stolen identification, or a violent altercation. The unusual circumstance of an epidemic, attack or accident could result in hospital overcrowding, spread of disease, or panic for certain medications or procedures. Preparation for and implementation actions for both day-to-day events and unusual circumstances need to be in place. Most of the laws that apply in these situations are local and state statutes that require close coordination with nearby police, fire and other emergency personnel.

In order to remediate the risks associated with Hospital Physical Security, we recommend the Compliance Office, as part of its annual risk assessment, review the following items:

  • Know Who is in the Facility, including Patients, Staff and the Public
  • Know What Materials Come In and Out of the Building
  • Respond to Disruptive Behavior
  • Respond to Weapons in the Building
  • Secure Drugs, Toxic Material, and Hazardous Waste
  • Have Sufficient Security Technology
  • Know Your Security Personnel

Again, most of the work on physical security will be handled by Public Safety Staff, Engineering Staff, the Pharmacy Department, Human Resources, and Patient Care Staff, but the Compliance Office should ensure that remedial steps are being taken to address these topics.

Compliance Offices focus primarily on laws and regulations dealing with Medicare and Medicaid payments, and FDA and OCR regulations. Risks associated with Anti-Kickback, Cost Reports, Claims Submission, HIPAA, EMTALA, PATH, Quality, Laboratories, Clinical Research, and Corporate Governance are the more usual compliance categories. However, other Federal, State and Local statutes and hospital safety regulations need to be considered when examining the overall risks in the hospital. Keeping your hospital’s emergency preparedness up to date and secure from environmental and physical harm certainly must be included as part of any comprehensive risk assessment.

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