Comments on Revisions to Safety (EC1) and Security (EC2)
Note: ASHE comments are highlighted in yellow.
General Comments
Safety and security are two distinct functions. They are closely related, and in the existing EC standards, have several EP’s in common. However there are many issues that are uniquely safety or uniquely security. ASHE believes that for the standards to best serve all hospitals, the security and safety standards and EPs should be separate.
Current Standard: EC.1.10 Current EP: 4
The organization conducts comprehensive proactive risk assessments that evaluate the potential adverse impact of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to the organization’s facilities.
Revised Standard: EC.2.01.0 Revised EP: 1
The [organization] identifies potential physical environment safety and security risks to anyone in the organization.
Note: Risks include, but are not limited to, portable oxygen cylinders, Magnetic Resonance Imaging equipment, and those that could contribute to potential patient suicide.
What is the purpose of the note? There are numerous potential risks in a physical environment. There is no reason to list these three. Leave it up to the organization to identify the risks.
Current Standard: EC.1.10 Current EP: 9
The organization ensures that all grounds and equipment are maintained appropriately.
Revised Standard: EC.2.01.0 Revised EP: 6
The [organization] maintains all grounds and equipment.
This EP is not needed. It is covered under 2.01.0 EP 4.
The EP as written does not provide an expected outcome for maintaining all grounds and equipment. There is no evidence to support the theory that maintaining all grounds and equipment reduces safety and security risks. The expected outcome needs to be stated.
If this EP remains is should read "The [organization] maintains grounds and equipment to minimize safety and security risks as identified in EC 2.01.0 EP 1.
Current Standard: EC.1.20 Current EP: 1
The organization conducts environmental tours to identify environmental deficiencies, hazards, and unsafe practices.
Revised Standard: EC.9.01.0 Revised EP: 14
The [organization] uses its tours to identify environmental deficiencies, hazards, and unsafe practices.
Eliminate this EP. It is redundant with EC 9.01.0 EPs 12 and 13.
Current Standard: EC.1.20 Current EP 2:
The organization conducts environmental tours at least every six months in all areas where patients are served.
Revised Standard: EC.9.01.0 Revised EP: 12:
The tours should be used to look for new hazards and risks as well, not just evaluating the effectiveness of previously implemented activities. Revise to read;
“The [organization] conducts environmental tours every 6 months in [patient] care areas to identify environmental deficiencies, hazards, and unsafe practices and to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment of care.”
Current Standard: EC.1.20 Current EP 3:
The organization conducts environmental tours at least annually in areas where patients are not served.
Revised Standard: EC.9.01.0 Revised EP: 13:
The [organization] conducts annual environmental tours in non-[patient] care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment.
The tours should be used to look for new hazards and risks as well, not just evaluating the effectiveness of previously implemented activities. Revise to read;
“The [organization] conducts environmental tours annually in non-[patient] care areas to identify environmental deficiencies, hazards, and unsafe practices and to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment of care.”
Current Standard: EC.2.10 Current EP 3:
The organization conducts proactive risk assessments that evaluate the potential adverse impact of the external environment and the services provided on t the security of patients, staff, and other people coming to the organization's facilities. The potential for workplace violence is considered during the risk assessment.
Revised Standard: EC.2.01.0: Revised EP 1:
The [organization] identifies potential physical environment safety and security risks to anyone in the organization.
Note: Risks include, but are not limited to, portable oxygen cylinders, Magnetic Resonance Imaging equipment, and those that could contribute to potential patient suicide.
Why have this note? There are numerous potential risks in a physical environment. There is no reason to list these three. Leave it up to the organization to identify the risks.
Current Standard: EC.2.10 Current EP 6:
The organization controls access to and egress from security-sensitive areas, as determined by the organization.
Revised Standard: EC.2.01.0: Revised EP 9:
The [organization] controls access to and from security sensitive areas including vehicular access to emergency care areas.
The EP should read "The [organization] controls access to and from security sensitive areas based on a risk assessment."
The statement regarding vehicular traffic is too broad. A risk assessment should be used to identify what controls, if any are needed.