Conducting Access Control Security Audits

Evaluating your hospital’s entrance security now will help to ensure you comply with Joint Commission standards and effectively respond to emergencies.

Mother Nature can severely affect hospitals — both the physical environment and the care they give to patients. In August of 2007, St. Margaret Mercy Hospital in Dyer, Ind., had to evacuate 70 patients when a nearby creek flooded the facility. Five people, including four patients, were killed at St. John Mercy Hospital in Joplin, Mo. in July, 2011 when a tornado roared through the building. This past year, six New York and New Jersey hospitals were shut down as the result of Hurricane Sandy. But the threats don’t stop there.

Without warning, a hospital can be overrun with a massive influx of patients as was Hillcrest Hospital in Waco, Texas, in April of this year after a fertilizer plant explosion sent 60 patients streaming into their emergency room. Or on the same day, when Boston’s Beth Israel was inundated with some of the patients hurt in the Boston Marathon bombing and which, several days later, was swarming with police officers and media when accused bomber Dzhokhar Tsarnaev was transported to them for treatment.

There has also been a trend of increased violence in healthcare facilities with family-on-patient, family-on- staff, staff-on-staff, gang-related and behavioral health patient attacks becoming major concerns of public safety professionals. Hospitals also must be concerned with infant abductions, pharmacy break-ins and a host of other problems, all of which call for being prepared for just about anything. To emphasize this, the Joint Commission requires hospitals to plan and test for these events on a regular basis.

One way to assure that your hospital is prepared for an emergency is to focus on security audits and compliance assessments. Security audits assess your organization’s compliance with the standards that you are required to meet or have agreed to abide by. For instance, if a policy or procedure has been written around emergency lockdown, an audit will determine if your organization is doing what it has said it will do such as practicing the lockdown procedures twice a year. And, if you are following the policy, are you documenting the exercise, analyzing the results and planning for improvements?

For example, during a lockdown exercise, it may be determined that the process took a total of 20 minutes rather than the preferred three minutes. The assessment would spell out where and why the process broke down, make recommendations for improvement to either the process or systems and technology involved and, most likely, call for an additional lockdown exercise to test if the improvements effectively altered the results.

Evaluating the following four aspects of access control at your hospital is a great way to begin the audit process.

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