On March 1, the Joint Commission issued Sentinel Event Alert (SEA) No. 57, “The Essential Role of Leadership in Developing a Safety Culture.”

While on the surface, this alert seems to speak more to the “safety” function in healthcare, those who do not have the shared responsibility for safety and security disciplines at their organization should consider the potential impact it might have on security programs in the healthcare industry, especially since this alert is highlighting some key action items regarding the Joint Commission’s leadership standards. Let’s begin with a simple definition of what the Joint Commission considers a “leader.”

Per SEA No. 57:
The Joint Commission accreditation manual glossary defines a leader as: “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.”

If you are responsible for the security of your facility or campus, then chances are you fall under this rather broad category.

It should also be noted that this is not the first time the Joint Commission has specifically focused on this standard. In July of 2008 they issued SEA No. 40, “Behaviors That Undermine a Culture of Safety” in preparation of this then new standard LD 03.01.01 — “Leaders create and maintain a culture of safety and quality throughout the hospital,” which went into effect Jan. 1, 2009.

This preliminary SEA No. 40 focused primarily on two elements of performance of the standard (EP4 and EP5), while this latest iteration of SEA No. 57 includes EP 1, “Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.”

Element of performance (EP) No. 1 in SEA No. 57 is of direct concern to the healthcare security leader, as this can be interpreted to mean the types of security assessments, surveys and tools are being used to determine appropriate levels of and types of security.

Aside from the annual hazard vulnerability that everyone must conduct, security leaders should consider “just in time” tools such as OSHA’s workplace violence checklist or the National Center for Missing and Exploited Children’s “Self-assessment for health care facilities” tool.

Element of performance No. 4 is “Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety.” This element speaks directly to your organizational policies, procedures and practices on topics such as what constitutes workplace violence and/or threatening behavior involving your employees, while EP No. 5 states that “Leaders create and implement a process for managing behaviors that undermine a culture of safety.” It follows EP No. 4 by determining how often such policies and procedures are taught and in what manner the information is disseminated (just once in initial employee orientation/onboarding or is security provided a role in annual continuing education efforts?).

Considering the current scope of workplace violence in the healthcare industry and all of the attention it has garnered recently, this element of performance should definitely be looked at closely to make sure all reasonable efforts are being made to educate employees based upon up-to-date assessment findings (per EP No. 1) and current best practices/regulatory requirements.

Take as an example the OSHA general duty clause, which reads in part, “Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

This seemingly innocuous clause has been used with increasing success in recent months by OSHA surveyors to fine healthcare facilities for a lack of adequate and reasonable security measures and education to prevent workplace violence, which is a known hazard in our industry.

We, as healthcare security professionals, should research the potential impacts of SEA No. 57, compare it to the recent interpretations of the OSHA general duty clause in our industry and be prepared to add it to our toolbox as a reference when we are called upon to validate resources and “prove our value” as a business enabler.

Bryan Warren, MBA, CHPA, CPOI, is a security consultant for the healthcare industry.

If you appreciated this article and want to receive more valuable industry content like this, click here to sign up for our FREE digital newsletters!

Related Content