Health Care Institute Logo




News & Resources

  HCI News 
  HCI in the News
  Tips Tricks Traps





  Health Care Institute News and Insights

Experts Reveal Trending Strategies for Reducing Patient Risks at NY Healthcare Facilities Summit

  by Megan Headley | October 22, 2018
  Nervous about your next Joint Commission survey? Not sure if you’re addressing all areas of concern when it comes to a surge emergency? Facing questions from hospital staff about ligature risks? These compliance and safety questions were among the topics addressed during the 5th Annual NYC Hospital, Outpatient Facilities & Medical Office Buildings Summit held in September.

Tools for planning for surge emergencies

  According to an article from event organizer, surge emergencies are on the forefront of emergency planning right now, so there is an increase in tools available to help you plan.

Nick Gabriele, Vice President of RPA /A Jensen Hughes Co. described medical surge as the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community.

Surge capacity is the ability to manage a volume of patients, while surge capability is specific to managing patients with unique issues, such as Ebola. Both terms encompass healthcare organizations’ ability to survive a hazard impact and maintain, or rapidly recover, operations that were compromised.

Multiple companies today provide software and dashboards that can help organizations analyze and plan surge capacity and capability.

Key considerations around medical surge capacity include ensuring continuity of care, getting the right staff-to-patient ratios, managing supply issues throughout the chain, among other factors, while meeting the 96-hour assessment requirement—assuming a waiver from section 1135 of the Social Security Act isn’t in place.

Nick Gabriele, Vice President, RPA Jensen Hughes Co.    

Resources for mitigating ligature risks

  Ligature risk has become a major emphasis for The Joint Commission in the last year. Michael S. Bernstein, Life Safety Code surveyor for The Joint Commission, explained why: “A facility surveyed [first quarter 2017] had ligature risks identified during survey, and before they could be mitigated there were two successful suicides.”

To better prevent these risks, Bernstein encouraged FMs to not confuse value and price when it comes to ligature-resistant products. He encouraged his audience of listeners to ensure they’re picking products that are durable and that will what they are supposed to do. To meet this last requirement, Bernstein advised speaking to people using the products daily at other facilities before purchasing for your own facility.

In addition, Bernstein recommended reviewing guidelines that address ligature risks, starting with state rules and regulations and including:

Michael S. Bernstein, MSE, MBA, PE, CCE, CHFM-Life Safety Code Surveyor, The Joint Commission

Tips for Life Safety Code survey success

Bernstein offered some additional tips for ensuring TJC survey success:

  • Organize your testing document binder in the same order as your checklist.
  • Once you close all open issues, place the work orders right behind the report.
  • Schedule 1 fire drill per shift per quarter. While these must be more than an hour apart, Bernstein recommended scheduling these drills every three months, plus or minus 10 days. The best practice, he said, is to vary days.
  • Place central station and Fire Department Connection checks on your fire drill form. This saves time and money and eliminates missed annual and quarterly requirements.

For more tips and insight from the summit, read the full recap at