Hospital Accreditation

A simple approach is to conduct a comprehensive risk assessment that would include input from infection control, risk management, safety officer, security, and consulting with your local authority having jurisdiction. Where hospitals get into trouble with The Centers for Medicare & Medicaid Services (CMS) and their accreditation organization on this issue is the failure to assess the risk to patient and staff safety when these doors are left unlocked. Each of the accrediting organizations have standards that require your hospital to both identify safety and security risks in the environment and to maintain a safe environment for their patients.

Conditions or situations that you should consider when conducting the assessment include the patient and visitor population within the area. Consider where pediatric patients’ may be, visitors’ access, and the general patient environment. These should be compared to the risks that reside within the disposal and storage locations such as soiled utility rooms, trash/linen chute access doors, hazardous materials and waste rooms, cross contamination and dangerous equipment located in the area. Do not forget that surveillance is also a form of security, so the assessment should consider proximity to staffed areas such as nursing units, dietary, shipping and receiving, operating rooms and other departments in the hospital. Can staff in these areas monitor unauthorized personnel attempting to gain access or entering storage locations to this material? Remember the primary objective is to prevent access by unauthorized personnel in locations where the biohazard waste is being stored.

One of the primary objectives during your assessment is to evaluate if locking the doors to these areas is required? While there is no specific code requirement for the locking of all hazardous rooms, some accrediting organizations, such as CIHQ, does require locations where biohazardous waste is stored to be secured at all times.

As mentioned earlier, national authorities have standards that require hospitals either to identify safety and security risks in the environment, or to maintain a safe environment for their patients. Basically, an unlocked utility room that contains a risk to patients would certainly be suspicious to a surveyor. For example, a housekeeping room may contain cleaning supplies or soiled utility rooms may contain items considered biohazardous that could be considered dangerous to unauthorized individuals (such as children). If the door to the room was left unlocked, then individuals who are not authorized could gain access to the hazardous items and possibly hurt themselves or even others. This does not mean all soiled utility rooms or housekeeping rooms need to be locked. They just have to be assessed for safety or security risks associated with their contents. In many cases a soiled utility room in a hospital may be unlocked, with exceptions such as rooms near where children are abundant. On the other hand, most (if not all) housekeeping janitor’s closets are locked, generally due to the hazardous cleaning chemicals stored in them. After you have completed a comprehensive assessment of the disposal and storage locations both inside and outside of the hospital, it is suggested that you have a policy that addresses your findings on rooms that you will require to be locked, as well as, follow-up training with affected staff that have access to these rooms.

Another area of concern around maintaining controlled access to biohazard waste and hazardous chemicals is how to deal with a large accumulation of such items during a disaster. This would not be an uncommon situation and can result from your hospital responding to emergencies especially with an influx of patients. Therefore, it would be wise to conduct a controlled emergency exercise designed around the excessive accumulation of biohazard waste and identify possible gaps in maintaining secured access to this material while at the same time not affecting the ongoing operations of the hospital in a negative manner.

Understand, if there is a perceived risk to safety because the door is left unlocked and the hospital has failed to assess that risk, then a surveyor has every right to cite your hospital for interior spaces which are unsafe to occupants of the facility.