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Safety | Security | Emergency Management | Accreditation Success July 9, 2012 | Vol. 17, No. 14


Develop an active shooter policy to react quickly when the worst happens

IN THIS ISSUE Security Develop an active shooter policy to react quickly when the worst happens .....................1 How to communicate with staff, others during an active shooter event ........................7

Develop a hospital-wide reaction policy to active shooter incidents to ensure quick staff responses in an emergency situation. Recent years have shown an increase in active shooter cases throughout the country, and a significant number of those cases took place in health care facilities. There have been approximately 30 incidents of shooters in workplaces in 2012 alone (as of mid-June), according to the Center for Personal Protection and Safety (CPPS), Spokane, Wash. About a quarter of those happened in health care facilities. Active shooters attempt to maximize casualties – to kill and seriously injure without concern for personal safety or the threat of capture, according to David Milen, bioterrorism/disaster preparedness coordinator for the Sisters of Saint Francis Health Services,

Environment of care Perform regular medical gas systems inspection to ensure compliance, safety ..........1

Emergency management Plan early, set limited goals for an effective, targeted drill ....................................2

Leadership Implement a computer-based training program to cut long-term costs .......................3 Benefits of computer-based training ................4

What’s wrong with this picture? Answer to last week’s life safety forensics photo ..............................................8

(see active shooter, p. 8)

Environment of care

Perform regular medical gas systems inspections to ensure compliance, safety Create a calendar for regular inspection of your medical gas systems and safety alarms to stay in compliance with Joint Commission and industry standards. New requirements from the National Fire Protection Agency (NFPA) detailing how often you need to check items like articulating booms and manufactured assembly should be incorporated into your regular inspection and maintenance schedule. Joint Commission standard EC.02.05.09 requires that you inspect, test and maintain critical components of piped medical gas systems, including your master signal panels, area alarms, automatic pressure switches, valves, flexible connectors and outlets. The (see gas safety, p. 5) Environment of Care Leader | Toll-free: 1-855-225-5341 | Two Washingtonian Center | 9737 Washingtonian Blvd., Ste. 200 | Gaithersburg, MD 20878-7364


July 9, 2012

Emergency management

Plan early, set limited goals for an effective, targeted drill Start planning large-scale drills early and limit the number of objectives to avoid undermining the effectiveness of your drill results. Note that when you plan drills that involve multiple organizations, each organization may want to add individualized responses. But it’s crucial to focus down on the main goal of the drill so you can conduct the drill effectively, understand the implications of your response, and correct any errors. A hospital must conduct a minimum of two drills each year to evaluate the effectiveness of its emergency operations plan, according to Joint Commission Standard EM.03.01.03, (the hospital evalutates the effectiveness of its emergency operations plan). Hospitals are encouraged to collaborate with local law enforcement and other organizations in the area. If your hospital has responded to actual emergencies, you can use these as stand-ins for your drills, according to Joint Commission requirements.

Use planning committees to iron out drill details Use these tips when planning your emergency response drills: s Start planning early. The best large-scale drills are planned at least six months in advance to include more

organizations, agencies and people, says Joe Gordon, former Joint Commission surveyor and president of Survey Resources, LLC, in Manchester, N.J. The further out you start planning, the more detail you can go into and the more prepared you can be for the drill. The most successful operations, with high levels of community involvement, usually take place on weekends – most likely because individuals working through the week can actually participate, Gordon notes. Example: The Yellowstone (Mont.) County Local Emergency Planning Committee (LEPC) conducts a standing large-scale drill every two years called Operation COYOTE (County of Yellowstone Operating Together in Emergencies), explains Joe Marcotte, the LEPC’s chair of 11 years. Planning happens months and years in advance of the projected dates. The largest exercise the committee ever conducted involved approximately 12,800 people – more than double the average amount of people involved in an exercise. Example: Good Samaritan Hospital Medical Center in West Islip, N.Y., plans its large-scale drills a minimum of six to nine months out, explains Bruce Litwack, director of emergency medicine at the facility. A readiness drill can be conducted without extensive planning on a day’s notice, but when you want to include more than 25 different organizations, there are a lot of details you need to iron out. s Develop a committee and sub-committees for different elements of the drill. Coordinate with other members of your community to plan the drill. If you have

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many organizations involved in the drill, you’ll need to set up committees to represent each organization’s needs. These committees will help develop the specifics of the drill, such as what you want to test, how you will develop the drill criteria, who will be responsible for each aspect of the response, how many people will be involved and how you will reach out to volunteers. Example: You can set up a sub-committee of your planning committee that will focus only on developing the objectives for the drill. s Develop your scenario from an item in your hazard vulnerability analysis (HVA), Gordon says. When working on a large-scale drill, address one of the top four items in your HVA. That way, you’ll get a sense for how well the community as a whole can respond to a situation you’ve determined is most likely to occur. Because it’s highly unlikely that an actual emergency will be exactly like a drill, make sure the drill is broad enough that the procedures can be modified to work in a real emergency response situation. s Include no more than four objectives in your scenario, Litwack suggests. The ideal number for a targeted drill is one or two objectives. Limiting the number will help you better evaluate your response to those specific goals. s Develop sufficient detail to discuss what will happen with other organizations and be open to suggestions for your drill from those agencies, Gordon suggests. Don’t be so rigid that you would refuse input from the other organizations you’re working with on the drill. Example: Your facility wants to conduct a decontamination drill. Your planning committee can set up a drill where a simulated chemical spill injures 20 people. Then you can escalate the drill by causing road blocks when the ambulances are bringing in the casualties, which would also divert police and fire response organizations. There are endless possibilities, Gordon says.

July 9, 2012


Implement a computer-based training program to cut long-term costs Consider implementing computer-based training (CBT) as a long-lasting, cost-effective way to supplement handson education. Research conducted as early as the mid-1990s has shown that CBT is about five times less expensive than traditional training, and it’s only improved in the years since. Though employee training costs certainly vary from hospital to hospital, training on regular, necessary job functions and on hospital policy and procedure can take up a significant portion of a department’s budget. Mount Desert Island Hospital, a 25-bed critical access facility in Bar Harbor, Maine spends more than $294,400 on group training and clinical and professional training for nurses, doctors, emergency room workers and other staff members that need to maintain licenses, according to a news report on Maine hospital spending. CBT can be particularly cost-effective for facilities which conduct large-scale training on a regular basis,

Learn from a response leader to the 2011 Joplin, Mo. tornado Receive experience-based tips and lessons learned on how to respond to any emergency situation directly from Dwayne Doran, one of the response leaders to the Joplin tornado. When you attend this one-hour webinar, you will learn: s How to set up a line of communication with your team, hospital staff and the public in the wake of an emergency, including how to: Use an emergency broadcast system that can be adjusted to any scale Set up a mobile communication unit

Note: At least one of your annual drills requires an influx of simulated patients and at least one drill needs to include an escalating event in which the local community is unable to support the hospital. – Rachael DeNale (

s How electronic medical records play a critical role in following up with patients

Joint Commission standards:

s How cameras can be used in rebuilding with better layout and materials for future hospital construction

s EM.03.01.03, the hospital evaluates the effectiveness of its emergency operations plan.

Use social media to get in touch with staff, patients and the public

For more information or to register, go to http://decisionhealth. com/conferences/A2276/register.html or call 1-855-225-5341.

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July 9, 2012

according to research conducted by the Center for Human Services (CHS) in Hanover, Pa., an affiliate of the Maryland-based University Research Co., LLC. “Costs decrease in proportion to the number of learners using CBT programs, whereas costs for classroom instruction increase in proportion to the number of learners,� according to the study. The study also states that CBT is equally and, in many cases, more effective than traditional training methods, with participants completing the material more quickly and getting higher scores on exams. Compliance with training is helped by the fact that CBT can be made available via hospitals’ intranet or the Internet at all times for ease of access and continuity of training, said Connie Lackey, director of emergency preparedness, safety and security with Providence Health and Services in the Valley Service Area in California, at the Joint Commission Emergency Preparedness Conference in April.

CBT is a cost-effective and preventative form of training that can be used for any subject matter, says Ruben Gurrola, director of public safety at University Medical Center (UMC) in Las Vegas. But both Gurrola and Lackey recommend using CBT only in addition to hands-on training. Example: For hazmat training, you can use step-bystep images explaining how to put on a decontamination suit. CBT can prepare you for this task, and it can refresh your memory on how to complete the task when necessary, but you’ll want to actually try it first hand to be truly prepared for an emergency.

Steps to develop your CBT program 1. Determine the subject matter you wish employees to understand. Is it: s A process they’ll have to do on a daily basis? s Something they’ll have to do/know in an emergency? s Necessary to learn this information now?

Benefits of computer-based training Connie Lackey, director of emergency preparedness, safety and security with Providence Health and Services in the Valley Service Area in California, explained many of the benefits of computer-based training at the Joint Commission Emergency Preparedness Conference in April, including: s%FFECTIVENESSFORVARIOUSLEARNINGSTYLESCBT can be designed for linear or non-linear, facilitator-led or self-paced teaching/learning styles. It can also be visual and aural, interactive or text-based, depending on how your hospital chooses to develop each module. s0ERSONALIZEDSOFTWAREIt’s easy to include photos and information specific to your organization when you have the training programs created, instead of a generic scenario with a general topic, Lackey says. This allows your employees to engage with the program more and may enable them to better retain the information. s,ONG TERMSUSTAINABILITY“Once the program is initially put together, it doesn’t take much to update and maintain,� Lackey adds. So, if you’ve used grant money to set up your program, training is easy to continue once that up-front income is no longer available. s#OST EFFECTIVENESSCBT is versatile in what it offers, including initial, refresher and just-in-time training, meaning CBT programs can reinforce, augment and enhance practical training. Because it’s much less expensive to have employees conduct CBT than to do hands-on


exercises, employees can refresh their training as often as needed. And you only need to pay for employees to attend occasional practical or “hands-on� classroom training once the program is set up. s$EPARTMENT SPECIALIZEDPROGRAMSWhile there is information everyone in the hospital must know, other information is specific to certain departments or personnel. CBT allows for the development of those specific modules. Example: Lackey’s organization found that personnel were very responsive to computer-based training and wanted to create an emergency department-specific training module. It developed a four-hour course that was required every two years for emergency department personnel, including training on medical equipment, triage, patient surge and personnel preparedness for emergencies. s/WNERSHIPOFTRAINING “Create leadership ‘super-user’ courses� where additional tools for training others, such as training books and equipment, are passed along to the trainees, Lackey suggests. Then train department leaders to become ‘super-users’ on each shift in each department. These super-users will conduct ongoing annual or refresher training with their staff. Tip: Make sure everyone in the emergency department gets this type of super-training. These personnel are the first to notice symptoms and respond to patients. – Rachael DeNale (

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2. Decide whether the training should be mandatory. UMC has more than 15 mandatory computer-based training modules that every employee completes online, Gurrola says. The program is designed so that if an employee misses any of the questions, he or she has to retake the entire test. 3. Develop the content for the training and tests. During development, each department must take ownership of its own training modules, Lackey says. The department director will know best what’s important and what’s critical for each employee to know and should develop the testing questions, Gurrola explains. Other members of staff should review the questions to determine whether they make sense and whether the employees will get the most critical information out of the learning module and test. Tip: Include pictures and step-by-step instructions on how to carry out tasks and conduct practical training in your computer modules before your staff members begin those aspects of their education, Lackey says. That way, they’ll be better prepared for hands-on training and actually going through the steps during their regular hospital duties. 4. Determine how you want to communicate with your staff about computer-based training, Gurrola recommends. Newsletters, email, bulletin boards and face-to-face interactions are all viable communication options, so you’ll need to choose how you want to pass along that information. The best way to communicate depends on the training subject matter, Gurrola says. Consider implementing multiple communication methods for mandatory training. You may need to call a department meeting to inform employees about the details instead of relying on email alone.

July 9, 2012

Organizations like the NFPA have required testing schedules. But more frequent inspection and maintenance will allow you to spot problems before they happen and keep your systems running smoothly without a major breakdown, says Jonathan Willard, president of Certified Medical Gas Services in New Boston, N.H. “The more proactive you are, the more you are going to solve any problems before they become life-threatening or put patients at risk,� says Willard. Here are some recommended inspections from Willard based on the ASSE 6000 Standard for Medical Gas Systems, the CGA E-10 Maintenance of Medical Gas and Vacuum Systems in Health Care Facilities, the 2005 edition of the NFPA 99 Standard for Health Care Facilities, manufacturers’ requirements and his experience in hospital facilities.

Step 1: Daily visual inspections Start with daily visual inspections of all new systems, says Willard. If you are comfortable that things are operating properly, you can scale back the frequency. Include the following items in your daily review: s Check pressure to make sure there are no dayto-day variations. If you notice something unusual, you can do a more detailed review.

16th Annual EC Summit The 16th Annual EC Summit is set for Oct. 10-12, 2012, in New Orleans. Find out how to: s Avoid Joint Commission survey top targets and RFIs; s Prepare for emergencies and disasters; and s Maintain accreditation using the latest best practices.

s Review and modify training content at least every three years, Lackey suggests. UMC evaluates and updates each module annually to determine if everything makes sense and conveys the information employees need to know. – Rachael DeNale (

Site visit:

gas safety

Interim LSU Public Hospital (Medical Center of Louisiana) – Visit a hospital that is still rebuilding from Hurricane Katrina.

(continued from p. 1) standard doesn’t prescribe how often you need to perform these tests, but does require you to document your process.

For the first time, choose from two site visits – two unique opportunities not available at any other conference. Children’s Hospital – See how Children’s Hospital successfully evacuated 103 children during Hurricane Katrina and learn the steps it’s taken since to improve the hospital for another emergency.

To find out more about the EC Summit and to register, go to www. html or call 1-855-CALL-DH1 (1-855-225-5341).

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July 9, 2012

s Inspect all main line positive pressure indicators to ensure pressures are within acceptable limits plus or minus 5 percent, says Willard. s Review all main line vacuum indicators for water accumulation. Drain if necessary. s Check the medical air system to make sure the receiver drain is operating properly. s Inspect the dew point and carbon monoxide monitors for proper operation and to make sure the readings are within acceptable limits. s Check the tank contents of the bulk liquid oxygen system for adequate supply and to ensure there is no unusual icing or system leakage, says Willard.

Step 2: Monthly inspections These will involve more than just a visual review and may require testing and calibration of certain systems, says Willard. s Inspect your master, area and local alarm warning systems to ensure audible and visual signals are functioning properly. Most of the newer systems will have a simple push button test, says Willard. s Calibrate the carbon monoxide dew point monitors. The calibration requires a kit and is more complex than a mere visual inspection, he says. s Inspect all reserve manifolds to determine if you have an adequate supply. Replenish if needed.

Step 3: Quarterly inspections and maintenance Compressors and vacuum pumps are going to need regular cleaning and maintenance. You need to change the

oil in vacuum pumps for the same reason you change the oil in your car on a regular basis, Willard says. Review the following systems to determine if maintenance is required:

s Inspect the zone valves, gauges and manifolds for leakage. This ensures you aren’t dumping oxygen or nitrous oxide into public areas.

s Inspect medical air system intake and medical vacuum system exhaust locations for changes in condition, any debris and proper clearance.

s Check the valves for proper labeling, configuration and cleanliness.

s Test the function of the automatic alternating controls. s Test the control of the automatic pressure switches to ensure proper operation and correct settings. s Inspect the compressor hours meter for required maintenance. Tip: Document every inspection, cleaning and oil change you do on your systems, says Willard. Many hospitals keep their documentation attached to the equipment so it can be reviewed by all members of the facility.

Step 4: Semiannual inspection and testing There is a new requirement in NFPA 99 to test the articulating boom and manufactured assembly at least every 18 months, says Willard. But more frequent testing for leakage of the flexible connectors and for any physical damage or excessive wear to the hoses will keep things operating smoothly. Review these additional areas on a semiannual basis, Willard advises: s Test the function of the alarm sensors. Remove the sensors from the pipeline and use a hand pump to run the pressures up and down to make sure the sensors are functioning properly.

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s Take a look at cylinder pigtails for physical damage or excessive wear. s Inspect and test critical care inlets and outlets for proper gas flows, terminal leakage and proper operations. Stations outside the critical care area can be tested annually. s Check access to the valves. Items like beds or carts have a way of finding themselves in front of the valves, notes Willard. This is a safety hazard and lowhanging fruit for a surveyor. Tip: Mark the floor below the valves with yellow and black tape and mount yellow signs on the wall on each

July 9, 2012

side of the valve case, recommends Scott Heller, director of emergency management with Albany (N.Y.) Medical Center (631 beds). This doesn’t completely eliminate the risk of violations, but it has worked extremely well to minimize the storage of supplies and equipment in the area, he says.

Step 5: Annual requirements NFPA standards require testing of many of your systems on an annual basis. Some of this testing – such as the alarm push button testing – can be done more frequently, but make sure you are documenting the following at least annually: s Inspect and test the master area alarm panel. Make sure the audible and visual warning signals function properly with the push button test. Also, test the function of all the alarm initiating devices.

How to communicate with staff, others during an active shooter event Use these tips to ensure your communication procedures hold up during an actual active shooter emergency: s$EVELOPANALERTINANAUTOMATICNOTIlCATIONSYSTEM that will inform staff via text message and email of an active shooter on the campus. It’s best to use multiple modes of notification, including computers, phones, banners on hospital screens and overhead paging both inside the building and on the hospital campus, suggests Lisa Pryse, healthcare division president of Old Dominion Security in Richmond, Va.

Example: The Wisconsin Hospital Association, which requires member hospitals to have standardized codes and has recommended a switch to plain language codes (ECL 5/14/2012), suggests the use of “security alert + intruder or show of force� in overhead pages. Example: Aurora Health Care, a non-profit health care network of 15 hospitals in Wisconsin, uses the following alert for an active shooter, as of January 1 of this year: “Security alert + active shooter + instruction.�

s5SEAPLAIN LANGUAGECODEFORANACTIVESHOOTER, Pryse recommends. “The last thing you want is for people not to know what’s going on,� she says.

s$EVELOPAPROCEDUREONHOWYOULLCOMMUNICATEWITH law enforcement. If you’re near the active shooter, wait until you reach a secure location, are no longer under duress or will not draw attention to yourself if you make a call to the police. On a hospital response level, have someone contact the police as soon as possible. If you set up an incident command center, maintain ongoing communications with the responding law enforcement team. Include information such as the description and background of the shooter, the weapon used, any information on victims or hostages, locations the shooter has been and the current location of the shooter. Ensure you provide law enforcement personnel access to facility maps, access codes, keys or anything else they’ll need to get around within the facility without impediments.

s$EVELOPSTANDARDALERTLANGUAGEFORANACTIVESHOOTERSITUation. You can send the automated message out through a computer overhead announcement after the necessary added descriptions are included. All the person who is responsible would have to do is hit the send button, Pryse adds.

s$ETERMINEWHOWILLHAVERESPONSIBILITYFORENSURINGALERT messages are sent out. Make sure there are multiple points the message can be sent from, such as the security department, communications or marketing and IT, Pryse suggests. – Rachael DeNale (

The International Association for Healthcare Security and Safety (IAHSS) recommendations for active shooter incidents also suggest using intercoms, call boxes and pop-up messages. From the hospital standpoint, it’s as important to inform people outside the building as those within it, adds Pryse, president elect for IAHSS.

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July 9, 2012

s Test the gas flow rate on all outlets and inlets. Inspect and test for proper location, labeling, operation performance and leakage. s Inspect the bulk oxygen system with thirdparty verification. This should be done by a qualified representative from your medical gas supplier, but make sure you have someone in there with them to verify the testing is done. s Test the gas purity and concentration to ensure there is no contamination. Willard makes sure the purity levels meet the same standards as when the gas was put into the cylinder, based on U.S. Pharmacopeial standards. – Kevin McDermott (

active shooter (continued from p. 1) Saint Margaret Mercy Hospital, in the Illinois and Indiana area. Milen spoke at the Joint Commission Emergency Preparedness Conference in April. Most damage is done in the first 10 minutes of an active shooter incident, with shooters often moving throughout an area until stopped by law enforcement, suicide or some other method, Milen says.

Create, practice hospital response The International Association for Healthcare Security and Safety (IAHSS) recommends the following steps in its active shooter guidelines:

s Create a multidisciplinary team to develop a response policy. This team should coordinate with local law enforcement agencies and develop a written response procedure for active shooter events. s Develop communication procedures for an active shooter situation. This includes methods to communicate among staff, as well as with patients, visitors and law enforcement, says Lisa Pryse, healthcare division president of Old Dominion Security in Richmond, Va., which specializes in health care security issues (for more details on how to create effective communication procedures for active shooter incidents, see box p. 7).


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s Include your interim response in the policy. In an active shooter situation, you may be able to set up an incident command center to coordinate your hospital’s response with the police. Determine which situations would allow for this in your policy. Also consider restricting access to the facility, diverting incoming patients and disabling utilities after you’ve consulted with police. The time before police arrive on scene, known as the extreme danger gap, has become shorter and shorter in recent years due to Immediate Action Rapid Deployment (IARD), a police tactic where first responders are often regular officers, Pryse explains. s Plan and drill together with both your local law enforcement and clinicians at least annually, Pryse recommends. You should conduct full drills whenever possible, but a walkthrough or a tabletop exercise is also beneficial (for more on how to conduct drills with outside organizations, see story p. 2). – Rachael DeNale (

WHAT’S WRONG WITH THIS PICTURE? Life Safety Forensics: How can you fix the RFIs? Herb Detrick, safety director at Logansport (Ind.) State Hospital, got it right when he spotted the following: “The two cylinders are just sitting on the floor with what looks like only a small wire running from the handle of the job cart to the necks of the cylinders, to keep them from falling over. The fire extinguisher is just sitting there completely unsecured. “I can see a seal on the extinguisher, but can’t see any inspection tags to know when the last yearly was done or that it has been checked monthly.� Thanks for everyone who wrote in, and if you have a photo you’d like to share, please send it to ECL editor Rachael DeNale at and we’ll run it anonymously in an upcoming issue.


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