How one clinic breezed through OSHA inspection
Documentation is key to avoiding citations
When an OSHA inspector contacted Bruce Cunha, RN, MS, manager of employee health and safety at Marshfield (WI) Clinic, about a complaint, Cunha had only one thought: He would provide enough information to prove the clinic’s safety program was more than adequate.
In fact, Cunha was so effective in answering the inspector’s questions and concerns that the clinic breezed through the inspection without a single citation.
The key to successfully weathering an Occupational Safety and Health Administration (OSHA) inspection is documentation, Cunha says. "Giving them as much information as you can is very, very important," he emphasizes.
The complaint at Marshfield Clinic and nearby Howard Young Hospital in Woodruff, WI, concerned prevention of exposure to bloodborne pathogens. The inspector arrived on Oct. 29; OSHA’s updated bloodborne pathogen directive came out on Nov. 1. That made Marshfield and Howard Young among the first facilities to fall under that directive. (The clinic and the hospital are independently owned. The clinic supplies doctors and other staff who have work duties at the hospital.)
Cunha showed the inspector logs of safety devices that had been evaluated and put into place. He printed out an incident report log and explained that incidents can be reported by e-mail, voice mail, or in writing. "She found there was no evidence that incidents were not being reported," he says. "You try your hardest to get people to report things."
Clinic exceeds OSHA’s tracking requirements
The inspector also wanted to see information on each needlestick incident, including corrective action taken. That isn’t required on the OSHA 200 log if the source patient had no bloodborne pathogen and no follow-up was necessary. Furthermore, OSHA’s more detailed needlestick reporting requirements have yet to be released as a part of the agency’s pending recordkeeping standard.
Nonetheless, Marshfield Clinic tracks every incident by computer, including information on testing and follow-up. "In 97.2% of exposures, we’re able to locate the source patient and get their support for testing," he says.
Cunha was able to show other evidence that the clinic maintained a safety program that more than met the scope of the standards. For example, the clinic switched to latex-free exam gloves in 1996 and hasn’t had any employees who had to be reassigned due to latex allergies.
"The OSHA inspector wanted to see our policy on hepatitis B immunization," he says. "We offer hepatitis B immunization to every employee, whether they have a potential for blood exposure or not. We believe it’s that important."
Cunha, who has worked for 21 years in employee health in the health care, forestry, and steel industries, says he has learned from experience how to respond to OSHA inspections.
Give inspectors everything they need’
"This is probably the 14th or 15th OSHA inspection I’ve been directly involved in," he says. "I try to work with the inspectors and get them everything they need."
Here is some other advice from Cunha:
• Approach the inspection in a professional manner.
While you want to be open with information the inspector requests, you don’t need to throw open all your files and invite the inspector to dig in. For example, in a walk-around of the facility, you can limit the inspector to the areas covered by the complaint, although Cunha does not always do so. Everything should be handled in the context of a professional conference in which the inspector outlines his or her needs. Cunha also asked the clinic’s legal counsel to be present at the initial meeting.
• Keep track of the inspector’s information requests, and duplicate any video or photographic documentation the inspector makes.
Cunha writes down all the information the inspector requests. "When I go around with an OSHA inspector, I always ask if they’re going to be videotaping, photographing, or recording," he says. "If they are, I go around with the equipment and I have the same thing. I want to be able to see exactly what she’s seeing. I always document whatever they’re documenting."
• Identify one knowledgeable person as the main contact for the OSHA inspector.
That could be a safety officer, compliance manager, director of employee health, or an infection control officer. This key person who supplies information to the inspector should be aware of the OSHA system and the rights and responsibilities of the hospital.
• Be aware that providing safety devices and protective equipment is not enough.
Cunha notes that Howard Young hospital was cited for not ensuring that employees actually wore personal protective equipment. Documentation of efforts to ensure compliance may help avoid such a citation, he notes.
• Monitor compliance of non-employees who work in your hospital with health and safety regulations.
You can receive a citation for actions of a physician or other employee who isn’t actually employed by your facility. Document that these employees have appropriate training in your facility’s programs, that they are provided with personal protective equipment, and that they are periodically evaluated for compliance, Cunha says.
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