Hospital Safety Not Child’s Play

How high is the sky? As the motto and ethos at Children’s Mercy Hospitals & Clinics in Kansas City, Missouri, that questionreflects the natural inquisitiveness of the children treated there, the hope the center holds for these patients, and the high standards it demands of itself in providing a wide range of pediatric care. The security department at Children’s Mercy shares the center’s upward-looking approach, setting its sights on maintaining a safe and secure environment.

The centerpiece of the hospital is the 241-bed Children’s Mercy Hospital and Hall Family Outpatient Center in Kansas City, known as the main campus. It comprises three six-story towers connected by a common floor at street level. Satellite facilities include a 54-bed hospital in suburban Overland Park, Kansas (Children’s Mercy South), and Children’s Mercy Northland, home to an urgent-care unit and clinics for pediatric cardiology, neurology, speech, and many other specialties.

In addition, the center has other primary-care and specialty clinics throughout the region. These multiple facilities are run by a staff of 3,500 employees and 1,000 volunteers. From mid-2004 to mid-2005, the staff tended to more than 111,000 children as ER patients, 272,000 as outpatients, and 13,000 as overnight patients.

A New Approach

Children’s Mercy—like many similar healthcare facilities—had a fairly unrestrictive access policy before 9-11. But driven partly by the changing threat environment nationally and partly by a few disturbing instances at the hospital, the security team decided after September 11 that it was time to abandon its come-and-go-as-you-please environment.

A new approach to restrict and regulate visitor, patient, and staff access control was designed by the security team, headed by Director of Security Dan Malaun. The revised program establishes numerous procedures for controlling entry into the facility, including sign-in requirements for visitors, protocols for special restrictions, and attention to instances or events that might create a risk of contamination.

The center also takes a layered approach, with additional controls at internal doors and the use of

CCTV for remote surveillance throughout. In addition, the center understood that the new protocols and equipment would require staff increases.

Monitored Entryways

Under the old system, patients, visitors, and staff could enter the main facility (on the main campus) from about 15 different doors. There was no feasible way to monitor and account for people coming in from so many different entry points, says Dan Arnett, assistant director of security at Children’s Mercy. At most, it was only possible to staff five sign-in posts (more on staffing and posts later).

The security team decided that it made sense to turn the remaining 10 doors into emergency-exit-only throughways. All doors already had magnetic locks that would release after 15 seconds of alarm, so they met the fire code standard and could be for emergency use only.

The team then had to decide which five doors would remain open. They considered levels of historical traffic flow and areas where immediate access was needed, including the emergency room. Accordingly, one of the selected doors is the entrance to the ER. Another is the entrance to the same-day surgery department, where children come for procedures such as tonsillectomies.

Two other doors are side by side at the main entrance to the main hospital. The fifth entrance is the door to the bridge which links Children’s Mercy to the Truman Medical Center—an acute care and outpatient center for both adults and children—across the street. At night, when traffic in the hospital slows, the five entrances are reduced to three: the two main entrances and the entrance to the ER.

Five entry posts, custom-made by the hospital’s carpenter, are stationed just inside these five doors. Each station has wheels so that it can be moved to accommodate changing patterns of influx into the building.

Each post is equipped with a computer, an in-house phone, and a clock. In addition, there are basic personal protection supplies, such as masks and gloves, in case officers are about to admit someone who might have been exposed to hazardous materials. (More on protocols for dealing with contaminated patients later.)

The south campus. Because the south facility is newer, designers took into account the need to minimize entrances from the outset. The south campus uses two mobile posts, one just inside the main entrance and the other inside the urgent-care entrance. There is a third door equipped with a card reader, and employees use their magstripe ID cards to enter there.

There are a few other exterior doors that are kept locked and are currently fire-exit-only doors. The building was built with plans for it being expanded, to include taking on more clinics and becoming a full-blown ER. As the building gets busier, more entrances will be opened, and guards will have to monitor these extra entrances.

Sign-In Procedures

Officers at public entrances require visitors to sign a log sheet and note their time of arrival and where they are going. In general, all visitors, even spouses of employees, must show a valid photo ID. But with a supervisor’s approval, exceptions may be made for parents or grandparents who have rushed to the hospital. The ID requirement may also be waived for someone with extraordinary circumstances, though that again would require a supervisor’s approval, Arnett says.

The sign-in sheet has been tailored to protect patient and visitor privacy under the Health Insurance Portability and Accountability Act (HIPAA): the sheet has a sliding protective cover that shields from view all previous information entered on it. Thus, a visitor sees nothing but the information he or she has written. Arnett explains that allowing visitors to see others’ sign-in information could reveal the presence and medical issue of a patient, which could violate HIPAA protections.

Officers next check to determine whether the patient to be visited has been admitted to the hospital. At least twice a day, the hospital prints lists of admitted, ER, and same-day-surgery patients, which are distributed to the sign-in posts. The same information can also be found on the hospital’s computer system, which guards can access from any sign-in post.

Visitors then receive a sticker imprinted with that day’s date, color-coded to indicate where on the premises they may go. For example, visitors to the ER get a red sticker, while guests visiting patients other than those in the ER get a green sticker. If an officer wants to place additional restrictions on where a person can go, he or she can write a specific location on the sticker. The ER sticker also has a large, superimposed “ER” on it “so there’s no mistake,” Arnett adds.

Arnett admits that the system is not ideal for long-term patients and their visitors. “We’d like to get them a more permanent badge,” he says, but that could lead to problems. “We’d have to worry about whether they’re still here, how to get the badge back,” and other issues.

Restrictions. To keep out persons who might pose a problem, the hospital places what it calls entry “restrictions” on anyone the administration has reason to believe might create a disturbance. A list of these potentially disruptive persons, most of whom are recently terminated employees, is distributed to officers at entrance stations, along with their photos. At the beginning of a shift, the station officer is expected to review this list.

The list includes the date the employee was terminated and whether badges and keys have been returned. Only one or two names are on the list at any one time, says Arnett.

Sometimes parents or other caregivers want to add a name to the restrictions list. For example, they may want the hospital to prevent visits from estranged spouses. A spouse must have a court order on the other spouse as the basis for a restriction. And the paperwork must be provided before the hospital will take action.

In addition to restricting any one person’s visitation privileges, parents have the right to require that the hospital not disclose their child’s location, room number, religion, or condition, Arnett says. When a parent requests such a restriction, security dispatches a supervisor to the child’s room to explain to the parent what it entails: that the hospital can’t give out the phone number to the room, allow flower or food delivery, or even acknowedge that the child is in the hospital. “Ninety percent of the time they say that’s not what we wanted,” says Arnett.

The hospital enforces about one to three such restrictions at any given time. They are highlighted in electronic and hard-copy versions of patient files.

Children’s Mercy imposes its own restriction—called a blackout—if a child is a victim of a shooting. It involves the coordination of the security department with the ER, the social work department, and other hospital units.

When the child is admitted, anyone other than the parents who asks about the child will be told that he or she isn’t there. After about an hour or two, the parents can make a list of ten people who will be allowed to see the child. Anyone else will be told that the child isn’t at the hospital. “Someone may be coming to finish the job,” Arnett explains.

There is also a general standing restriction on the number of visitors that may be admitted at any one time. If dozens of family members show up together, they will be shepherded to a private area by a chaplain or another appropriate person, who can get the group under control. They will then be allowed to visit the patient a few persons at a time. Large groups are not allowed to remain on the premises for extended periods, however.

Contamination Control

Another objective of the new access control procedures is to prevent contamination of the facility and its occupants in the event of a nearby incident in which persons are exposed to contaminants.

Protocols have been established by which the health department, ambulance personnel, or other first responders would call ahead to the hospital to say that patients who might be contaminated are being brought in. Security officers and other front-line personnel would then don their protective gear. The sign-in stations would be moved either just inside the doors or right outside the doors so that any contaminated patients would not infect the hospital population.

Children’s Mercy is prepared to treat contaminated patients in its ER, where it can set up different size decontamination tents depending on the extent of the exposure. The hospital conducts two mass-casualty drills per year in which staff practice these procedures and liaise with first responders such as firefighters and EMTs. Security and ER staff also conduct tabletop exercises to run through possible scenarios.

To deal with patients who might have been exposed to hazardous materials and who might try to enter through a non-ER entrance, officers receive training from a safety officer every other month. There they learn verbal techniques and specific language for determining whether a person is contaminated, for routing that person to the ER, and for stopping that person from gaining admittance through an entrance other than the one to the ER. Officers perform scenarios where they must put these techniques to use.

Basic protective gear, such as masks and gloves, is at each post for officer use. If a possibly contaminated person rushes past the post, the hospital would close down the affected area and bring everybody, including security officers, to a safe area. Fortunately, that hasn’t happened.

Internal Doors. After being admitted into the main campus facility by a guard, visitors encounter a second layer of security at their destination floor. At each floor, the elevators open onto a self-contained lobby/waiting area. Visitors push a button that alerts a nurse or other staff person on the floor. The staff have a monitor to see who is asking to get in and to make sure that they have the correct credential. Once allowed to enter, visitors have to sign in here as well. After visiting hours, only parents and grandparents may enter patient areas.

Staff can enter any area by using their magstripe ID cards. Several hundred card readers control access around the hospital, including at the entry into pharmacies and medical-specialty units. Employee IDs are encoded with permissions determining where they can go and when. The security team can track anyone by door use, time of use, and other factors, and it creates reports accordingly.

CCTV. The hospital used CCTV cameras even before it tightened its access control procedures. It factored the existing surveillance capabilities into the revised plan and is in the process of enhancing the coverage as the budget permits.

The main campus uses 175 cameras, many of which include pan-tilt-zoom capabilities. The cameras give security the ability to remotely monitor the entire perimeter. In addition, all entrances and sign-in posts are covered, as are main hallways, the waiting room for the ER, the cafeteria entrance and exit, and anywhere with a cash register, such as the gift shop.

Pharmacies are blanketed by cameras: cameras watch every door, the pickup window, and the accounting area, and several cover the shelves where medicines are kept. The south campus uses a smaller, separate system. Footage from both can be viewed live, and all of it is recorded on digital video recorders (DVRs).

Video feeds go to the main security office, but they are also available on the hospital’s network. Security personnel can monitor video from their desks, with the ability to pull up any camera feed from either campus, in either real time or from recorded footage. “I can follow anyone throughout the hospital in real time,” Arnett says. He can also pull archives and track a person via recorded footage.

Plans are underway to upgrade the system, which now uses mostly analog components but gets some of the benefits of digital through the DVRs. The department is poised to put out a request for proposal for conversion of the system to one based on Internet Protocol and Ethernet networks. The conversion will be phased in, Arnett says, because of the work and expense involved.

Staffing. In addition to enhancing access control protocols and equipment, the administration recognized the need to boost staffing. Two events occurred at the hospital that—along with 9-11—drove home to the administration the hospital’s need to invest in additional personnel to enhance security. One involved theft of money from the cafeteria, another a holdup of a landscaper outside the hospital.

At the time, the hospital had about 25 security officers for all of its complexes. That meant that staff were stretched pretty thin. The administration boosted the security budget by $1 million for additional staffing, which enabled security to upgrade to about 85 officers.

The funding paid for more patrols as well as for more officers to perform access control functions, such as watching the main gate where cars arrive, monitoring the garages, and staffing the newly deployed sign-in posts.

Results. The tightened access control procedures have reduced security incidents and have won the support of staff. But some problems arose early on.

For example, Children’s Mercy is located near a dental school, and students would routinely dine in the hospital cafeteria or shop in the store. That changed overnight, to the dismay of students and the operators of the gift shop and cafeteria, who lost revenue.

“When we locked down, we decided that we’re not in business for the gift shop and cafeteria,” Arnett says. Students have come to accept that the hospital isn’t a site of general public access, he adds. Similarly, after slight resistance from the operators of the gift shop and cafeteria, the change in policy was well accepted because hospital staff understood that the facility’s primary mission was helping patients in a secure environment, not making money.

Another problem early on was making sure that parents and other visitors who stayed overnight remembered to get the next day’s visitor badge. At first, many of these visitors would forget to replace the sticker or would continue using the elapsed credential from the day before. Staff now remind visitors to update their credentials at any of the sign-in posts.

Getting employees—especially doctors—to support the tighter access control procedures was also a challenge. They often forgot their badges and wanted simply to be let in. In a hurry to exit, for instance, doctors might leave their IDs on their desks. They might then get upset when pressed for an ID before being allowed to reenter.

The problem has since dissipated because of the administration’s support. “Top doctors and the administration have been behind this 110 percent,” Arnett says. “Everyone now has bought into the plan, seen that the administration is not pulling back, and seen that it works,” he adds.

Occasional petty thefts of the past are now almost nonexistent, says Arnett, and word has got out in the city that Children’s Mercy is not an easy mark. In one case, a person bypassed security and took the elevator straight to the clinics. There he roamed the halls until he found an unlocked doctor’s office, where he swiped a purse. But security got footage of the man leaving the building with the bag under his arm, and it distributed a color photo of him to all of the officers. Within a week, the man returned to the hospital, and an officer apprehended him.

Not only did the incident show outsiders that the hospital was no longer a soft target, it also helped demonstrate for the staff and administration the value of the program and the importance of following procedures, such as keeping internal doors secured. Security made this point directly to the people who left the doctor’s door open, and Arnett uses this story during staff security orientation as an example of what can go wrong when attitudes about safeguarding valuables are lax.

Additionally, there have been no incidents of unwanted people getting access to a patient. The security staff is not complacent, however. It is constantly looking to improve and fine-tune access control, as by updating its camera system.

Security is also eyeing a switch from magstripe to proximity technology for employee IDs, and it has been tracking the development of computerized visitor credentialing, with plans to go in that direction when the technology gets more user-friendly or when funds for the additional training that would be needed become available.

Some automated visitor systems currently meet Arnett’s desired throughput time of 30 seconds per person, he says, even printing a picture from a driver’s license on the credential. But he considers them too complicated for most officers to use; only people highly proficient with the software could make the 30-second limit, he surmises. Training is too cost-prohibitive for now, he says.

Children rely on the expert practitioners at Children’s Mercy to help them get well. The physicians and researchers rely on security to keep them well away from worries about safety so that they can concentrate on the children.

Michael A. Gips is a senior editor at Security Management magazine.