Consulting, Education, and Support
Providing education and regulatory preparation services for healthcare by conducting training, facility and life safety surveys with supporting document review (Joint Commission, CMS, OSHA, EPA, CAP, CLIA, AAAHC).
Partnering for Superior Performance
Meet Marge McFarlane
PhD, MS, MT (ASCP), CHFM, CHSP, CJCP, HEM, MEP, Principal Superior Performance Consultants, LLC
Marge McFarlane brings over 47 years of comprehensive healthcare experience in the environment of care, life safety, emergency management and infection prevention for construction. McFarlane has authored handbooks on the GHS update to the OSHA Hazard Communication Standard, OSHA training for Medical Facilities and was a contributing author on the special Dark Report for “COVID Risk Assessment/Testing for Laboratories.” She is a frequent presenter for seminars, regional conferences, and audio conferences on OSHA topics, infection prevention (for construction, legionella and COVID-19), hazardous materials/RCRA waste streams, and emergency management. She is currently working with healthcare systems and clinics nationally to identify and mitigate risks in the physical environment and help ensure regulatory compliance.
McFarlane holds a PhD in Safety Engineering and master’s degrees in Environmental and Public Health (ENPH) from the UW – Eau Claire and Risk Control from the UW–Stout. She is an active member of the Wisconsin Healthcare Engineering Association (WHEA) Code Committee and the American Society For Health Care Engineering (ASHE).
We completed the online OSHA safety training today as a small group. We each registered so that we would get our certificates of completion. We really like the format because we could pause the session and discuss the information specifically as it applies to our small facility. Nice presentation! Thanks.Mary Landeher, MD - Sunrise Family Care Clinic
Miron Construction engaged Marge McFarlane to collaborate with us on the creation and launch of our new Healthcare Construction Handbook, a reference tool for our Project Managers, Superintendents, and Foremen who work in new or existing healthcare facilities. Working with Marge was an extraordinary experience. Not only did she offer her wide experience of Infection Prevention and best practices, she integrated her knowledge with Miron’s existing policies and procedures to create a truly unique product. The creation of the manual was not the end of the journey for us. Marge then introduced the manual to our staff and with her real life examples of the risks of working in healthcare facilities--she helped our field staff understand the true complexity of their work. I would recommend Marge to any individual or group that wants to raise their awareness of the inherent risks of healthcare construction and how to mitigate them. We tried to implement a formal program for several years and had only limited success. Without Marge we would never have achieved the goal we did. We and our clients and their patients are all better due to her efforts.Rob Chartier, PE, Vice President of Healthcare - Miron Construction Co,. Inc.
Marge McFarlane was incredibly knowledgeable and helpful throughout the education process. She was able to explain the importance of infection prevention and interim life safety processes to Facilities Maintenance Technicians, Healthcare Contractors, Quality & Safety personnel, and Infection Preventionists. Marge’s style of educating was effective yet entertaining. She answers all questions promptly and in a manner that is clear without being patronizing. We have organized numerous training sessions throughout our system and I’ve received many compliments on her presentations from the staff. I would highly recommend Marge McFarlane to any facility or organization looking to educate and improve employee awareness on the importance of infection prevention and interim life safety for day to day maintenance, repairs as well as construction.Mark Herbert, CHFM, Regional Director - Aurora Health Care, Inc
I have known Marge McFarlane for over 25 years, and it is rare to find an individual as experienced, knowledgeable, conscientious, and reliable as her. One of the things that makes Marge amazing is her ability to accurately recall environment of care, interim life safety, emergency preparedness, and other safety requirements--she is a walking safety database. Another valuable asset is Marge’s speaking skill. She can make a topic that could be dry and boring into an entertaining and memorable presentation. I whole-heartedly recommend Marge McFarlane.Susan Peiffer, MT-ASCP, MS-MT, MHA, CSSBB - Performance Improvement Specialist
OSHA: Beyond COVID-19
Although the Public Health Emergency Declaration ended in May 2023, COVID-19 remains a public health threat. OSHA requires all facility to follow all the General Duty Clause provisions: to maintain a workplace free from recognized hazards that could cause physical injury or death. This includes maintaining mitigation strategies against all infectious diseases: hand hygiene, surface disinfection, employee screening for communicable diseases. Masking and vaccinations are key mitigation strategies.
OSHA also requires all healthcare facilities to have a written Blood Borne Pathogen (BBP) Exposure Control Plan (1910.1030), a written Hazard Communication Plan (1910.1200), general safety and emergency plans, Infection Prevention/TB written Plans as well as annual training. A written Respiratory Protection Plan (1910.134) with fit-testing and annual training is required if any employees wear N95 respirators or powered air purifying respirators (PAPRs). I can assist with annual plan review, revisions/updates, and training.
The OSHA penalties have been increased in 2023 to $15,625 per serious violations and $156, 259 per willful or repeat violations. OSHA will also enforce an instance-by-instance (IBI) citation structure for high hazard willful violations such as falls, trenching, machine guarding, respiratory protection, permit-required confined spaces and lockout tagout. Many OSHA citations were written in 2021 and 2022 to health care facilities that did not comply with the training and fit testing requirements of the OSHA Respiratory Protection Standard.
Environment of Care EPA/RCRA
The Environment of Care is the physical environment in which safe patient care, treatment and services occurs every day. I provide education to clinical staff as well as to those conducting environmental surveys to transition from “finding and fixing” to “tracking and trending.”
Services include Environment of Care plan reviews for safety and security, hazardous materials and waste, fire response, medical equipment and utilities; selection and tracking of performance indicators, review of the annual evaluation of effectiveness and assistance with documenting risk assessments.
OSHA regulates worker safety, CMS (Centers for Medicare and Medicaid) controls reimbursement for safe patient care, treatment and services and the EPA (Environmental Protection Agency) regulates hazardous waste. Healthcare is faced with complying with the complex and sometimes conflicting regulations from these federal agencies.
Services include navigation of the regulations and a gap analysis to ensure that all elements of compliance are addressed.
All facilities are expected to be in full compliance with all published updates to the CMS Emergency Preparedness Conditions of Participation (CoP). Healthcare is structured to provide very good care every day. There are times when there is a rapid increase in the demand for services. Emergencies may be handled by the resources on hand or with the need for additional resources. Everything gets accomplished but at a quicker pace. Disasters may require significant amounts of external resources and coordination and every need may not be met.
Emergency management is the process of planning for and mitigating (reducing the impact of) internal and external events that may require additional resources. Emergency response is the activation of pre-planned processes to respond to and recover from internal or external events and to restore the day-to-day operations of the hospital.
Exercises, drills and actual events are ways to test the current emergency capabilities related to communications, the allocation of resources, staff roles, safety and security, utilities and patient care and staff support. After action reports identify strengths to be maintained and opportunities for improvement.
Services include tailored checklists for exercise design, Emergency Management Committee education, exercise evaluation and after action reports with opportunities for improvement and periodic assessments for completion and sustainability of the improvements
Life Safety Mock Surveys & Plan Review
A mock survey follows the agenda of regulatory surveys. Joint Commission mock surveys use the life safety document review and facility tour to assess compliance with the standards and elements of performance. The mock survey includes an Environment of Care and Emergency Management session for coaching and plan review. The EOC plan reviews include each of the management plans for safety and security, hazardous materials and waste, fire response, medical equipment and utilities well as the annual evaluation of effectiveness.
CMS mock surveys include life safety document review and facility tour to assess compliance with the Conditions of Participation. The mock survey includes a session for coaching staff in the Conditions of Participation, the expectations for federal surveys and mitigation strategies for the opportunities for improvement identified.
Hospitals are built to “defend in place.” Managing facilities is a challenging and ongoing proposition. I provide an extra set of eyes to help identify opportunities for improvement and strategies for managing those opportunities.
AAAHC mock surveys include a review of the physical environment chapter and supporting documentation
Services include facility tours, life safety plan and document review, interim life safety staff education, and associated plans for improvement as well as assistance in developing a prioritized list for implementation.
Infection Prevention for Construction
Infection prevention for construction has evolved from “just for” large construction and renovation projects to include a required risk assessment for maintenance and small projects. These small projects may fly under the radar of the facility planning and construction committee but may impact vulnerable populations, even if only for a short period of time.
Services include staff and contractor education as well as strategies for and preparation of risk assessments, monitoring of projects related to the project and document review.
See the facilities modification risk assessment (FMRA)
This document can be used as an infection prevention risk assessment for maintenance and repairs.
Legionella and other waterborne pathogens continue to cause illness and fatalities in the U.S. The Centers for Medicare and Medicaid (CMS) as well as other Authorities Having Jurisdiction (The Joint Commission, DNV, HFAP) have required Water Management Plans for several years. The focus for healthcare surveys now includes a review of implementation, monitoring, control, and validation. I can assist with a risk assessment for your facility, plan review and training. A key element to success regarding a flushing program can include the use of a Water Infection Control Risk Assessment (WICRA) as outlined in the recently published ASSE 12080 Standards. I have successfully completed the ASSE 12080 requirements for the Legionella Water Safety & Management certification. Let’s review the status of your WMP and make updates as needed.Learn more
Aids to Understanding Compliance
The Support You Need
Forms, Checklists, Webinars, & More
Marge provides education and regulatory preparation services for healthcare by conducting training, facility and life safety surveys with supporting document review.Learn More
OSHA Training Handbook for Healthcare Facilities, 2nd Edition
Identify specific methods to train staff, identify hazards, and document assessments to become a highly effective safety professional.Learn More
The Compliance Guide to the OSHA GHS Standard for Hazardous Chemical Labeling
Written for medical and dental offices and healthcare facilities of all sizes, this handbook includes a downloadable Hazard Communication plan template that is easily customized.Learn More