Think about the potential dangers that lurk beyond your four walls — that tough turn across traffic into your facility's main entrance, the cars that whiz by your front door or perhaps that questionable neighborhood on the other side of the parking lot. They all put patients and staff at risk every time they enter or leave your facility. You should assess environmental threats at least annually, including ground surveys and a hazard vulnerability assessment. Here's what to consider.

Traffic flow. Watch the speed and flow of traffic around your facility and entry roads. Do traffic lights assist cars into and out of the complex? Does the main flow need to navigate against fast-moving traffic to enter your parking lot? Is your building well lit and is directional signage viewed easily from the main access road?

While your center may be unable to control driving patterns on public roads, you can take reasonable actions to ease traffic flow within parking areas and access drives. One of my centers owns its access road and resorted to installing speed bumps to slow traffic. Consider working with your city or town to upgrade road signage when an access street name changes, as one center in my area did many years ago.

Traffic lights can be installed if you demonstrate a reasonable need to the local government. You may have to cover the entire installation expense, but check with the government or other businesses in the area to see if they'll share the cost. It's worth a shot. At the very least, detail the best way to access your center during pre-admission telephone contacts with patients. Send the same directions to the physician offices that refer patients to your facility.

Parking. You have a great amount of control over the parking conditions around your facility, and therefore a large responsibility for maintaining adequate lighting, paving, curbing and speed control. Be sure to evaluate the parking areas at night to check for burned-out lights, dark corners that could benefit from more lights and hard-to-see barriers. Well-defined parking spaces help patients avoid parking too close to another car or in handicapped parking spaces.

Think about adding speed bumps to maintain a safe traffic flow (also realize that they create the potential for patient falls). Add signage, use colorful paint and place bumps outside of patients' usual walk patterns.

Look at the layout of your facility's parking lot. Do the parking rows run parallel or perpendicular to the building? Rows running parallel create a potential hazard for patients, who might have to walk over grass dividers or step out from between cars when crossing oncoming traffic. Is a cordoned pedestrian walkway needed in those instances? If you're involved in a new project, be sure to consider the path pedestrians take to get from their car to your front door. Major design changes are not economically feasible once a parking lot is built.

Also consider the potential for accidents when cars enter your parking areas. Large and well-lit directional signage is helpful, but should be positioned to avoid blocking the vision of drivers entering or exiting the area. Apply the same test to landscaping materials than can grow and block visibility.

Observe the traffic flow around your patient drop-off and pick-up area. Should you employ one-way traffic? Is there a covering to protect patients from the rain and potential slips and falls on slick cement? Ensure entryways are even with outside pavement or flooring and consider floor mats for rainy or snowy days, so long as the mats don't easily fold or bunch underfoot. Of course, have adequate weather-related maintenance contracts for ice and snow removal.

Security. Patients, visitors, staff and physicians have the right to a safe and secure work environment. Personal safety is a concern in all settings, but is of particular importance in high crime areas.

Methods to reduce personal dangers while entering or leaving your facility include both physical- and process-related interventions. Adequate lighting, self-locking doors and alarm systems should be coupled with processes to improve staff safety. Leave work in pairs or groups. Employees should move their cars close to the building before sunset when planning to leave work after hours. Some centers may choose to hire a security team or work with local authorities to provide periodic patrol of the facility's campus. Staff education about personal safety when leaving or entering the facility should stress the importance of handling purses appropriately, being aware of their surroundings and having keys in hand so they can sound their car's panic alarm or quickly enter their vehicle.

Hazard Vulnerability Assessment (HVA). Perform annual hazard vulnerability assessments of your surrounding neighborhood and community's geography.

• Is your area prone to flooding? Sink holes? Dust storms? Mudslides?
• Does your facility adjoin a large interstate roadway or railroad, potentially leading to the need for disaster response, or worse, to facility damage?
• Is there a nuclear power plant, natural gas line or oil refinery nearby?
• Are you in a tornado or hurricane prone area?
• Are you in a high crime area?

Discuss and plan for potential dangers or crises. The annual HVA should include both a review of past adverse events, the response of the facility team to those events and plans for dealing with future potential problems. You might think that an annual assessment is unnecessary, but changes can occur in and around your facility that might alter environmental safety concerns.

For example, one of my centers will soon have a 24/7 emergency room opening on its campus. Patients and staff arriving at all hours will create new security concerns. Natural disasters may not be a pressing concern during your daily routine, but let's not forget about the devastating hurricanes we've seen ravage parts of our country in recent years. The unlikely is still possible. Plan for it.

Prepare for the worst
While surgery is fraught with many potential dangers that require careful focus and attention — falls, burns, medical errors and more — it's equally important to address the external factors that threaten staff and patient safety. Be careful. It can be rough out there.