The McLaughlin File


  • Chief operating officer, MSL Healthcare Partners, Barrington, Ill.
  • President, SBM Consulting, Barrington.
  • Director of safety and compliance at the American Society for Health Care Engineering (ASHE).
  • Team leader of the standards interpretation group and associate director of standards interpretation, The Joint Commission, Oakbrook Terrace, Ill.
  • Director of safety and clinical chemistry supervisor, Northwest Community Healthcare, Arlington Heights, Ill.


  • ASHE President’s Award recipient, Senior and Fellow, faculty and former board member.
  • Chair of the National Fire Protection Association’s NFPA 99 technical committee on emergency management and security, and former chair of the NFPA’s health care section executive board.
  • Certified Healthcare Facility Manager.
  • Certified Healthcare Safety Professional.


  • Master of business administration, Keller Graduate School of Management, Chicago.
  • Bachelor of science in medical technology, Northern Illinois University, DeKalb.

A well-known compliance expert with many years of high-level service to the field, Susan McLaughlin, FASHE, CHFM, CHSP, was a natural choice for the President’s Award at last summer’s American Society for Health Care Engineering (ASHE) conference. This month, she tells Health Facilities Management how she made the climb.

How did it feel to win the President’s Award at last year’s ASHE Annual Conference & Technical Exhibition?

I was surprised when [2018 ASHE President] Brad Taylor called to tell me I would be receiving the award, having never expected it. It is also amazing, in part, because I am in a traditionally male-dominated field. It’s humbling to receive such an honor from your professional organization and your peers, especially considering all the other potential recipients who give so much to ASHE.

How did you get into health care?

From the time I was young, I always wanted to go into health care. I’d considered a variety of professions, from dietetics to medicine. A friend of my mother’s was a research chemist for a pharmaceutical company, and I was intrigued by that. She suggested that I go into medical technology as a first step, so that was my college major. My first job after college was as a medical technologist in a clinical chemistry lab, where I advanced to become supervisor in 1978.

When did you transition into the compliance arena?

After a number of years in chemistry, the clinical chemist for whom I worked suggested that I further my education, and I pursued an MBA. Upon graduation, I interviewed for a few positions outside of the laboratory, and ended up accepting a newly created job of safety officer in the same hospital. I remember going through all of my interviews, saying, “I can do this position, but I don’t want to do safety forever … .” Later, restructuring led to the elimination of the safety-officer job, and I was assigned to a variety of other projects. I began looking for other employment. After a number of interviews in mostly lab-related jobs, I saw an ad for an associate director of environment of care standards interpretation at The Joint Commission. From the moment I read that, I knew it was the job I wanted.

Did you face any unique challenges as a woman involved in Environment of Care and Life Safety compliance?

I have experienced a gradual career transition. Medical technology is a profession typically comprising women, clinical chemistry is more of a gender mix, and then I got to health care engineering, which predominantly consists of men.

But I’ve never felt hindered in my career because of that, nor that anything or anyone was standing in my way. I’ve had some interesting anecdotes that I can laugh about, though, such as picking up the phone at The Joint Commission to be told, “I was holding for an engineer” or being the only woman in the room during ASHE committee meetings or walking into a hospital conference room with a group of men sitting around a table and knowing immediately that I needed to review my credentials.

Occasionally, I run into someone at a hospital site who covertly wonders what I’m doing there. Not that anything is said, but you can just tell. I really don’t let any of that bother me. I just do what I need to do to the best of my ability.

Has the field changed in that regard over the past 20 years?

Yes. I’m happy to see so many female students and interns in programs leading to health care engineering. ASHE has significant female representation on its committees and among its emerging leaders, not to mention the female facility managers — not great in number, but very talented. I occasionally meet a female in facility maintenance — still a rarity, but wonderful to see. But, as I infamously said upon receiving the President’s Award at the ASHE conference: There are still no lines for the ladies’ room at the ASHE conferences.

How have the overall compliance challenges changed over this same period?

When I first started in safety management, The Joint Commission basically told us what we had do to, but then it moved to nonprescriptive standards, where it identified the topics and health care organizations had to tell them how they managed the issues.

The Statement of Conditions as a get-out-of-jail-free card has come and gone, along with the building-maintenance program allowing a 5 percent leeway in the number of devices tested when you could prove a program was effective.

The Environment of Care standards have undergone a major reorganization at least three times. Emergency Management and Life Safety have been made separate chapters in the accreditation manual. Real-life emergencies have driven the change and influenced the Centers for Medicare & Medicaid Services’s (CMS’s) Conditions of Participation for Emergency Management. Life-safety specialists have been added to the accreditation team.

Importantly, there has been an increased emphasis on infection prevention, with the addition of elements of performance addressing waterborne pathogens, airborne contaminants and pre-construction risk assessment. These have focused attention on these critical issues and seem to be contributing to an important difference in health care-associated infections.

Perhaps the most significant changes we’ve seen are the most recent ones, with the adoption of the 2012 editions of [the National Fire Protection Association’s] NFPA 99, Health Care Facilities Code, and NFPA 101, Life Safety Code®, which generated many new and specific elements of performance. Coupled with this is the increased oversight of CMS over all third-party accreditors, and the use of the see-it-cite-it survey methodology.

And now, we’re also focused on ligature risk, with the physical environment findings all scored in the environment of care. This brings us to a point at which surveys are more detailed with more findings than ever before.

What major compliance challenges do you see in the future?

One challenge that ASHE and the field has been discussing is succession planning. The aging and retirement of facility professionals is not just coming — it’s here. We’ve seen progress in college and university partnerships, with success in recruiting students to the field, but there is more work to be done and a looming shortage of individuals to fill the open positions.

Emergency management is growing in focus and compliance, and I expect that to continue. It seems that each year brings new challenges for hospitals, as we learn from every response to actual events. Undoubtedly, compliance requirements will continue to change over time with all of the lessons learned.

The increased oversight and scrutiny of regulators continues to be challenging, and I see that intensifying. It is also notable that the standards of third-party accreditation organizations are all coming together under CMS oversight. There are distinctions in the approach of each, but all are looking at the same requirements. It will be interesting to see how that impacts the field.

Photo by Buschauer Portrait Design