When a Joint Commission EP goes "ghost"

Suppose we have a pre-Nixon-era building in which we have not yet introduced emergency power into the patient rooms (no recent renovations of significance, etc.), but we do have emergency power outside each of the rooms.

The area complies with EC.7.20, EP #11 (providing emergency power for areas where electrically powered life-support equipment is used) because patients in this location don't require ventilators and the usual run of life-support type equipment. If we had to provide emergency care, the defibrillator is plugged into emergency power out in the hall and, if really pressed, we could run an extension cord on a temporary basis into the room until the patient was stable enough for transport.

I mean, after all, we do have emergency power in this area "where electrically powered life-support equipment is used," according to EP #11, so we-re on solid ground here--yes? Also, we've identified as a PFI plans to address this improvement opportunity, so again, we seem good to go.

Ah, not so fast grasshopper! It appears that, from a compliance standpoint, EP #11 is a veritable onion of a standard, with several layers of requirements that come into play.

Note EC chapter references to the American Institute of Architects' Guidelines for Design and Construction of Hospitals and HealthCare Facilities (2001 edition) and NFPA 99, Standard For Healthcare Facilities (1999 edition).

Both of these august tracts reference a section of NFPA 70, National Electric Code, that requires hospitals to provide one duplex emergency power outlet per bed, connected to the critical branch of the emergency power distribution system, in general care patient rooms.

You might argue that when this building was constructed, these codes referenced above weren't in effect, and you would be correct. But in a similar real-life case that I'm familiar with, an intrepid Joint Commission surveyor did not quite see it that way, resulting in an RFI under EC.7.20.

It took several back and forths with The Joint Commission before the determination was made that we had been in compliance with the EP as it was written in the standards, but the underlying NFPA 70 requirements had "caused" the noncompliance. Further relief came as the result of grandfathering this area's configuration due to it not having been updated, since adoption of  the applicable codes came long after the condition had been established.

So, the take-home lesson? It is in your best interest to use The Joint Commission's clarification process and always:

• Look at what the surveyor has identified as the issue
• Lock at which EP is cited as the result of that identification
• Keep at it until you get relief

When a survey ends and you have any number of RFIs, start the clarification process as quickly as possible. Work with your organization's survey coordinator, your Joint Commission account representative, even engage the assistance of a consultant--the important thing is to leave no stone unturned.

The last thing you want to have to do is to fix something that is not broken. In the long run, you have enough other things that legitimately require your attention.