Surprise, surprise, surprise

Just a few weeks ago I was involved with an unannounced survey by The Joint Commission (formerly JCAHO). I encountered one of those funny little happenstances that really isn't that funny: a surveyor who expressed surprise when the data that he had recorded during the survey was sufficient to warrant a requirement for improvement (RFI) under EC.5.20.

For the record, I wasn't surprised--and I don't think it has anything to do with math skills.

Now for those of you who "believe" in the 95% rule based on the practical implementation of a building maintenance program (and especially to those who have disagreed with my interpretation of how the BMP gets surveyed), please consider this in the spirit of holiday giving. The following items added up to an RFI:

• A single exit sign that the surveyor thought should be pointed in a different direction
• A single smoke door with a gap greater than 1/8 inch and no astragal
• A single penetration in a rated wall
• A single location requiring fire-proofing of a steel beam

Oh, by the way, the exit sign, smoke door, and rated wall had all been repaired before the end of the survey.

Now I am very hopeful that these citations (with the possible exception of the beam) will be overturned on clarification. The folks in question have a solid BMP in place, but the numbers involved (1+1+1+1 = RFI) are important to keep in mind as you go through survey.

I've likened this, probably ad nauseum, to a death by a thousand cuts. But thing that really gets me: Do the surveyors really not understand how the scoring works? Was he really surprised at the RFI?

I know that the mark for just about any B or C element of performance is:

• Zero to one instances of not meeting the EP means you fully comply
• Two instances is generally partial compliance
• Three or more instances is noncompliant

The above scoring is in effect during survey. Post-survey becomes a lesson in determining compliance percentages (90–100% for full, 80–89% for partial, and you know what happens when you go south of that point).

So where's the surprise, especially with four instances of noncompliance under EC.5.20? Oy!

You need to do your presurvey assessments very carefully and keep a close eye on those mounting instances of noncompliance. All those supplementals of years past are living together in the land of the surprise RFI--and that's one "foreign" land that doesn't require a government-issue passport for entry.