If your policy says you "must" use ILSMs, get out your highlighter

Now, you may be getting sick of hearing me talk about this, but I keep running into folks who are getting hammered during survey because their ILSM policy is so restrictive that they get cited for not following their own policy.

I happen to think, among Joint Commission (formerly JCAHO) survey indignities, that this is the greatest indignity of all.

We shouldn't have to discuss the individual ILSM elements identified in EC.5.50. There are 11 of them--you know 'em, I know 'em--it's all part of the firmament at this point. And there's nothing that says you can’t come up with your own additional measures for your organization.

But you've just gotta have a policy, you've gotta include consideration of the effervescent 11 (I'm trying to come up with a sobriquet that will catch on), and then you have to follow your policy. It can be that your ILSM process is too prescriptive, which I continue to run into--sometimes before survey (I like it when that happens, big smile!), sometimes after survey (no smiles then, just wailing of souls and gnashing of teeth).

OK, right now, I want you to pull out your ILSM policy. That's OK, I’ll wait . . .

Back? Good!

Now look at the first couple of paragraphs. At any point in the verbiage does your policy say that you "must" do anything? It does? Okay, so what is it that you must do?

If your policy says you must do anything other than to assess for the appropriate implementation of ILSMs, consider it a red flag. Regardless of the situation--construction, renovation, PFIs, any Life Safety Code issue--we assess and implement ILSMs as appropriate.

If your policy in any way speaks about mandatory implementation, then get out your yellow highlighter and earmark that language for extinction.

More on this next time. . . .