The cause and effectiveness of ILSMs

Those of you who have been paying any attention know that the scrutiny of interim life safety measures (ILSMs) and their practical application has in no way subsided.

In some instances, interpretations are heating up in this regard, and my best advice is to be thinking about the effectiveness of your process and practice. As with any risk assessment, it is not merely enough to conduct an initial ILSM assessment. You really need to look at the effectiveness of the intervention in order to keep out of the CON 04 doghouse, which can lead to a finding of conditional accreditation.

For example, a hospital that was surveyed in January got into trouble because the surveyor reportedly felt that the ILSMs the facility implemented were “not working” and “weren’t specific enough” and, to boot, weren’t sufficiently detailed.

That situation brings up a contradiction of sorts. If memory serves me, EC.5.50, EP 2 provides very specific detail as to the provenance of each ILSM. Are we to think that these “administrative actions to be taken” in the event of deficient conditions are somehow not sufficiently detailed to adequately protect our facilities from excessive life safety risks?

In the vernacular, what up with that?

I have my standards book in front of me, I’m looking at those 11 ILSMs, and in all candor, I don’t see a whole lot of gray. But as I think about it, is this an exercise in compliance or is it more about doing what is right and appropriate to ensure the safety of your facility’s occupants?

Yeah, you got me--it is both. But let’s stipulate that if you take care of the latter (doing the right thing), the former will be well cared for. I’m kind of liking that as an operational imperative.