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When it comes to fire safety in the 2009 EC standards, one troubling aspect for me is EC.02.03.01, EP 4, which requires the maintenance of “free and unobstructed access to all exits” in business occupancies (e.g., a medical office building).
The maintenance of free and unobstructed access to all exits in healthcare occupancies is addressed in the new life safety standards.
My concern: Business occupancies are most likely not going to be visited by The Joint Commission’s life safety specialists; instead, “regular” surveyors will visit them. How will these surveyors define “free and unobstructed access to all exits,” given they may not have the same in-depth code knowledge of their life safety specialists?
This is one of those situations where you are going to have to take the surveyors by the horns (metaphorical, though sometimes you have to wonder) and educate them to what compliance with this EP means for your organization.
“Free and unobstructed” can be a very fine line, so start enforcement now. Otherwise you'll be running from the survey bulls.
One of the important points raised by our presenters was that despite The Joint Commission’s (formerly JCAHO) new life safety chapter, certain aspects of fire safety will remain in the EC standards in 2009.
For example, fire protection equipment inspections (currently under EC.5.40) will become EC.02.03.05 next year. Some of the elements of performance under the standard have been clarified, such as for monthly fire extinguisher inspections, so pay close attention to the 2009 wording.
Happy Labor Day . . .
Hi everyone, it's Scott Wallask checking in today.
When I was at the ASHE conference last month, George Mills (senior engineer at The Joint Commission) mentioned that life safety surveyors would now be reviewing a trio of leadership standards in addition to giving their well-known EC scrutiny.
Here's the list of the LD standards Mills specifically mentioned, along with examples from him about how they might work into life safety concerns:
- LD.2.20, EP #2--Facility leaders hold staff members accountable for their responsibilities. Example: Not having fire protection equipment inspection records available from third-party contractors.
- LD.3.80, EP #4--Leaders provide for adequate equipment and resources. Example: Administrators cut off budget spending for plans for improvement (PFIs) under the Statement of Conditions.
- LD.4.50, EP #2--Leaders give priority to problematic processes. Example: Establishing unrealistic PFI completion dates (e.g., fixing a large fire barrier penetration by 2015).
Mills covered a whole lot more about Life Safety Code matters, which we'll detail in the upcoming issue of Healthcare Life Safety Compliance.
Thanks, Scott Wallask, swallask@hcpro.com
I recently chatted with someone about items you need to monitor in the EC.
There are myriad activities, primarily represented through the "C" elements of performance (EPs) in the EC chapter, that revolve around the "care and feeding" of the care environment--medical equipment, life safety equipment, emergency power equipment, conduction of safety rounds, and the like.
A solid EC program is going to have a process for monitoring compliance with all these "have to" elements, just to ensure that the EC program’s baseline competencies, if you will, are in place and functioning appropriately.
Beyond the activities and processes that you "have to do," things get a whole lot grayer in very short order.
The key standard for the rest of the monitoring expectations is EC.9.10 (the hospital monitors conditions in the environment). These expectations are pretty much a function of the risk management process in the care environment. There are six EPs involved in EC.9.10, pretty much divided into constant activities and periodic (at least annually) evaluations of the whole kit and caboodle.
More on this topic in my next post . . .
Did you hear that great sighing sound earlier? In all candor, I have to tell you that I was one of those sighers.
(Is “sighers” a word? Probably not, but the blogosphere can’t rest on such formalities).
The other shoe has dropped, and The Joint Commission 2009 standards changes have (finally!) been posted on the Web.
The question then becomes: Celebration or commiseration? What do we do?
For the moment, it appears that a moderately restrained celebration will suffice. The key words indicating the disposition of the current standards I noted in reviewing the materials are the following:
- Retention--No change in the applicable EP, i.e., the song remains the same.
- Consolidation--A slight change, a blending, if you will, of risk management activities under a general umbrella. For instance, all the safety education elements are now living in one happy house, EC.03.01.01, and, perhaps most controversially, the safety and security standards have become one under EC.02.01.01.
- Split--EPs previously containing multiple component requirements are broken down into the individual components. For instance, EC.3.10, EP #3 under the 2008 standards speaks to the risk management of chemicals, which has been further broken out in the 2009 standards under EC.02.02.01 to reflect the risk management of hazardous chemicals, radiation equipment and lasers, and hazardous gases and vapors.
As near as I can tell (and this has pretty much been the indication as this initiative has rolled out), there are no new requirements, per se. What appears to be changing is more a function of how EPs could be scored during a survey, especially those (banana) splits.
In my client work, I have often compared the current survey process’ arrival at “jeopardy” as not so much death by a sucking chest wound, but more death by a thousand cuts--and the Swiss survey knife appears to have grown a couple more blades. While my obsessive-compulsive disorder has not yet resulted in my counting up the number of EPs in play, rest assured I will.
There is a fundamental constant that every time The Joint Commission deck gets shuffled, there is a likelihood of some resulting confusion, not only in the EC community at large, but also in the surveyor community.
Hi everyone --
It's Scott Wallask at HCPro logging in.
Just a quick FYI, The Joint Commission has posted its 2009 standards, including the revised EC and new life safety and emergency management chapters:
I'm sure Steve Mac will have more to say on this soon on the blog.
Meanwhile, I'd also like to mention that HCPro has an upcoming seminar on September 5 that will dig into all these new standard changes prior to January 1 effective date.
Thanks...Scott W.
Howdy folks --
First off, I want to thank everyone who tuned into Tuesday audioconference, "Steer Clear of the Top EC Citations," where my colleague Brad Keyes and I discussed various compliance activities associated with troublesome EC standards.
There were lots of great questions and discussion. My favorite part is the Q&A--I'd much rather help folks directly.
I also want to give props to the good folks at St. Cloud Regional Medical Center in St. Cloud, FL. They gave me a space and took care of every conceivable comfort--without them, I would probably have had to call from a phone booth at the Orlando airport. Thanks a million!
One interesting thing (of many) that came up this afternoon (beyond the exhortations of both Brad and I for the audience to conduct some hazard rounds this afternoon) was the relatively small number of folks that indicated they were having challenges with EC.5.40 compliance.
Now it may be that bigger challenges were luring elsewhere, but I did want to take a moment to emphasize the importance of making sure your life safety systems and equipment maintenance processes were up to snuff.
Brad and I have discussed at length our experiences doing client work in which there were just enough "holes" in the documentation to trip folks up, putting them into RFI territory. There are a lot of EPs under EC.5.40, a number of which are "A" EPs, which means if the surveyor finds one instance of noncompliance, you flunk the EP, and potentially the standards.
I would encourage you to pull out that old Joint Commission (formerly JCAHO) accreditation manual, dust it off, go through the list of EPs, and make sure that you can succinctly account for each of those elements (and all the little sub-elements lurking about).
Push back on your vendors, too. Don't settle for, "Yeah, we tested all of them." You need to be able to demonstrate compliance in a measurable fashion.
Also (and I've been running into this a bit of late as well), if you are managing these processes in-house, make sure that the folks responsible understand all the component pieces under EC.5.40. The components are frequently not simple, and sometimes not as straightforward as one would presume.
So, what are you waiting for? Crack those books!
Thanks again for listening to our audiconference, and stay tuned for more . . .
Just in case this one cruised in under the radar, the Hospital Safety Center is sponsoring an audioconference next Wednesday called “Steer Clear of the Top EC Citations.” It starts at 1 p.m. Eastern time.
While we all wait with bated breathe to see what the final EC standards and chapters and verses are going to look like, we noticed that folks are still facing some challenges with the current slate of Joint Commission expectations, and we thought that it might be a good time to talk about some hard-core compliance tips. I think it's a pretty safe bet that the 2009 revisions won't result in any shortcuts for the front-line safety pros, either.
And to sweeten the pot, we'll be introducing the newest member of our team, Brad Keyes. In his most recent former life, Brad worked as one of the original Life Safety Code surveyors for The Joint Commission, and he brings a wealth of practical knowledge to the table (as opposed to my rather post-practical yammerings).
That's right folks, you can ask questions of a genuine former Joint Commission surveyor--so don't delay, get yours today!
Some important elements to consider as you prepare for your next unannounced survey (and the one after that, and the one after that).
Minimize the low-hanging fruit. In survey report after survey report, I see the same types of findings over and over and over again:
- Unsecured compressed gas cylinders
- Too many compressed gas cylinders
- Storage in front of medical gas zone valves, fire extinguishers, and fire alarm pull stations
These types of conditions can very quickly populate a survey report filled with RFIs--and I don’t think that we can characterize these types of conditions as “surprises” when they crop up during survey. You know they shouldn’t be; hopefully your organization knows that they shouldn’t be, and, sure as shootin’, the surveyors (all of them--not just the life safety specialists) know they shouldn’t be.
My experience is that the organizations that work those first couple of hours when the surveyors show up, and get out in front of these minor deficiencies, are the ones that have the most successful survey experience.
Those that do not suffer the indignities of what I like to call “death by a thousand cuts.” In other words, it’s not one or two big things found (you don’t have any of those do you?). Rather, it’s those myriad small risks for which open season can be declared quite readily by surveyors.
Use your ongoing surveillance rounds, use your fire drills, to identify those little things that will croak you during survey and work proactively with the folks in the field to identify that swat list for Survey Day 1.
Ideally you want these to develop into someone’s responsibility, an assignment if you will. The more you can do to make those first survey moments genuinely purposeful, the smoother the sailing.
It is a grand cliche, but it is so true during survey: You only have one opportunity to make a first impression.
I was intrigued by a question posed on one of HCPro's talk groups about whether it was permissible for staff members to have emergency codes, such as RACE, on the back of their ID badges.
There is certainly no standards-based prohibition on them from The Joint Commission. However, there are surveyors that do not find this an appropriate practice, especially when it comes to your fire response plan. To be honest, I tend to agree that staff need to be able to respond to a fire without consulting their ID, but I digress.
Ultimately, the proof is in the practice. Using the fire response plan as the example, does someone monitor how often staff are consulting their badges during drills? EC.5.30 requires each organization to annually evaluate the effectiveness of fire response training. If staff are relying "too much" (again, for you to decide what that means) on the badge to walk through the process, it may well be representative of an improvement opportunity relative to education.
Hi everyone, it’s Scott Wallask with our last update from the Second Annual Hospital Safety Symposium, which ends this morning in Las Vegas.
Brad Keyes, a former life safety surveyor for The Joint Commission and now a consultant with The Greeley Company in Marblehead, MA, had a quick tip for tracking your required quarterly test of fire alarm off-premises transmission equipment: Put a line on your quarterly fire drill form to check off the alarm transmission test.
For example, the form might say, “The fire department received the fire alarm signal during this drill,” along with a yes/no choice.
One thing to be careful with: Some fire drills might not include an alarm transmission (e.g., a drill conducted during the overnight shift), so be vigilant about keeping up with the transmission test each quarter.
Meanwhile, lab safety expert Terry Jo Gile wrapped up the symposium with some great training ideas for attendees.
Posters are an effective visual aid to get safety messages across, and Gile suggested having staff members in departments create posters as part of a contest, with the best poster receiving a prize. The activity is fun, promotes creativity, and also helps workers recognize safety topics, she said.
Well, that’s it from Vegas. Thanks for reading our blog updates from the Hospital Safety Symposium.
Unsecured E cylinders have contributed to quite a few Joint Commission findings in the last year. I told attendees at today’s Hospital Safety Symposium that I find this quite astonishing.
To be prepared for a survey, you want to watch for the low-hanging fruit--cylinders being an excellent example of that. An unsecured cylinder here, a fire door that doesn’t close properly there, and surveyors start adding these things up.
Hi everyone --
It’s Scott Wallask writing in today. I wanted to let you know that we've just posted three free audio interviews on the main page of this Web site that I conducted with presenters at our upcoming Hospital Safety Symposium.
The interviews include discussions with:
- Dean Samet, director of regulatory compliance services at Smith Seckman Reid, who talks about The Joint Commission's 2008 emergency management standards and what surveyors will focus on
- Brad Keyes, a safety consultant at the Greeley Company, who discusses why smaller hospitals need to pay special attention to the duties of The Joint Commission's life safety specialists
- Steve MacArthur, primary author of this blog and also a Greeley consultant, who reviews how surveyors look at safety risk assessments under EC.1.10
To listen to the interviews, click on the Hospital Safety Center logo at the top of your page and then go to the right-hand column. Please be patient as the audio downloads may be slow depending on your system. I hope you find the info in the interviews to be helpful.
Thanks,
Scott W.
There's a story coming out soon in the next issue of our Healthcare Life Safety Compliance newsletter about how on occasion, The Joint Commission's life safety specialists are arriving at different times than the regular survey team.
Just to confirm this, I had a client recently surveyed who was informed that the life safety surveyor would be on site "sometime in the next two to three weeks" (I'm quoting the client, not necessarily the survey team).
One of the fascinating dynamics is that when the regular survey team members left, they only provided a verbal report of their findings--nothing in writing until the life safety tour is completed.
It's my understanding that The Joint Commission is hoping to get things on track by sometime this summer (or as we say here in the Boston area, "summah"). However, those folks in the mix until then are likely going to have some anxious moments (not at all like waiting for the next installment of your favorite blog entries, but I digress) as they try to identify post-survey strategies.
On the consultative advice front, I guess my best thought would be not to take any concrete post-survey steps until you have the full survey report in hand. The absolute key to post-survey response is to base either your clarification or evidence of standards compliance on the exact verbiage in the survey findings.
And, please, please, please (I'm channeling James Brown again--do it on the one, heh!) don't fix something that isn't broken. You know what compliance looks like in your house, so embrace the courage of your convictions and you'll be doing the right thing--once the life safety surveyor comes and goes.
Talk about building suspense.
Posted At : April 11, 2008 10:58 AM
| Posted By : Scott Wallask
Related Categories:
Life Safety Code
Hi everyone, it's Scott Wallask over at HCPro jumping into the blog today. I thought it might be a good idea to give everyone a trio of links that I've found very helpful over the years when it comes to tracking CMS developments with the Life Safety Code (LSC).
1. LSC page. This gives an overview of CMS' enforcement of LSC provisions for hospitals, nursing homes, ambulatory surgical centers, and other medical settings.
2. Downloads of CMS forms. The fire safety forms fall under the 2786 series of forms, to which you can scroll down or search for by typing in "2786," which will then open a zip file.
3. Memos to state agencies. These memos outline CMS rulings or interpretations of LSC requirements and are useful documents to have handy before and during inspections. You'll see they've already been busy with two postings from January. You may need to play with the sorting tool to view the most recent posts. www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage
Thanks,
Scott W.
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.
Posted At : January 30, 2008 9:58 AM
| Posted By : Steve MacArthur
Related Categories:
Life Safety Code
I was chatting with someone about the decibel level that fire alarms must be set at, and I thought, "Hey, a nice blog idea."
The National Fire Alarm Code (NFPA 72) requires fire alarms to have an output (i.e., sound level) at least 15 decibels above the average ambient sound level or 5 decibels above the maximum sound level having a duration of at least 60 seconds, whichever is greater. You measure this decibel level 5 ft above the floor in the occupied area.
That said, NFPA 72 does say that audible signaling volume can be reduced, or in some cases, eliminated, when:
- Approved by the AHJ (generally the local fire department)
- Visible signaling is in place
If a fire alarm horn is so loud that the PA announcement can't be heard, I would consider that an improvement opportunity and time to call the fire inspector.
There is a footnote in the proposed life safety standards relative to the manual transmission of alarms that references an issue of Environment of Care News, which is a Joint Commission newsletter.
Does this somehow introduce EC News into the realm of "enforceable" information sources? Or is it merely mentioned in the context of the draft and the mention will be removed when the chapter is finalized?
I find it curious that the reference cites the Joint Commission's "policy on the manual transmission of fire alarm signals." I can't say that I've ever run across their "policy." Is it in the Comprehensive Accreditation Manual for Hospitals? Has it been in Perspectives?
What the heck are they talking about?
You know, it occurred to me the other evening in the wee small hours that the separation of the Life Safety Code into its own accreditation chapter could have devastating results when it comes to counting RFIs towards conditional and preliminary denial.
Prior to this, life safety citations all rolled under EC.5.20 (with maybe slight diversions into EC.5.10). Now we're looking at nine life safety standards to score.
Can you imagine if surveyors find stuff in a couple of different directions? You could be dead in the water at the end of day one--ouch, ouch, ouch!
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.
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