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How to comply with three problematic standards
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August 1, 2010
If your hospital isn’t staying on top of fire safety issues, you could be in trouble during your next Joint Commission survey.
EC and Life Safety (LS) standards continued to cause hospitals some pain during 2009 Joint Commission surveys. In fact, three of the top five most frequently cited standards last year are from the EC and LS chapters of the Comprehensive Accreditation Manual for Hospitals.
The Joint Commission revealed the top five standards that were most frequently identified as “not compliant” from surveys conducted from January 1 to December 31, 2009, in the May 12 edition of Joint Commission Online.
If you’re looking for surprises, this will come as a disappointment, as these are some of the perennial problems challenging hospital safety officers and facility directors. They include:
- LS.02.01.10 (number two on the list, with 48% of hospitals surveyed noncompliant)—requires hospitals to design and maintain building and fire protection features to minimize the effects of fire, smoke, and heat
- LS.02.01.20 (number three on the list, with 46% noncompliant)—requires hospitals to maintain the integrity of the means of egress
- EC.02.03.05 (number four on the list, with 38% noncompliant)—requires hospitals to maintain fire safety equipment and fire safety building features
“It seems they are the same old things,” says Jennifer L. Frecker, healthcare specialist and fire protection engineer at Koffel Associates, Inc., in Elkridge, MD.
Some of the standards’ requirements are obviously not easy for hospitals to meet, but it’s important to understand what specifically is leading to citations and what hospitals can do to improve their compliance.
Although The Joint Commission doesn’t provide a breakdown of which elements of performance (EP) surveyors are citing under each standard, there are common issues that crop up again and again in surveys, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
Below we examine each of the standards.
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