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A primer on construction readiness and compliance in your facility


March 1, 2019

A new year brings new beginnings, and many hospitals entered 2019 either with new construction projects on the horizon or with projects already in progress. Lest you forget the power of the accreditation agencies that will be monitoring your efforts, though, you should be aware of many things that could affect those projects from a life safety perspective.

You might think you have the most well put-together life safety compliance program, but the minute your facility decides to make changes to the physical environment of the building, that can change. A construction project disrupts the day-to-day life in a hospital and can present many security breaches, as well as fire and life safety dangers that pop up unexpectedly every day—even if you thought you had everything covered.

“To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas,” writes Steven MacArthur, senior consultant and safety expert for The Greeley Company in Danvers, Massachusetts, in his blog, Mac’s Safety Space. “With the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.”

Our life safety experts helped us come up with a list of things you MUST do before starting a construction project to help mitigate the dangers.

Do a thorough risk assessment. As you would with any new plan or project, you should always take a good look at the potential risks you are introducing to the building and plan to mitigate them. Where in the facility is the project? Will it upset asbestos that will need to be removed? Will the project plan involve shutting down the fire alarm system? If it will, you’ll have to set up a fire watch. Where will construction crews enter and exit? Who will ensure security at those points? Will hazardous materials be introduced into the construction area? If so, you’ll need proper permits and waste disposal efforts. Figuring out what you need before the shovels break ground is an important first step.

“One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks,” writes MacArthur. “For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).”

Hire an expert. A life safety consultant could perform a peer review of all the construction documentation you will need to remain in compliance, says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance.
Keyes says it’s always a good idea to have someone go over your construction diagrams and documents before the project starts, because in many cases, it’s easier to change plans than it is to go back and fix problems later.

“He or she may be able to find potential LSC deficiencies before they are built,” he says.

As an example, Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants in Chapel Hill, North Carolina, recalls being involved in the opening of a state-of-the-art hospital, but plans were not thoroughly scrutinized and therefore, many major security flaws were not found until after it opened. Bottom line: Let everyone have a look and a say into design.

  “As nice as [that hospital] is, it has a near-fatal security flaw that was identified too late in the design process to correct,” Smith says. “Bottom line, the stairwells were located away from the elevator lobbies, therefore requiring persons needing emergency access to the elevators to traverse through areas that would normally be secure such as clinic spaces and administrative offices. This design flaw took months and several hundred thousand dollars to retrofit additional security features into the building that could have been avoided. It also severely reduced the normal use of the stairwells for anything except emergency exit.”

How will your emergency plan affect construction plans? Regulatory agencies such as The Joint Commission and CMS are cracking down on making sure hospitals can maintain operations during a crisis, which means administrators will be under more pressure to either renovate their current facility or look to new construction. If you are building a new facility or wing for your hospital, now is the time to be thinking of future compliance.

Where is your emergency infrastructure located? If your emergency generators and fuel supplies are in the basement where a flood could affect their operations, perhaps now is the time to design backup generators and other critical infrastructure in higher floors or even in the roof. By doing this, you’ll be positioning yourself for compliance with anticipated CMS emergency management rule changes that will require hospitals to prove they can stay operational in a crisis.

“I think perhaps the way to look at this is much in the vein of our emergency management Hazard Vulnerability Analysis (HVA) process,” says MacArthur. “There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible. But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your ‘packaging’ is a little tidier than it was previously.”

Make inspections a daily occurrence. Most safety professionals advise that safety inspections and rounds take place at least once a week. For the most part, it’s easy to get to know your building enough so that you know what’s out of place. But a construction project can introduce so many factors (e.g., dust, unknown visitors, hazardous materials, cut wires, propped doors, etc.) that it becomes imperative to make inspections happen every day to help get extra eyes on the job and catch any potential safety hazards.

“A construction project can leave the building vulnerable as there are strange people coming and going, fire hazards, and other vulnerabilities that can affect safety. In my various safety and security roles, an area that I always felt the need to stay on top of was construction in the hospital,” says Matthew Daniel, security director of ODS Healthcare Security Solutions at Sampson Regional Medical Center in Clinton, North Carolina. “It is so important to be constantly checking in to make sure that staff and contractors are following safety precautions as per the Infection Control Risk Assessment (ICRA) and Interim Life Safety Measures, and to make sure no hazards are prevalent each evening when the construction crews go home.”

Consider all logistics. Will utilities need to be moved, will the area remain occupied, and will traffic have to be rerouted? Will your ambulance bays be able to remain open, and your emergency room operational? Any construction project will change the way your facility operates on a normal basis, and you will need to make sure that contingencies are in place to deal with it.

“The more of these that get addressed early, the easier it will be,” says William Wilson, CFPS, PEM, CHSP, fire and life safety coordinator for Beaumont Health in Royal Oak, Michigan.

Make sure the specifications are appropriate for your situation. If you have standardized materials from a particular manufacturer or need materials approved by your insurer, make sure your contractors understand that.

“Some of our construction standards include a pre-approved manufacturer list,” Wilson says. “If you want certain brands to be installed, make sure that is included. If the facility is insured by FM Global, they may want to include that materials and equipment are FM-approved when available, and not just listed.”

Include your safety requirements in the bid documents. Contractors are willing to comply, but you must let them know what you expect. Waiting until the contractors walk into the building for the first day of work is not the time to discuss how workers will reduce dust and vibrations, how they will enter the building, and where materials will be stored during the job.

“I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be,” says MacArthur. “You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations, so better to have visible postings.”

Consider what happens after construction is finished. It’s important to realize that things will change once the project is done. Take training, for instance. Were new people hired, was new diagnostic equipment bought, or did construction cause a complete change in the layout of the wing of the building? You may need to conduct worker training on, say, a new fire alarm system, or emergency response plans based on the new floor plan. You may be compliant on training based on old plans, but a new construction job may make those plans moot.

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