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Get ready to measure for accurate square footage- BBI is now required


September 14, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

Get ready, folks: BBI is back!

Well, the requirement for Basic Building Information never really left—although at one point it was on life support as part of several changes that CMS in 2016 told The Joint Commission (TJC) to make.

You might remember that those changes included eliminating the open Plan for Improvement (PFI) that allowed hospitals longer than the CMS-required 60 days to fix a Life Safety (LS) issue as long as the problem was self-identified, there was a plan to implement the repair or renovation, and the plan was approved by TJC.

The PFI along with the BBI made up the Statement of Conditions™ (SOC).

Then CMS began to push to have LS issues dealt with quicker as part of the switch to the 2012 Life Safety Code®. TJC announced that as of August 2016, the PFI would no longer be reviewed and that it would begin enforcing the 60-day Evidence of Standards Compliance, with limited time waivers approved by CMS.

At the time, TJC said that its leadership, “after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC  no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process.”

The BBI did, however, remain part of the SOC, as explained in the introduction to that first LS standard, as a way to manage survey-related deficiencies.

LS.01.01.01, element of performance (EP) 3, was eventually expanded to require hospitals to maintain current and accurate drawings of fire safety features and related square footage, and EP 4 was updated to outline requirements for time waivers.

Now BBI required

Not only is the BBI now mandatory, it’s a requirement with its own EP. And you might need your tape measure.

As of January 1, 2020, the new EP 7 says that hospitals must have “current basic building information (BBI) within the Statement of Conditions (SOC),” according to the prepublication standard online.

In addition, the BBI will be expected to include specific square footage of your facility’s buildings.

Announcing the new requirement in the July issue of TJC’s Perspectives, the commission said, “The new requirement emphasizes the importance of providing Basic Building Information (BBI) on an accredited organization’s Statement of Conditions™ (SOC). In addition, some revisions will be made to the BBI section of the SOC, such as requiring organizations to provide the specific square footage of their buildings versus ranges or approximations of square footage, which will better assist Joint Commission surveyors when preparing for an organization’s building tour.”

The online SOC is a tool that LS surveyors use to look up information about the facility before they arrive, notes Steven A. MacArthur, senior consultant for The Greeley Company in Danvers, Massachusetts.

Noting that TJC initially said in 2016 that the BBI was optional, “I think most people continued to pay attention to the BBI information. It was a handy way to keep track of certain building features, etc.,” says MacArthur.

In that respect, the new EP is “is probably less of an issue for folks than it might otherwise be.”

Why now?

The number of LS surveyors TJC sends for triennial visits might be one reason driving the change.
Facilities that only estimated their square footage could have been inadvertently inviting more LS surveyors than necessary because TJC would always send the number needed to handle the high end of an estimate and end up with too many surveyors on-site.

MacArthur observes, “I’m presuming there was at least some feedback from the LS surveyors that they were running out of stuff to look at by the last day of the survey, as well as feedback from their clients”—clients justifiably worried about surveyors with time to fill.

“Nobody wants to have a surveyor twiddling their thumbs,” he says. “Surveyors are never more dangerous than when they are standing still.”

Associate Content Editor Brian Ward (bward@hcpro.com) contributed to this report.

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