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Simple steps may help avoid life safety compliance woes

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May 1, 2009

Preview of the Hospital Safety Center Symposium

Simple steps may help avoid life safety compliance woes

Although it might sound like obvious advice, plenty of safety officers have nonetheless slipped on this thought: If you want to stay on top of Joint Commission life safety compliance, you first need to carefully look over the life safety and EC standards.

As a firsthand observer of life safety compliance concerns, Brad Keyes, CHSP, said he is stunned at how many managers haven’t actually read the standards in the first place.

Keyes, who is a consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, spoke during HCPro’s free January 29 audio conference, “Hospital Safety in 2009: A Sneak Preview of the 3rd Annual Hospital Safety Center Symposium.” He will also be a featured presenter at the 3rd Annual Hospital Safety Center Symposium, which takes place May 14–15 in Las Vegas (go to www.hospitalsafetycenter.com for more details).

Keyes offered the following suggestions for hospitals to polish their life safety compliance efforts:

  • Understand which codes apply to you beyond the Joint Commission standards. Find out which National Fire Protection Association standards, local and state fire codes, and other applicable regulations apply to your locale—and read them.
  • Verify that you’ve documented the results of your inspections. This seems like simple advice, but Joint Commission surveyors are continually citing facilities for slipups with fire protection inspection and documentation requirements under EC.02.03.05. That standard’s predecessor, EC.5.40, was among the top 10 most-cited standards in hospitals in the first half of 2008, according to the most recent Joint Commission statistics. Don’t forget to have paperwork handy that details how you corrected any deficiencies found during inspections.
  • Take advantage of renovations and construction. If crews are popping a room’s ceiling tiles or gutting walls, or new construction is showing the bones of a structure, grab your flashlight and conduct an inspection on the spot for improperly sealed smoke barrier penetrations from pipes, computer wiring, or other objects.
  • Track down undocumented room changes. Life safety deficiencies sometimes crop up from projects that safety managers or facilities directors were unaware of involving repurposing of rooms. For example, find out whether patient rooms have been taken out of service and turned into storage. Such changes may trigger additional Life Safety Code® requirements under new construction for items such as sprinklers and rated doors.
  • Keep administrators informed about plans for improvement (PFI) in your Statement of Conditions. Remember that when you open a PFI, it enters your hospital into a contract of sorts with The Joint Commission (formerly JCAHO) to address the deficiency. The PFI includes a completion date that figures into accreditation decisions under LS.01.01.01 if the deadline isn’t met or formally extended. Keep administrators apprised of your actions at every turn in the process so they don’t try to pull funding for a PFI, which won’t meet Joint Commission muster, Keyes said.
  • Continue to use a building maintenance program (BMP). Although a BMP no longer gives hospitals a scoring break come survey time, conducting a BMP still gives you a structured, regular method of assessing your life safety compliance.



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