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Expect continued survey focus on life safety compliance

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October 1, 2009

ASHE conference also tackles airborne diseases and risk assessments

Compared to prior years in which sweeping emergency management changes or new life safety standards captured the spotlight, this year’s annual conference of the American Society for Healthcare Engineering (ASHE) was one of interesting tidbits and regulatory hints.

Perhaps the only surprise during the conference, which took place in August in Anaheim, CA, was the pushback by some attendees against what they said was excessive scrutiny of The Joint Commission’s life safety requirements.

It was high on many people’s minds that the old EC.5.20, which required compliance with the Life Safety Code® (LSC), was the most cited standard in hospitals in 2008, according to the latest statistics released by The Joint Commission. EC.5.20 expanded into the life safety standards this year.

There are at most a handful of deaths each year in hospitals due to fires, compared to the tens of thousands of patients who die annually from contracting hospital-acquired infections. Some attendees questioned during a town meeting session how life safety could be the most cited area in hospitals and not infection control, pressing for answers from George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission.

“With the life safety chapter, we’ve got to maintain an emphasis on that,” Mills said, adding that long-time problems such as unsealed penetrations continue to be frequently caught by The Joint Commission’s life safety specialists.

Mills suspected that with the splintering of EC.5.20 into more than 100 elements of performance in the life safety chapter, LSC compliance may not keep its No. 1 rank on the citation list.

“I understand the concerns, but I also understand the real world,” Mills said. Although many hospitals establish effective life safety management programs, there are other facilities Mills described as “train wrecks” when it comes to LSC compliance.

(See “Surveyors now note deficiencies fixed during Joint Commission visits” on p. 5 for more information from Mills.)

California rolls out airborne disease standard

Meanwhile, eyes are on California’s state OSHA agency, known as Cal/OSHA, as it begins enforcing a new aerosol transmissible disease standard to protect employees, including healthcare workers, from the spread of airborne pathogens.

Cal/OSHA’s standard is the first of its kind in the country. Several important employee safety initiatives used throughout the United States today originated in California, including needlestick safety regulations, so the state’s moves may be a sign of things to come in hospitals.

The aerosol transmissible disease standard was inspired by drug-resistant strains of tuberculosis, pandemic flu worries, and the outbreak of severe acute respiratory syndrome in China and Canada in 2003, Bob Nakamura, senior safety engineer at Cal/OSHA, said during the ASHE conference.

Federal OSHA has been “watching us very closely,” Nakamura said. However, it remains to be seen whether federal OSHA will follow California’s footsteps, as there is much more scrutiny and regulatory hurdles involved with federal rulemaking, he added.

Under the standard, hospitals and other affected employers in California will be required to:

  • Develop exposure control procedures for airborne pathogens
  • Train workers on how to follow these procedures
  • Involve employees in periodic review and assessment of these procedures

Basic exposure precautions such as source control, hand hygiene, and decontamination procedures are fundamental parts of the standard, according to Cal/OSHA. (For more information about the standard, go to www.dir.ca.gov/dosh.)

Track and simplify risk assessment results

A key component of risk assessments is to track trends in the results over months or years, Dale Thompson, threat assessment manager at Kaiser Permanente in San Diego, told attendees at the ASHE conference.

For safety committee members, an important piece of advice is to avoid providing too much information to leaders regarding risk assessment results (e.g., sending them a hazard vulnerability analysis spreadsheet with dozens of lines of risks, each weighed with a value of 1–3).

“If you walk in with a five-page Excel sheet and show it to leadership, their eyes will cross,” Thompson said.

Instead, opt for a summary sheet, perhaps just listing the top five or 10 results from the risk assessment.

Surveyors now note deficiencies fixed during Joint Commission visits

Suppose a surveyor sees an exit light with one of its bulbs out. You radio to your maintenance crew and have the bulb replaced right away. Should that small deficiency count against your hospital’s accreditation decision?

Surveyors now have formal direction on how to deal with violations that are easily fixed before the team leaves, known as issues that are “observed but corrected on-site.” Certain findings that are corrected on-site will not count against the threshold of direct impact standards that result in an adverse accreditation decision, George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, told attendees at the American Society for Healthcare Engineering’s annual conference in August in Anaheim, CA. Mills said the “observed but corrected on-site” provision may apply but isn’t limited to:

  • A ceiling tile not in position
  • A gurney that blocks access to a medical gas alarm panel
  • A food cart blocking a portable fire extinguisher
  • Exit lights with one bulb burned out
  • A single fire door that doesn’t latch properly

However, Mills noted that the provision doesn’t apply in situations such as the following:

Unsealed or improperly sealed penetrations in barriers and rated walls

A required policy that is not in writing

Multiple fire doors that don’t latch




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