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Resolve to improve your life safety programs in 2010


January 1, 2010

With no major new Joint Commission deadlines passing on January 1, 2010, the changing of the calendar offers an opportunity to take stock of your life safety management plans.

The Joint Commission released statistics in November that showed four fire safety–related violations among the top 10 cited standards in surveys for the first half of 2009. Three of them used to fall under the old EC.5.20, which was 2008’s No. 1 trouble spot for hospital surveys.

The latest round of top citations includes the following standards:

  • LS.02.01.20 (No. 1 cited standard during the first half of 2009, with 45% of hospitals receiving findings), which requires hospitals to maintain their means of egress
  • LS.02.01.10 (second most cited at 43%), which requires hospitals to design and maintain building features to minimize the effects of smoke and fire
  • EC.02.03.05 (tied for fourth most cited at 38%), which requires hospitals to inspect, test, and maintain fire protection equipment
  • LS.02.01.30 (sixth most cited at 36%), which requires hospitals to maintain building features to protect people from smoke and fire

These issues are prevalent at every facility, and their monitoring programs can almost always be reevaluated, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and contributing editor for Briefings on Hospital Safety.

“I have no reason to think that these [standards] won’t stay up near the top, because everybody has to deal with these. Everyone has doors that don’t close and latch or [has] unsealed penetrations or missed testing,” MacArthur says. “We do not live in a perfect world, so there are no perfect programs, and thus one can find deficiencies anywhere at any time—it’s the reality of the situation.”

Stay tight on ILSM oversight

One area to review is your plans for improvement (PFI) and interim life safety measures (ILSM) that go with those PFIs, says Dean Samet, CHSP, director of regulatory compliance services at Smith Seckman Reid, Inc., in Nashville.

Don’t let PFIs that haven’t been completed yet slide by, as doing so could put your facility on thin ice. Failure to make sufficient progress toward the corrective actions described in a previously accepted PFI (see LS.01.01.01) or failure to carry out applicable ILSMs (see LS.01.02.01) can result in citations and even conditional accreditation.

Scrutiny of ILSMs has been “ratcheting up for the last several years,” Samet says. “All people have to do is follow the rules and stick to the schedules, and they should be okay.”

Hospitals have had plenty of opportunities to shore up ILSM compliance, Samet says. “Now it’s time for The Joint Commission to get tough, in my opinion,” he says. “It’s all in the name of providing a safe environment for the patients and punishing the slackers.”

Be careful with initial safety training

The new hospital accreditor on the block, Det Norske Veritas’ (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO), surveys its accredited hospitals once per year.

The Centers for Medicare & Medicaid Services (CMS), however, validates an initial DNV survey for reimbursement purposes and those occurring every three years thereafter.

That timeline means DNV-accredited hospitals need to be in compliance with life safety issues from the get-go with CMS, says Randy Snelling, CPEO, chief physical environment officer at DNV Healthcare.

CMS granted DNV “deeming authority” in September 2008, which means a hospital that receives NIAHO accreditation also meets CMS’ Conditions of Participation for Medicare funding.

DNV’s top-cited physical environment concerns, based on Snelling’s interactions with hospitals working on NIAHO accreditation, include unprotected penetrations in barriers and door latching problems.

Another item that crops up is initial employee safety training, Snelling says. OSHA requires training for new employees on hazard communication, personal protective equipment, needlestick prevention, and possibly fire extinguisher use.

Many hospitals fall short of these requirements, letting inadequately trained employees start working before they’re ready.

“We’re finding that training isn’t always necessarily happening before an employee’s initial assignment,” Snelling says. “If you’re handing out little packets and telling people to read them on their own and you’ll get back with them in three or four weeks, you’ve made a statement about where that safety orientation is on the priority list.”

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