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Joint Commission notebook: Verify fire response plan roles under EC.02.03.01

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March 1, 2010

Joint Commission notebook

Verify fire response plan roles under EC.02.03.01

Make sure to review the steps listed for fire safety plan training under EC.02.03.01, element of performance (EP) 10. Hospital safety managers who don’t pay attention to this EP could run into problems during a survey, said George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission. Mills spoke during a Joint Commission Resources Webcast on December 15, 2009.

Although the Webcast was aimed at managers in critical access hospitals (i.e., small or rural facilities with no more than 25 beds), the tips from the show can apply to regular hospitals because The Joint Commission has the same physical environment expectations for both settings, Mills said.

EC.02.03.01, EP 10, requires the fire response plan to describe the responsibilities of staff members and licensed independent practitioners at and away from a fire’s location.

Specific duties noted include how to:

  • Activate a fire alarm
  • Contain smoke and fire
  • Evacuate to areas of refuge
  • Use a fire extinguisher

That’s not to say staff members must know how to use extinguishers, but rather the fire response plan must detail what employees are expected to do, if anything, with extinguishers. Some hospitals only train certain employees to use such equipment.

Keep tabs on contractor training

During the Webcast, The Joint Commission offered further insight into how to manage contractors working at a hospital.

Review with contractors issues such as their roles in fire response, how they can help with infection control, and life safety compliance through interim life safety measures.

If a contractor is on-site for only a few hours, there may be little oversight necessary in terms of safety provisions. However, for significant projects lasting several days or longer, “training similar to full-time staff may be needed” for contractors, according to material provided during the Webcast.

As always, it is up to the hospital to determine the scope of a contractor’s work and the risks to patient safety. Special attention should be paid to contractors who might perform work that involves penetrating a rated smoke or fire barrier. Unsealed penetrations can lead to findings under a variety of life safety standards.

Confirm proper extension cord use

The Webcast provided the following other EC and life safety tidbits:

  • Extension cords may not be connected to light fixtures in anesthetizing locations and in any patient care areas, as outlined in the 1999 edition of NFPA 99, Healthcare Facilities. Extension cords are allowed in other areas but are not intended as permanent wiring.
  • There are no standards that address supply boxes left on floors. The Joint Commission expects hospitals to conduct risk assessments on these boxes in terms of infection control risks, tripping hazards, and egress route obstructions.
  • The Joint Commission has no specific requirements for managing hazardous drugs. However, the EC standards do point to compliance with various federal regulations, such as OSHA and Environmental Protection Agency rules.



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