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The Joint Commission Continues to
Increase Emphasis on Life Safety Compliance
By the time you read this, you may or may
not have experienced your first Joint Commission survey
with a dedicated Life Safety Surveyor. The Joint
Commission has been increasing the emphasis on life safety
compliance for several years and all indications are that
they will continue to do so moving forward. To look back
in recent history, prior to 2005, all surveys were
completed by surveyors with an administrative or clinical
background. These surveyors were charged with conducting
the life safety document review and site inspection in
addition to all the duties of performing the clinical
survey. While they did receive basic training on the Life
Safety code, surveyors were not Life Safety code
professionals. Realizing the potential weakness in this
approach, the Joint Commission began to utilize Life
Safety professionals to complete the Life Safety survey in
hospitals of 200 beds or more in 2005.
In 2006, more changes took place. Surveys
would no longer be a scheduled event. It was obvious that
hospitals would utilize the luxury of knowing when their
next 3-year cycle survey was going to be, down to the
exact day, to hold off on preparation until the final
months prior to the survey. And so was born the concept
of “constant readiness.” Also in 2006, demonstrating
again their commitment to life safety compliance, the
Joint Commission began to assign a dedicated Life Safety
Surveyor for all hospital surveys not just those in
hospitals larger than 200 beds.
Upcoming changes
Beginning in 2009, “Life Safety” will now
have its own Environment of Care (EC) standard, which is
based on the NFPA Life Safety Code®. To view a draft of
the 2009 Life Safety Standard use the following link:
http://www.jointcommission.org/NR/rdonlyres/088DB0A9-B95A-49B5-AFB5-5C686DB999B9/0/HAP_LS.pdf
So what does it all mean?
Be prepared for a new level of scrutiny.
Hospitals that are 750,000 square feet in size or smaller,
will have a one day survey with a Life Safety Surveyor.
Hospitals that are larger than 750,000 square feet will
have a two day survey. In either case, your surveyor
will review your Statement of Conditions (SOC) and review
any Plan for Improvement (PFI) activity. If you utilize a
Building Maintenance Plan (BMP) the surveyor will ask to
review your BMP records. The surveyor will also ask to
see inspection and maintenance documentation on
fire-safety equipment and building features, emergency
power systems maintenance, test, and inspection records,
and medical gas maintenance, test, and inspection
records. Also, the surveyor will ask to see your Interim
Life Safety Management (ILSM) plans to demonstrate that
your hospital develops and implements plans to ensure the
safety of occupants during times when the building may
have a life safety code deficiency or a temporary change
in life safety systems or plans due to construction
activities.
When the document review is complete, the
next phase will be the site tour. While the surveyor may
request to see other spaces, the tour will focus on
hazardous areas like trash collection areas, soiled linen
rooms, kitchens and oxygen storage rooms. The surveyor
will inspect smoke and fire separations, fire exits,
kitchen grease producing devices, laundry and trash
chutes, the main fire alarm panel, fire pump, emergency
power systems, and medical gas systems and alarms.
The Joint Commission publishes a complete
Survey Guide at:
http://www.jointcommission.org/NR/rdonlyres/481CE5EA-D02C-46C3-AA5F-DF328FE13174/0/08_HCO_SAG_3.pdf
For a complete breakdown of the Life Safety
Code Building Assessment, use the above link and go to
page 41 of the guide.
Recommendations
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Be Prepared! The surveyor will expect you
to be able to produce requested documents in a
reasonable amount of time.
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Keep records and files up to date. You
don’t want to be scrambling to gather information on the
day of the survey.
-
If you reference a work order for a life
safety repair, be sure you can produce that document.
-
Wherever possible, compile records in a
convenient format. For example, maintain testing and
inspection documents in a 3 ring binder that can be
handed to the surveyor (for example one for emergency
power system records and one for fire alarm records).
-
Have a runner to retrieve needed
information. You may even need to produce a document
while on the site tour.
-
Get a “heads up”. Make sure your
hospital has a designated staff member checking the
Joint Commission extranet website each morning for the
name of your organization. At 7:00 AM E.S.T. the Joint
Commission will post the names of any sites being
surveyed on that day. The surveyors will arrive at 8:00
AM. One hour does not seem like a long warning time,
but it should give your hospital a chance to initiate
any internal notification procedures and get you
thinking about how to prepare for the survey. According
to the Joint Commission, your survey will take place 18
to 39 months from the date of your last unannounced
survey so there is a rather large window of time in
which the name of your hospital might appear on the
extranet site.
-
Don’t refer to the “surveyor” as
“inspector” and no longer refer to the Joint Commission
as “JCAHO”.
-
Be ready. The best way to avoid
“sweating it” on the day of the survey is to constantly
be ready.
Questions
regarding the Joint Commission can be directed to Wayne
Bates at Capaccio
Environmental Engineering, Inc. at (508) 970-0033 x121 or
by e-mail at
wbates@capaccio.com.
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