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Sneaking Sally through the OR…

…when up pops somebody, eventually…

Interesting story in the news last week about someone infiltrating the perioperative area at a hospital in the Boston area (the news story identifies the hospital, so no need to do that here, IMHO). Every time I see one of these types of stories, it makes me glad that I do not still have operational responsibilities for a hospital security department. (In many ways, I have made something of a career of embracing thankless jobs in the healthcare realm; well, maybe not completely thankless, but it can be tough for folks at the bottom of the healthcare food chain. But enough about that.) Apparently, this individual was able to gain access to the perioperative areas, including the restricted portions, without having an identification badge. Now I will say that, based on my observations, the healthcare industry is much better about wearing ID badges, but I will also say that the OR is a tough spot to practice enforcement of your ID policy, especially during the busy times. And then there is the subject of tailgating, which is a time-honored tradition, particularly when you move to an electronic/badge access solution for controlling who gets where in your organization. And, short of installing turnstiles at all your entry points (now wouldn’t that create some noise?), tailgating is going to continue to be a vulnerability relative to security. Much as learning that the NSA was listening in on lots of conversations, I didn’t find this particular news story, or indeed the event, particularly surprising. In all likelihood it happens more than we know—from salespeople to distressed families to the media, the list of potential candidates for such an incursion is rather lengthy. (I’m sure you can add to that list and please feel free to do so!) The source article for the above story indicates that the individual was identified as an interloper when “physicians caught on” (I could be glib and throw out a “maybe she didn’t know the secret handshake,” but that would be catty), so I guess it’s good to make sure that you have good participation from your medical staff in the matter of ID badge compliance.

All that said, and in full recognition that logic doesn’t always prevail, I have a sneaking suspicion that this might just join active shooter response on the regulatory survey security hot topic list (remember when nuclear medicine deliveries were the flavor of the month?). I think anyone having survey over the next little while would be well-served in considering how to respond to queries regarding access control in your ORs and other areas.

It is a most delicate balance: protecting folks and yet providing access to all the patients we serve. Maybe there will be some grant money floating around that could be used for this purpose—nah!

What a long strange trip it’s been…

And we’re still in the first month!

As I’ve been working with folks around the country since November 8, there’s been a lot of thought/concern/etc. relative to how the new administration is going to be impacting the healthcare world and the end of January may have offered us a taste of what’s to come with the issuance of an executive order to reduce regulatory influence/oversight of the healthcare industry by establishing a plan that requires federal agencies to remove two existing regulations for every one new regulation that they want to enact (for the healthcare take on this, please check out the Modern Healthcare article here. As with pretty much everything that’s been happening lately, there appear to be widely (and wildly) disparate interpretations on how this whole thing is going to manifest itself in the real world (assuming that what we are currently experiencing is, in fact, the real world), so for the moment I am adopting a wait and see attitude about the practical implications of these moves (and acquiring truckloads of antacid). I don’t know of too many healthcare organizations that are so fantastically endowed from a resource ($$$$) standpoint to be able to endure further reimbursement reductions, etc. In fact, once you start looking at the pool of available cash for capital expenditures (and for too many, it’s more of an almost-dried up puddle), it hardly seems worth the effort to plan on expenditures that are likely never to come to fruition. Quick aside: section 482.12(d) of the Conditions of Participation requires each participating organization to have an institutional plan and budget, including a capital expenditure plan for at least a three-year period, though for far too many 3 x 0 is still a big fat goose egg, but still you must plan.

I would like to think that there’s a way forward that will result in greater financial flexibility for hospitals—in spite of some late-2016 chatter about allowing failing hospitals to do just that—fail! There were some closures last year. Hope nothing that impacted you; I couldn’t find anything that specifically indicated how many hospitals might have closed in 2015, so I can’t tell if last year was an aberration or business as usual. I do know that it is very tough when safety and facilities have to compete with some of the sexier members of the technology family; particularly those that generate revenue—growl! I couldn’t tell you the last time I saw an ad saying how clean and comfortable a hospital was (I think it would be a nice change of pace). And while I absolutely recognize the importance of wait times, technology advances, etc., if the physical environment is not holding up its end of the equation, it doesn’t really make for the best patient experience and that’s kinda where things are headed. It’s the total patient experience that is the measure of a healthcare organization—you’ve got to do it all and you have to do it good.

So, I guess we’ll have to keep an eye on things and hope that some logic (in spite of recent tendencies) prevails.



Who can turn the world on with her smile?

As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!

As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!

And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…

Until next time, have a Fabulous February!

Don’t ask, don’t tell, don’t tell, don’t get in trouble…

Hope everyone is having a good week and that the rather stormy weather impacting so many parts of the country has not created too much of a challenge for you and your organizations.

This week is another (sort of) catch-all of topics, starting first with a little bit of CYA advice.

Lately there have been several instances (of which I am aware—can’t say for sure if this is an iceberg, but it “feels” like it might) of some very adverse accreditation/deemed status decisions based on insufficient documentation that organizational leadership had been effectively informed of conditions in the physical environment that required additional resources, etc. It’s not that organizational leadership was unaware of the conditions, but more that there was no trail of documented discussion (committee minutes, surveillance rounds, etc.) by which the organization could demonstrate to the surveyors that they had everything under control. In fact, the impression given because of the lack of a documented trail was exactly the opposite.

While nobody is really keen on telling their boss about problems of significance, especially problems for which the means of resolving them are elusive or beyond one’s resources (don’t want to look like you can’t do your job effectively), it is of critical importance to be able to escalate these types of issues to (or near) the top of the organization. Typically, this is about having to fund something (at least in my experience); maybe it’s a roof replacement; maybe it’s replacing some HVAC equipment—I’m sure most folks have a list of things for which it is a struggle to get traction. Let’s face it, unless it’s a new building, facilities infrastructure improvements, safety stuff, etc., is not particularly sexy, so when the capital improvement budgets come and go, it’s a tough sell. But sell it you must and you must keep pushing it—eventually those improvements (or lack thereof) are going to impact patient care and that’s when things can go south in a hurry. We always want to be respectful and not panicky, etc., but, please believe me, when the three- and four-letter regulatory folks knock on the door, you want to be in a position to describe how issues are brought to the attention of leadership. It may not be too pleasant in the moment (okay, in all likelihood, it won’t be pleasant at all), but it can save a whole lot of grief later on.

Next up (and this is something in the way of a commercial), The Joint Commission is hosting a webinar on Tuesday, February 7 to provide information on the new SAFER matrix, which is going to be an important feature of your survey report. We first covered it back in May, but now that they’ve been using it for the past few months (in behavioral health hospitals), it’s possible (I’m hoping likely, but I don’t want to get too amped up) that they will be sharing some useful information from the field. At any rate, particularly for those of you anticipating surveys in the next six to 12 months, I would try to make time for this one. I truly believe that every good intention is put into these survey changes, but I think we can all agree that those good intentions figure very prominently on a certain road…

Finally, this week, I would encourage you to look really, really, really closely at your interim life safety measures (ILSM) policy. TJC conducted a consultant conference last week and it is my understanding that the one significant shift in the survey of the physical environment is that there is going to be a lot of focus on the practical application of ILSMs as a function of Life Safety Code® deficiencies that cannot be immediately corrected. You have to make sure that your policy reflects an ongoing, robust process for that part of the equation. I think the conclusion has been drawn that folks generally have it together when I comes to ILSMs and construction, but are rather less skilled when it comes to those pesky LS deficiencies. We know they tend to focus on areas where they feel there are vulnerabilities (how else might one explain the proliferation of EC/LS/EM findings in recent years). This is a big one folks, so don’t hesitate to dial in with questions.


One less thing to pull out of your arsenal…

As we play yet another round of mishegas, it occurs to me that it’s been a while since I’ve really been able to tee off on something. Oh well, I guess it’s the little stuff that makes things interesting…maybe the February issue of Perspectives will provide fodder for my rant-mill… stay tuned.

First up, we have the (probably timely) demise of that titan of healthcare apparel, the powdered medical glove. It seems that the Food & Drug Administration (FDA) has determined that the risks to the health of users and those upon whom those gloves are used (including bystanders) are so egregious that it instituted an immediate ban on their use, effective January 18, 2017. The potential dangers include severe airway inflammation from inhalation of the powder; wound inflammation and post-op adhesions from contact with the powder, and allergic reactions from breathing powder that carries proteins from natural rubber latex gloves. You can get the whole picture here. While I do believe that powdered wigs are still de rigeur in certain circles (constitutional re-enactors, for one) despite the opening line in the VIN News article, I hope that these actions are not a prelude to restrictions on powdered doughnuts (or donuts, depending on your preference—for the record, my favorite is raspberry jelly!)

Breaking it down with TJC

Our friends at the American Society for Healthcare Engineering (ASHE) announced this week that they will be offering a series of webinars aimed at uncovering the mysteries of deep space, no wait, to introduce us to the inner workings of the 75 new performance elements in the Joint Commission standards, effective, well, pretty much right now. The featured presenter for the kickoff presentation is none other than Joint Commission’s Director of Engineering George Mills and it promises to be a rollicking good affair. That said, I do hope you are an ASHE member: if you are, the webinar is free; otherwise it’s $125, which seems a little steep for a single program (the advertising says this is a series of webinars, but this appears to be the only program scheduled at the moment, so your guess is as good as mine at this point). If I may indulge in a short rant, I’m still not convinced that having to pay to obtain access to TJC information that is not otherwise available as part of one doing business with the accrediting agency is a good thing. Not everyone has money in their budgets to do this (either membership in professional organizations or accessing educational programs) or the personal means to do this stuff on their own. While I am absolutely in favor of participation in professional organizations, I’m not sure that access to the insight of regulators is, while nice, the way things should be. Shutting up now…

Cue heavy breathing…

And let us end on a note of “Holy smokes, that was a near miss” (and I definitely did not see this one at the time—nor did I hear a ton of squawking). Last May, CMS decided to disallow hospitals from having security units that provide care for justice-involved individuals such as inmates and those in the custody of law enforcement or the state Department of Corrections. I’ve not worked with a ton of hospitals that have forensic units, but they are an important means of enabling hospitals to provide a safe environment for all while ensuring your forensic patient populations have appropriate access to needed inpatient healthcare services. Again, I didn’t hear a lot about this one, so it may be that the hue and cry was aimed in other directions; the American Hospital Association took up the cause and were able to convince CMS to rescind the “ban” (you can see the revised Survey & Certification memorandum here). This would have been a big time pain in the posterior for at least some number of folks, and may still be – I would encourage you to take a peek at the memorandum, including the scenarios presented at the end of the document—probably worth sharing with your organization’s leaders. I’m not exactly sure why CMS would have elected to go the route of disallowing security units for “justice-involved individuals” (that makes ’em JIIs—probably not an acronym that will catch on), though I would guess that ensuring patient rights are not violated in the process is a likely contributing factor. That said, any time a memorandum goes out on a specific topic, it seems to result in that topic becoming a wee bit hotter in the aftermath. No guarantees, but this might be a focus area in the coming months…

Remember, technology is still a toddler

Or mayhap a preschooler…

When it comes down to the usual arc of things, our reliance on technology often exceeds technology’s “ability” to do everything we would want it to do when we want it done. In this regard, I imagine technology as a really precocious toddler that frequently astounds, but also frustrates more often than we would like (imagine when technology becomes a surly teen!), resulting in various and sundry risks, hazards, etc. Well, this is a landscape that the good folks at ECRI tend to watch very carefully, with the end result being regular recommendations to the folks actually dealing with the ups and downs (hopefully more ups) of technology operations, as well as the bosses. Now I will say that not everything on the ECRI list has a direct impact on the hospital safety world (though one could submit that the pervasiveness of technology provides potential issues for all manner of stuff) as information with which to be familiar. At any rate, this year there are two offerings, one to provide information to the folks occupying the environs of the C-suite, the most interesting/applicable offerings being those related to UV disinfection technology and the application of technology in caring for patients with opioid addiction (that one is less directly tied to safety operations, but this has such wide-ranging implications, it can’t possibly hurt to have a little background info). And then for us non C-suiters, a report on the top Technology Hazards in healthcare for 2017 is also on offer, with infection control and prevention being somewhat of a common thread in the hazards, but clinical alarm safety is also represented. The links provided here will take you to access portals where, for a nominal offering of contact information, you can download these reports.

Now, in looking out my window, it appears that winter has finally put in an appearance on the East Coast (though I guess the rains out in California over the past few days is also representative of a winter weather pattern, albeit less snow-covered) and it reminded me of my past days of having (personal and professional) responsibility for (among any number of things) snow removal. Now, to my way of thinking, there is a certain zen that can be experienced when one is combatting the forces of nature one on one (preferably at night) that is probably one of my favorite OCD moments (and believe me, shoveling snow in the middle of the night brings with it a certain inescapable essence of OCD, but I digress). At any rate, one of the more important aspects of the snow removal game is that of ensuring that any and all nearby fire hydrants are well and truly accessible in the event they are needed in an emergency. Just as there is many a slip twixt cup and lip, any delay in accessing firefighting resources can yield catastrophic results, so, as a community service, I give you this information. Particularly in those areas experiencing a little more snow than usual, this might even be worth sharing with the rest of the folks in your organization. I figure if it helps even one person to be a little safer, then it’s worth the effort to spread the news.

My heart is black and my lips are cold

Crash carts on flame with rock and roll!

I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.

On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!

Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…

As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.

So that’s the scoop for this week. I hope the new year is treating you well. See you next week!

It’s not funny how we don’t talk anymore

A mixed bag of stuff this week (dig, if you will, a picture: sleigh full of regulatory madness), including the Perspectives coverage of the Emergency Management standards. But first, a little musing to usher in the change of the seasons.

The nature of my work/vocation requires me to travel a fair amount—and I am not whining about that—it’s my choice to continue to do so, and I understand that if the travel gods are displeased, there is no point in kvetching, but I digress. One of my favorite travel pastimes is watching fellow travelers as they navigate the various and sundry obstacles that one might encounter as they complete the check-in/TSA gauntlet, etc., after which, they generally “crash” in the gate areas or airline clubs. One of the most fascinating/disturbing trends (and I suspect you’ve probably witnessed this yourselves—perhaps even in your own homes) is groups of people (even families!) staring at their devices…and saying not a word to each other. I can’t help but think that if we can’t (or I guess more appropriately, don’t) converse in our private lives, it’s going to have a not-so-good impact on discourse in the workplace. We are better when we are talking—and even technological isolation is still isolation-y.

Hopping down from the ol’ soapbox, just a quick couple of words on the Emergency Management stuff in Perspectives. Interestingly enough (almost to the point of being strangely enough), it appears that folks responding to emergencies have found that the EM standards facilitate effective response—go figure! While I am certainly glad to hear that, I’m not necessarily surprised, mind you. After all, the basic tenets of small “e” emergency management are what inform the big “E” Joint Commission chapter, so if there’s stuff that doesn’t lend itself to response, recovery, etc., I would hope that it would have been expunged by now. Another area of emphasis in the article is the importance of collaboration with the community and other health providers when you are dealing with a significant emergency (as an aside, the CMS final rule also highlights the importance of that collaboration), which (once again) makes a great deal of sense from a practical standpoint. The article closes out with some links to useful information; I’d encourage you to check them out once the stockings are hung by the chimney with care:

Finally, to close out this epistle, I would encourage you to climb into the wayback machine and revisit those halcyon days of Sentinel Event Alert #37 and the management of emergency power systems, etc. My gut tells me that e-power is going to continue (if not increase) to be a focal point for pretty much any and all regulatory systems and the advice provided in SEA #37 relative to evaluating your e-power capabilities, assessing the reliability of normal power, etc., can only become more timely as our reliance on technology grows at an almost exponential rate. We certainly don’t want to get caught unawares on the e-power front and I’d be willing to bet that there have been some changes in the technology infrastructure in your place that might be significant enough for some analysis. At any rate, some more links to peruse once you’ve laid out the cookie and milk for that right jolly old elf:

Beyond that, I hope that we all get a chance to turn off the technology for a bit over the next couple of weeks (and I mean that in the best possible way—I am no Luddite!) and allow some real-time reflection with our family, friends and, indeed, the world at large.

Here’s hoping that 2017 rings in the return of civil discourse!

Ring out, solstice bells!

And so we turn again to our perusal of the bounty that is the December issue of Perspectives and that most splendid of pursuits, the Clarifications and Expectations column. With the pending changes to the Life Safety (LS) chapter, it appears that we are in for a sequential review of said chapter, starting at the beginning (the process/program for managing LS compliance within your organization) and (at least for now) moving to a deep dive into the ILSM process in January—so stay tuned!

So let’s talk a little bit about the requirements relative to how the physical environment is designed and managed in such a manner as to comply with the Life Safety Code® (LSC). Previously, there were but four performance elements here: assigning someone to manage the process (assessing compliance, completing the eSOC, managing the resolution of deficiencies); maintaining a current eSOC; meeting the completion time frames for PFIs (did you ever think we would get to a point where we could miss those three letters?); and, for deemed status hospitals, maintaining documentation of AHJ inspections. For good or ill (time, as always, will be the final judge), the number of performance elements has grown to six with a slight modification to some of the elements due to the shift away from the eSOC as one of the key LS compliance documents and the evolution (mutation?) of our friend the Plan for Improvement into the Survey-Related PFI. With greater numbers of performance elements, I guess there will be a subsequent increase in confusion, etc. regarding interpretations (yours, mine, theirs) as to what it all means, which leaves us with requirements to:


  • Designate resources for assessing life safety compliance (evidence could be letters of assignment, position descriptions, documentation in meeting minutes); the survey process will include an evaluation of the effectiveness of the chosen method(s) for assessing LS compliance


  • Performance of a formal LS compliance assessment of your facility—based on time frames determined by your organization (big freaking hint: “best practice” would be at least annually); you can modify/adjust time frames based on the stability of your physical environment (if there’s not a lot going on, you might be able to reduce frequencies, though I haven’t been to too many places that didn’t have some activities that would impact LS compliance (Can you say “network cabling”? Sure you can!). Also, there is mention of the use of certain performance elements sprinkled throughout the LS chapter that will be used for any findings that are not specifically covered by the established performance elements. Clearly, there is a desire to leave no stone unturned and no deficiency unrecorded. Yippee!


  • Maintaining current and accurate life safety drawings; we’ve covered this in the past (going back to 2012), but there are still some folks getting tagged for having incomplete, inaccurate or otherwise less-than, life safety drawings. Strictly speaking, the LS drawings are the cornerstone of your entire LS compliance efforts; if they need updating and you have a survey any time in the next 12-18 months, you better start the leveraging process for getting them reviewed/revised. They don’t tell you how to do it, but if they’re not on auto-cad at this point, you better have a wizard for whatever program you are using. All they need to do is find one inconsistency and they can cite it…ugh! Check out the list in Perspectives and make sure that you can account for all of it.


  • Process for resolving deficiencies identified during the survey; we know we have 60 days to fix stuff found during the survey (and hopefully they don’t find anything that will take longer than that to resolve—I have this feeling that that process is going to be exceptionally unwieldy—and probably unyielding to boot). The performance element covers the process for requesting a time-limited waiver—that’s got to happen within 30 days of the end of the survey. Also, the process for requesting equivalencies lives here (if folks need a refresher on equivalencies, let me know and I will put that on the list for 2017 topics). Finally, this is also where the official invocation of the ILSM process as a function of the post-survey process is articulated (I think we covered that pretty thoroughly last week, but if you have questions—go for it!).


  • Maintaining documentation of any inspections and approvals (read: equivalencies) made by state or local AHJs; you’ve got to have this stuff organized and in a place you can lay your hands on it. Make sure you know how often your AHJs visit and make sure that you have some evidence of their “presence.” I think it also makes sense to keep any inspections from your property insurers handy—they are almost as powerful an AHJ as any in the process and you don’t want to run afoul of them—they can have a significant financial impact if something goes sideways with your building.


  • The last one is a little curious to me; I understand why they’re saying it from a global perspective, but it really makes me wonder what prompted specific mention. You can read the details of the language in Perspectives, but my interpretation of this is “don’t try any funny stuff when you’re renovating interior spaces and leave 4-foot corridor widths, etc., when you have clearly done more to the space than ‘updated finishes.’” I think this is the call-to-arms relative to having a good working knowledge of Chapter 43 of the 2012 You need to know what constitutes: repair; renovation; modification; reconstruction; change of use or occupancy classification; addition (as opposed to subtraction). Each of these activities can reach a degree/scope that “tips” the scales relative to the requirements of new versus existing and if you haven’t made that determination (sounds very much like another risk assessment, don’t it?) then you can leave it in the hands of a surveyor to apply the most draconian logic imaginable (I think draconian logic might be oxymoronic—and you can put the accent on either syllable), which will not bode well for survey success.


That’s the word from unity for this week; next week, we’ll check up on some Emergency Management doings in the wake of recent flooding, including some updates to the Joint Commission’s Emergency Management Portal (EMP?). Hope your solstice salutations are merry and bright until next time!

Gathering gobs of Grinchiness

As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.

So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.

At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.

Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!