August 27, 2007 | | Comments 0
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And now for something completely related…

Let’s talk more about The Joint Commission’s building maintenance program. Be forewarned that a BMP is not necessarily a panacea during survey.

Yes, there are some surveyors that might cut you some slack if you have a BMP, but, strictly speaking, if they find three Life Safety Code deficiencies during survey that cannot be reconciled with the items on your current PFI, and cannot be identified as having an approved equivalency, then you can receive an RFI under EC.5.20.

“What?” you might say, “That’s now how I understood it to work!”

Ah, my fine colleague, but what do we actually know about this process? If you look at the Statement of Conditions, it indicates that an organization may choose to resolve each of the noted deficiency types through a building maintenance program and goes on to describe an effective BMP as maintaining the noted life safety features at a 95% compliance rate.

What it doesn’t say is that there is no way, unless you have a very small inventory of a particular item, that a surveyor could inspect a sufficiently-sized sample to render a verdict on your actual compliance percentage.

But don’t jump off the ledge just yet! Where your maintenance data comes in to play is when you have to make your case on the back end, most likely during the clarification phase (each organization has a period of time post-survey in which they can provide The Joint Commission with data to support a finding of compliance).

At that point, through your organization’s survey coordinator, you would submit your BMP data for review by the folks at The Joint Commission’s Chicago headquarters. By the way, the commission has hired additional engineers to assist with the management of all things EC, including review of the electronic Statements of Conditions and PFIs.

Stay safe,
Steve Mac.

Entry Information

Filed Under: Life Safety Code

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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