September 22, 2010 | | Comments 2
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In 2011, set another place at the table

At the recent Joint Commission Executive Briefings Session held in New York, an announcement was made that will  infinitely increase the complexity of the Joint Commission survey process for all safety folks. And what, you might ask, is that? Beginning in 2011 (presumably January, but I don’t know that for certain), everybody within the sound of my voice and the sight of my words will be have a Life Safety Code surveyor in their facility for (at least) an additional day during a “triennial” survey.  If you had one day last time, now it’ll be two. Two last time, now it’ll be three for you, my friend. And so on.

The fact of the matter is that the data being collected during the survey process (four out of the top five most frequently cited standards are EC/LS related) demonstrates that we (collectively) are not doing a very good job when it comes to compliance with the standards, particularly when it comes to those pesky (and I use that term quite hyperbolically) Life Safety Code deficiencies. And, I have no reason to think that this is going to go away until there is a marked improvement in findings.

I think I mentioned elsewhere (and maybe here as well) that I am somewhat disappointed that EC.02.03.05 is still in that top five.  We have an obligation to the occupants of our buildings to make sure that every life safety system component is properly maintained, either by in-house staff or by vendor, and that documentation actually indicates that each component is in the mix.

How difficult can this be? I know we struggle with our vendors, and it is our obligation as managers to make sure that our vendors are delivering on everything that we are paying them for, but shouldn’t we have this under control by now (feel free to disagree and if you have particular barriers– we can all learn from this). The only surprise here is that they are still finding issues. Find the standards and read them; they are pretty straightforward. I’ll tell you, if EC.02.03.05 is still in the top five at the end of the year, so help me.

Each of us has to find a way to identify LSC deficiencies in the building and manage those deficiencies. The means they have provided, in allowing the use of work order systems and the Plan For Improvement process, should be sufficient to the task at hand (yes, I know that resources are limited, but if we don’t get our arms around this we may not even have limited resources to deal with if we are encouraged to find other employment).

They shouldn’t be able to find anything in our building that we don’t already know about (apparently there has been a collective throwing under the bus of the IT cabling folks). Someone on the podium suggested a bounty on these slippery simians, and I agree, whoever spots the most unauthorized folks in the ceiling – buy them lunch or something. Make sure that every authorized above-the-ceiling worker has a permit prominently displayed, and anybody who doesn’t have one gets bounced (for the day). A boss of mine once told me that some people are pain learners, so the question becomes – who would you prefer to have in pain, you or your vendors?

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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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  1. Hi Mac! I was a little confused by the comment you made in your article of 9/22/10, called “In 2011, set another place at the table,” in which you talk about ‘throwing IT under the bus.’ After re-reading EC.02.03.05, I don’t see how IS could cause a problem for a healthcare organization in this section of the EC standards (EC.02.03.05). However, I could see how IS, and Telecommunications for that matter, could negatively impact a healthcare organization in LS.02.01.10, EP9, which requires healthcare organizations to protect spaces in fire rated walls with an approved fire rated material. Our facility was cited for violating LS.02.01.10, EP9, due to problems in this area, but it was NOT cited at all under EC.02.03.05. Therefore, I was wondering if your comment about IT was actually in reference to LS.02.01.10 or did you mean EC.02.03.05? If you did mean EC.02.03.05, I was wondering how IS could cause healthcare organizations a problem under EC.02.03.05? Please let me know when you get a chance.


    Jack Oliver
    Life Safety Officer
    Engineering Dept.
    Saratoga Hospital
    211 Church Street
    Saratoga Springs, NY 12866

  2. Steve MacArthur

    Hi Jack,

    Sorry for the confusion, my rant about EC.02.03.05 in the middle of the post spilled over the whole post – sometimes that happens. So, as clarification, in discussing those standards citations dealing with penetrations in smoke and fire walls (LS.02.01.10 & LS.02.01.30), the somewhat inconsistenly reliable penetration sealing skills of IT vendors was specifically mentioned during the Executive Briefings session, so your experiences were very much in line with what they’re finding across the country. It all ties back to have a reliable process for keeping track of those folks scrambling above our ceilings, and getting the repairs on a systematic schedule for making sure that the holes are plugged appropriately when the cable runs are complete.

    Thanks for the comment!

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