January 05, 2011 | | Comments 0
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Mac’s Safety Space: Life Safety Surveyor

Q: I was just wondering what your thoughts are on the expanding life safety surveyor. I am in a 42-bed hospital and on my last survey cycle I got my first Life Safety Surveyor. My next survey should be any time. My last surveyor spent about five to six hours with me and asked many different questions, went through the grid of questions on the fire equipment, and at the end of the day, I thought he could not possibly have any more questions. But now I will have a surveyor for two days. What will the surveyor look at?

Steve MacArthur: You pose an interesting question–one for which I have given a fair amount of consideration as my client work tends to be in smaller facilities–so I’ve had a number of conversations in this regard.

One thing (or I suppose a couple of things) I can say for sure is that the survey of the physical environment will be conducted primarily, if not exclusively, by the Life Safety Code® (LSC) surveyor, including the Emergency Management review and the Environment of Care document review, which historically has fallen on the other members of the survey team.

So, the management plans, EC minutes, annual evaluations, disaster critiques, etc. will all be reviewed by the LSC surveyor. I see this as an absolute plus for folks with well-organized programs as the review will be conducted by someone with rather more current expertise so the review will be conducted by someone who understands the practical/operational considerations, so I am hoping that this will result in less need for us to defend our rational decisions to “opinions” that are not germane, or even possible, in the current regulatory environment.

The LSC surveyors generally have regular jobs at hospitals, though I suspect with the broadening of the survey scope we may see more folks taking this on as a retirement job, but that may not be for a while. Conversely, folks with “squishy” programmatic elements are much more likely to have those vulnerabilities exposed during survey. I’m not sure if I’ve mentioned this previously in the blog, but there is a certain recognition that we do not exist in a perfect environment, so it is how we proactively manage those imperfections that will be the benchmark at the end of the day.

Another benefit is that we won’t have to “bond” with different folks during the survey, which, especially in smaller organizations with not a lot of bench strength, can be a challenge in a short survey. You’re getting pulled in a million different directions (I’m sure you know that feeling). The survey of your area of responsibility has become, in effect, a one-stop shop, which will allow you to exercise greater control over the process. Sure, there is a chance that they can dig a little deeper and find a few more things, but really, are they going to be able to find something about which you are unaware? I think not.

As a final “benefit”, if you will, is that the LSC surveyor will stick around long enough for you to discuss the findings and, ideally, make your case for compliance. Although the “marching orders” at the moment are for everything to go into the report, you can discuss the findings as a function of compliance with the standards, which will help you make full use of the clarification process. If you look at the standards that are being cited most frequently, there are lots of “C” performance elements in the mix, so lots of post-survey opportunities.

I suppose you could say that I’m looking at this whole change from a “glass half full” perspective, but it’s not going to go away any time soon, so we might as well look at this as a positive development.

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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 stevemacsafetyspace@gmail.com.

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