October 05, 2011 | | Comments 0
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For those of you not so executively inclined: Mac’s Brief on the September TJC Executive Briefings

To the surprise of almost no one (as far as I can tell), when The Joint Commission (TJC) unveiled the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting, five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Each standard relates directly to the increasing coverage of the life safety surveyors. It also appears that their scope is going to be expanding into the realm of infection control (IC), but more on that in the next blog post (stay tuned).

While the EC/LS world had to settle for second place on the list with LS.02.01.20 (taking third: LS.02.01.10, fourth: LS.02.01.30, fifth: EC.02.03.05, and eighth: LS.02.01.35), it is clear there is a great deal of work yet to be done by hospitals to gain a little control over this deluge of deficiencies.

A whopping 57% of hospitals surveyed between January and June were cited on LS.02.01.20, which has everything to do with maintaining the integrity of egress. Hospitals were caught for a number of deficiencies: doors locked in a means of egress, projections, corridor clutter, and configuration/designation of suites.

My colleague Brad Keyes and I have spoken (some would say approaching ranting) about the importance of your life safety drawings and how they facilitate the survey process if they are accurately maintained. It appears the quality (or lack thereof) of life safety drawings are more frequently put to the test during survey, with not-so-glowing results. (I’m interpreting a 43% success rate as something less than A-level performance.) I suspect that a majority of the findings might still relate to corridor clutter (after all, how difficult is it to find two instances of unattended, unallowed stuff in the corridor, hmm?) Interestingly enough it was revealed that one cannot manage the corridor clutter LS deficiency through the plan for improvement (PFI) process, which is kind of stinky.

My opinion is that if you do your risk assessment for interim life safety measures (ILSM) to compensate for the LS deficiency represented by corridor clutter and actually resolve it in some way, then that is an appropriate use of the process. But, in this case—and so many others, it makes my head spin—my opinion matters not a whit. So egress woes top the list.

Moving on to LS.02.01.10, which also has a 57% rate of findings in hospitals for the first half of 2011. This one’s fairly straightforward: doors (not latching), doors (undercuts), doors (lacking closers), more doors (can anyone say door stops?), and then sealing around ductwork penetrating fire-rated barriers. Again, how difficult is it to find this stuff (and yes, I know that it is our job to make it difficult, but still…) Once again, accurate life safety drawings are the key; if your drawings say door is a fire door, then that’s how it will be surveyed, even if it’s a smoke door now since you’ve sprinkled your building–the drawings never lie!)

More top-cited standards will be discussed in the next blog post–stay tuned!

Entry Information

Filed Under: Environment of careLife 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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