March 14, 2016 | | Comments 0
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A most mortal portal: Yes, Virginia, you need to have an inventory of your devices…all of ’em

And so, the flying fickle finger of compliance finally points portally (via The Joint Commission’s Physical Environment Portal) in the direction of that most troublesome of standards, EC.02.03.05, and we return once again to the fireside of our intrepid duo, Messrs. George Mills of The Joint Commission and Dale Woodin of ASHE. There are two videos, one for the facilities audience and one for leadership (does anyone else find it fascinating that the duo dons neckwear for the leadership video?).

While I don’t want to engage in revealing any spoilers, in the video, EC.02.03.05 is described as being “most prescriptive” and “frustrating” and also notes that Mr. Mills has taken some pains to “tear apart” the standard in past “Clarifications and Expectations” columns in Joint Commission Perspectives. Yet, yet, yet, approximately 40% of hospitals continue to get cited for deficiencies relative to the myriad components represented in this standard. I personally would love to see how this actually breaks down in terms of which of the 20+ performance elements are the most problematic (I can’t imagine that there are some that “float” to the top more than any others), but the video does seem to indicate what the “problems” are:

 

  1. You have to have an inventory, by location, of each device class, meaning smoke detectors, heat detectors, pull stations, HVAC shutdown devices, water flows, tamper switches, fire extinguishers, etc. It seems to me that back in the day, there was a reluctance on the part of our Chicagoan friends to actually say the words that would indicate the need for an inventory. But it all comes down (or back—I think I’ve beaten this particular breathless equine once or twice in the past) to knowing that you inspected, tested, maintained, each device in the fire alarm system. So if you (or your vendor’s documentation) do not specifically indicate that each device was demonstrably inspected, tested, maintained, then (buzzer sound): you lose!
  2. The documentation has to be available “upon request”, so really, if you can’t produce the current documentation PDQ, then (buzzer sound): you lose! You can only get credit for those inspection, testing and maintenance activities for which you have available documentation—if you didn’t document it, you didn’t do it. Period. End of story.

Now I certainly recognize that a combination of findings under EC.02.03.05 would drive a finding under the Leadership standards (to be exact, LD.04.01.05 EP 4), based on past survey reports. But apparently there is indeed a magic number of EC.02.03.05 EP findings that will result in the Leadership finding—three or more EPs out of compliance, then (bell rings): you win a discussion with your boss as to how you allowed (and I’m using that term in its most pejorative sense) such a thing to happen. At that point, for example, it is way too late to admit that the fire alarm and sprinkler testing vendors have not given you very useful reports (and something tells me that that particular conversation is not as rare as it ought to be). From watching the video (and in providing a neckwear-enhanced video specifically for your organization’ s leaders and Mr. Mills indicates he had to edumacate his bosses too—we are not alone), there is a very clear expectation that you, the facility/safety professional, will make the effort to proactive communicate with your boss, particularly if you are experiencing service issues, etc., in getting these activities under control. You can certainly make the case that the protection of the entire organization can be compromised if your fire alarm and sprinkler systems are not appropriately maintained, so, really, any infrastructure concerns should be communicated in a timely fashion to the leadership of each organization to ensure that appropriate resources are allocated on an ongoing basis to make sure everything stays on an even keel.

At any rate, our duo takes great pains to point out that none of this stuff is new (the “seed” documents from NFPA 72, 25 and the like having been penned way back in the 20th century), but I do feel that the methodology for surveying has evolved/mutated over time. I mean, if it were really that simple, wouldn’t this go away? They also point out that ASHE has a fair amount of information to assist you in your compliance efforts (ASHE Focus on Compliance: you can be especially warm for their forms) and there’s even a PowerPoint presentation that The Joint Commission uses at the EC Base Camp presentations (you can link to the presentation on the left hand side of the portal page), which gives it the power of the Quadruple P—Portal PowerPoint Presentation! Ultimately, you’ve got to keep a really close eye on this stuff, aside from product expiration dates, the management of the various and sundry elements of EC.02.03.05 is among the most voluminous in sheer numbers—that’s a lot of spheres to keep up in the air—and you only have to drop a couple to earn that lovely chat with your boss. I am absolutely convinced we can make it happen, so let’s see what we can do to retire EC.02.03.05 from the top 10. (Or 20…wouldn’t that be a fine thing?)

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Filed Under: Environment of careThe Joint Commission

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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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