June 14, 2016 | | Comments 0
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A clear case of compliance interruptus

Greetings one and all from high above the 2012 Life Safety Code® (LSC) compliance track with a quick update on CMS plans for administering surveys, etc., in the wake of official adoption of the 2012 LSC. I’m climbing out on a limb just a little bit as the latest missive in this regard from The Joint Commission indicates that it will begin surveying to the requirements of the 2012 LSC on July 5 (Happy freakin’ Independence Day), but it appears that CMS has other ideas. In a member alert disseminated late last week, our friends at the American Society for Healthcare Engineering (ASHE) are reporting that a memorandum was issued by CMS to the various and sundry accreditation agencies (TJC, DNV, HFAP, M-O-U-S-E) indicating that hospitals have until November 7, 2016 before this new shiny hammer is wielded during accreditation surveys. Now, I think it was likely that there would be some sort of transition period for this process (the accreditors would have to update their standards manuals, etc., and I don’t think that happens overnight, but maybe there are manual elves that come in under cover of darkness), so I guess that has come to pass and the end date for that transition is November 7 (I guess they didn’t want to wait until the following month’s day of infamy).

As I’ve noted in this space recently, a lot of the basic tenets of compliance are going to pretty much stay the course. We will continue to manage rated barriers (walls, decks, doors); we will continue to manage egress (perhaps a little more simply, but clutter will still be clutter) and so on. There may be some efficiencies to be gained in the practical application of the various fire alarm and fire suppression system inspection, testing, and maintenance processes (I’ll have to do some edumacation on those), but I really think that the devil in all these details is going to come from how the requirements of NFPA 99 Standard for Health Care Facilities are administered and/or otherwise enforced. NFPA 99 has always kind of hovered in the background, but I think is going to be very much a coming out party. At any rate, ASHE has made available a fair number of resources (some readily accessible, some for members) and I would encourage you to do a little digging if you have not already done so. I still think the physical environment is going to figure quite strongly in the survey process, but maybe this is where we get to share the most frequently cited standards lists with the clinical folks.

On a closing, and most somber note, in the wake of events in Orlando this weekend (thoughts and prayers to all the victims, their families, the community at large, and pretty much everybody else), I can’t help but think that there’s got to be a better way. I know the circumstances that can lead up to events like these are extraordinarily polarizing—and I’ve noted that the polarization didn’t waste any time manifesting itself in the halls of social media. I wish that I had some sage bit of advice or encouragement, but nothing is coming right now beyond this old cliché (doesn’t make it any less useful or true)—cherish your loved ones…right now! We will all be better for it.

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Filed Under: CMSEnvironment 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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