September 20, 2021 | | Comments 0
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The Matrix Unloaded…Overloaded: Somehow stuff keeps happening…

Interesting read in the October 2021 Perspectives relative to some Life Safety chapter considerations that have earned a place in the Consistent Interpretation column. The thing that really caught my eye was the potential for these conditions to show up in the upper right hand corner of Ye Olde (SAFER) Matrix—a fate that befalls only a few choice conditions. I’m not so sure these are the conditions I would have thought could “bump” up into that corner, but I guess it’s all subject to interpretation. Fortunately, they don’t appear to be cited very frequently (from a high of just over 12% to a low of just over 0.5%) so perhaps it’s more a question of the frequency in which these conditions might be identified during a survey. While you’re definitely going to want to look at the details, the types of things identified in the article are things like: missing fireproofing; “missing” sprinkler heads; issues with two-hour walls, particularly occupancy separations; proper fire protection rated components in opening protectives (so, no 20-minute fire doors in 2-hour rated walls); painted-over door labels (How many of these would you need to have to push a high-risk/high-frequency finding? Beats me…).

Again, nothing that gets cited with any great frequency is in the mix (the performance element under which the door label issue would be cited “sits” at about a 10% finding rate), and, as I think about it, none of these are things I see with any frequency, though I suppose you could make the case that some of this extends into the territory of “if you look long enough and hard enough, there’s always one.” For example, in all likelihood, if you have fireproofed steel in your facility, there will be a section of fireproofing that was knocked off/removed/damaged, etc.; same thing with the painted-over door labels—there’s probably one somewhere (which causes me to reflect on the nature of environmental surveys as scavenger hunts). Definitely something to keep an eye on (and encourage your line staff to be on the lookout for them too).

To conclude with a little more LS goodness, I’ve been sitting on this one for a little bit (OK, maybe a little more than a little…since February), but as the intense chaos of the pandemic ebbs and flows (but never really subsides to any great degree), Health Facilities Management published a short article on the importance of the risk assessment process to ensure appropriate management of the risks associated with rapid-cycle facility modifications to accommodate all sorts of shifts in volume, acuity, patient types, etc. While some of the risk assessment would probably have to be retrospective (unless your policy specifically prohibits retrospective review), it might be worth going back to look at modifications to egress and, perhaps, fire protection features when you were creating COVID units from thin air. There are almost always lessons to be learned and the more we can hard-wire into the process moving forward, the safer we’ll all be in the long run.

That’s all for now. See you next week!

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Filed Under: The 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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