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Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7. Originally, this section of the LSC referenced 19.3.5.1 which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.

 

I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

In season, out of season: What’s the difference?

…when you don’t know the reason…

Some Joint Commission goodness for your regulatory pleasure!

For those of you in the audience that make use of the online version of the Accreditation Manual, I would implore you to make sure that when you are reviewing standards and performance elements that you are using the most current versions of the requirements. I think we can anticipate that things are going to be coming fast and furious over the next few months as the engineering folks at TJC start to turn the great ship around so it is in accordance with the requirements of the 2012 edition of just about everything, as well as reflecting the CMS Conditions of Participation. To highlight that change, one example is the requirement for the testing of the fire alarm equipment for notifying off-site fire responders (decorum prevents me from identifying the specific standard and performance element, but I can think of at least 02.03.05.5 things that might serve as placeholders, but I digress); the January 1, 2017 version of the standards indicates that this is to occur at a quarterly frequency (which is what we’ve been living with for quite some time), but the January 9, 2017 version indicates that this is to occur on an annual basis, based on the 2010 edition of NFPA 72. In looking at the 2010 edition of NFPA 72, it would appear that annual testing is the target, but I think this speaks to the amount of shifting that’s going to be occurring and the potential (I don’t know that I would go so far as to call it a likelihood, but it’s getting there) for some miscommunications along the way. At any rate, if you use the online tool (I do—it is very useful), make sure that you use the most current version. Of course, it might be helpful to move the older versions to some sort of archived format, but that’s probably not going to happen any time soon.

Speaking of updates, last week also revealed additional standards changes that will be taking effect July 1, 2017 (get the detailed skinny here). Among the anticipated changes are the official invocation of NFPA 99 as guidance for the management of risk; some tweaking of the language regarding Alternative Equipment Management (AEM) program elements, including the abolition (?!?) of the 90% target for PM completion and replacing it with the very much stricter 100% completion rate (make sure you clearly define those completion parameters!); expansion of the ILSM policy requirements to include the management of Life Safety Code® deficiencies that are not immediately corrected during survey (you really have to look at the survey process as a FIFI—Find It, Fix It!—exercise); the (more or less) official adoption of Tentative Interim Agreements (TIA) 1, 2, and 4 (more on those over the next couple of weeks) as a function of managing fire barriers, smoke barriers, and egress for healthcare occupancies; and, the next (and perhaps final) nail in the coffin of being able to sedate patients in business occupancies (also to be covered as we move into the spring accreditation season). I trust that some of this will be illuminated in the upcoming issues of Perspectives, but I think we can safely say that the winds of change will not be subsiding any time soon.

Also on the TJC front, as we move into the 2017 survey year, those of you that will likely be facing survey, I encourage you to tune in to a webinar being presented on the SAFER (Survey Analysis For Evaluating Risk) matrix, which (aside from being transformative—a rather tall order and somewhat scary to consider) will be the cornerstone of your survey reports. We’ve covered some of the salient points here in the past (this is quickly becoming almost very nearly as popular a topic for me as eyewashes and general ranting), but I really cannot encourage you enough to give this topic a great deal of attention over the coming months. As with all new things TJC, there will be a shakedown cruise, with much variability of result (or this is my suspicion based on past experiences)—it is unlikely that this much change at one time is going to enhance consistency or it’s hard to imagine how it would/could (should is another matter entirely). At any rate, the next webinar is scheduled for Tuesday, March 7, 2017; details here.

Please remember to keep those cards and letters coming. It’s always nice to hear from folks. (It almost makes me think that there’s somebody out there at the other end of all those electrons…) Have a safe and productive week as we await the arrival of Spring!

 

Doo doo doo, lookin’ out my back (fire) door…

Something old and something new(ish): old rant, new requirement.

As we move ever onwards toward the close of our first year “under” the 2012 Life Safety Code® (talk about a brave new world), there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies—for those of you keeping track, this activity falls under the EOC chapter under the standard with all those other pesky life safety-related inspection, testing, and maintenance activities (don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference—in this case, you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies). Also, please, please, please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree). The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening. Also, if you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute—while not exactly endless, the list can be pretty extensive. At the moment, from all I can gather, fire-rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.

I’m thinking you will probably want to capture this as a recurring activity in your work order system, as well as developing a documentation form. Make sure the following items are covered in the inspection/testing activity:

 

  • No open holes or breaks in the surfaces of either the door or the frame
  • Door clearances are in compliance (no more than ¾ inch for fire doors; no more than 1 inch for corridor doors; no more than ¾ inch for smoke barrier doors in new buildings)
  • No unapproved protective plates greater than 16 inches from the bottom of the door
  • Making sure the latching hardware works properly
  • If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
  • Making sure meeting edge protection, gasketing, and edge seals (if they are required—depends on the door) are inspected to make sure they are in place and intact

 

I think the other piece of the equation here is that you need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!). Now that this isn’t an optional activity (ah, those days of the BMP…), you might as well make the most of it.

 

Putting on my rant-cap, I’d like to steal just a few moments to lament the continuing decline of decency (it used to be common; now, not so much) when it comes to interactions with strangers (and who knows, maybe it’s extending into familial and friendial interactions as well—I sure hope not!) I firmly believe that any and every kindness should be acknowledged, even if it’s something that they were supposed to do! My favorite example is stopping for pedestrians (and if you’ve been behind me, yes that was me stopping to let someone complete the walk); yes, I know that in many, if not most, places, the law requires you to stop for pedestrians in a crosswalk, but I think the law should also require acknowledgement from the pedestrians. Positive reinforcement can’t possibly hurt in these types of encounters. Allowing merging traffic to move forward (signaling is a desirable approach to this, but you should also signal the person who let you in). I’m not sure if we’re just out of practice or what, but I’d ask you to just try a little more to say “hi” or “thanks” or give somebody a wave when they aren’t jerks (and just so we’re straight, a wave includes more than just the middle digit). Maybe I’m going a little Pollyanna here, but the world is just not nice enough lately. Hopefully we can make an incremental improvement…

Who can turn the world on with her smile?

As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!

As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!

And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…

Until next time, have a Fabulous February!

Don’t ask, don’t tell, don’t tell, don’t get in trouble…

Hope everyone is having a good week and that the rather stormy weather impacting so many parts of the country has not created too much of a challenge for you and your organizations.

This week is another (sort of) catch-all of topics, starting first with a little bit of CYA advice.

Lately there have been several instances (of which I am aware—can’t say for sure if this is an iceberg, but it “feels” like it might) of some very adverse accreditation/deemed status decisions based on insufficient documentation that organizational leadership had been effectively informed of conditions in the physical environment that required additional resources, etc. It’s not that organizational leadership was unaware of the conditions, but more that there was no trail of documented discussion (committee minutes, surveillance rounds, etc.) by which the organization could demonstrate to the surveyors that they had everything under control. In fact, the impression given because of the lack of a documented trail was exactly the opposite.

While nobody is really keen on telling their boss about problems of significance, especially problems for which the means of resolving them are elusive or beyond one’s resources (don’t want to look like you can’t do your job effectively), it is of critical importance to be able to escalate these types of issues to (or near) the top of the organization. Typically, this is about having to fund something (at least in my experience); maybe it’s a roof replacement; maybe it’s replacing some HVAC equipment—I’m sure most folks have a list of things for which it is a struggle to get traction. Let’s face it, unless it’s a new building, facilities infrastructure improvements, safety stuff, etc., is not particularly sexy, so when the capital improvement budgets come and go, it’s a tough sell. But sell it you must and you must keep pushing it—eventually those improvements (or lack thereof) are going to impact patient care and that’s when things can go south in a hurry. We always want to be respectful and not panicky, etc., but, please believe me, when the three- and four-letter regulatory folks knock on the door, you want to be in a position to describe how issues are brought to the attention of leadership. It may not be too pleasant in the moment (okay, in all likelihood, it won’t be pleasant at all), but it can save a whole lot of grief later on.

Next up (and this is something in the way of a commercial), The Joint Commission is hosting a webinar on Tuesday, February 7 to provide information on the new SAFER matrix, which is going to be an important feature of your survey report. We first covered it back in May, but now that they’ve been using it for the past few months (in behavioral health hospitals), it’s possible (I’m hoping likely, but I don’t want to get too amped up) that they will be sharing some useful information from the field. At any rate, particularly for those of you anticipating surveys in the next six to 12 months, I would try to make time for this one. I truly believe that every good intention is put into these survey changes, but I think we can all agree that those good intentions figure very prominently on a certain road…

Finally, this week, I would encourage you to look really, really, really closely at your interim life safety measures (ILSM) policy. TJC conducted a consultant conference last week and it is my understanding that the one significant shift in the survey of the physical environment is that there is going to be a lot of focus on the practical application of ILSMs as a function of Life Safety Code® deficiencies that cannot be immediately corrected. You have to make sure that your policy reflects an ongoing, robust process for that part of the equation. I think the conclusion has been drawn that folks generally have it together when I comes to ILSMs and construction, but are rather less skilled when it comes to those pesky LS deficiencies. We know they tend to focus on areas where they feel there are vulnerabilities (how else might one explain the proliferation of EC/LS/EM findings in recent years). This is a big one folks, so don’t hesitate to dial in with questions.

 

Ring out, solstice bells!

And so we turn again to our perusal of the bounty that is the December issue of Perspectives and that most splendid of pursuits, the Clarifications and Expectations column. With the pending changes to the Life Safety (LS) chapter, it appears that we are in for a sequential review of said chapter, starting at the beginning (the process/program for managing LS compliance within your organization) and (at least for now) moving to a deep dive into the ILSM process in January—so stay tuned!

So let’s talk a little bit about the requirements relative to how the physical environment is designed and managed in such a manner as to comply with the Life Safety Code® (LSC). Previously, there were but four performance elements here: assigning someone to manage the process (assessing compliance, completing the eSOC, managing the resolution of deficiencies); maintaining a current eSOC; meeting the completion time frames for PFIs (did you ever think we would get to a point where we could miss those three letters?); and, for deemed status hospitals, maintaining documentation of AHJ inspections. For good or ill (time, as always, will be the final judge), the number of performance elements has grown to six with a slight modification to some of the elements due to the shift away from the eSOC as one of the key LS compliance documents and the evolution (mutation?) of our friend the Plan for Improvement into the Survey-Related PFI. With greater numbers of performance elements, I guess there will be a subsequent increase in confusion, etc. regarding interpretations (yours, mine, theirs) as to what it all means, which leaves us with requirements to:

 

  • Designate resources for assessing life safety compliance (evidence could be letters of assignment, position descriptions, documentation in meeting minutes); the survey process will include an evaluation of the effectiveness of the chosen method(s) for assessing LS compliance

 

  • Performance of a formal LS compliance assessment of your facility—based on time frames determined by your organization (big freaking hint: “best practice” would be at least annually); you can modify/adjust time frames based on the stability of your physical environment (if there’s not a lot going on, you might be able to reduce frequencies, though I haven’t been to too many places that didn’t have some activities that would impact LS compliance (Can you say “network cabling”? Sure you can!). Also, there is mention of the use of certain performance elements sprinkled throughout the LS chapter that will be used for any findings that are not specifically covered by the established performance elements. Clearly, there is a desire to leave no stone unturned and no deficiency unrecorded. Yippee!

 

  • Maintaining current and accurate life safety drawings; we’ve covered this in the past (going back to 2012), but there are still some folks getting tagged for having incomplete, inaccurate or otherwise less-than, life safety drawings. Strictly speaking, the LS drawings are the cornerstone of your entire LS compliance efforts; if they need updating and you have a survey any time in the next 12-18 months, you better start the leveraging process for getting them reviewed/revised. They don’t tell you how to do it, but if they’re not on auto-cad at this point, you better have a wizard for whatever program you are using. All they need to do is find one inconsistency and they can cite it…ugh! Check out the list in Perspectives and make sure that you can account for all of it.

 

  • Process for resolving deficiencies identified during the survey; we know we have 60 days to fix stuff found during the survey (and hopefully they don’t find anything that will take longer than that to resolve—I have this feeling that that process is going to be exceptionally unwieldy—and probably unyielding to boot). The performance element covers the process for requesting a time-limited waiver—that’s got to happen within 30 days of the end of the survey. Also, the process for requesting equivalencies lives here (if folks need a refresher on equivalencies, let me know and I will put that on the list for 2017 topics). Finally, this is also where the official invocation of the ILSM process as a function of the post-survey process is articulated (I think we covered that pretty thoroughly last week, but if you have questions—go for it!).

 

  • Maintaining documentation of any inspections and approvals (read: equivalencies) made by state or local AHJs; you’ve got to have this stuff organized and in a place you can lay your hands on it. Make sure you know how often your AHJs visit and make sure that you have some evidence of their “presence.” I think it also makes sense to keep any inspections from your property insurers handy—they are almost as powerful an AHJ as any in the process and you don’t want to run afoul of them—they can have a significant financial impact if something goes sideways with your building.

 

  • The last one is a little curious to me; I understand why they’re saying it from a global perspective, but it really makes me wonder what prompted specific mention. You can read the details of the language in Perspectives, but my interpretation of this is “don’t try any funny stuff when you’re renovating interior spaces and leave 4-foot corridor widths, etc., when you have clearly done more to the space than ‘updated finishes.’” I think this is the call-to-arms relative to having a good working knowledge of Chapter 43 of the 2012 You need to know what constitutes: repair; renovation; modification; reconstruction; change of use or occupancy classification; addition (as opposed to subtraction). Each of these activities can reach a degree/scope that “tips” the scales relative to the requirements of new versus existing and if you haven’t made that determination (sounds very much like another risk assessment, don’t it?) then you can leave it in the hands of a surveyor to apply the most draconian logic imaginable (I think draconian logic might be oxymoronic—and you can put the accent on either syllable), which will not bode well for survey success.

 

That’s the word from unity for this week; next week, we’ll check up on some Emergency Management doings in the wake of recent flooding, including some updates to the Joint Commission’s Emergency Management Portal (EMP?). Hope your solstice salutations are merry and bright until next time!

Gathering gobs of Grinchiness

As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.

So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.

At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.

Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!

Now bring me some sticky findings—and bring them right here!

Another hodgepodge of stuff this week. I suppose with the holidays, I could be lazy and break these up into smaller chunks of bloggy goodness—maybe next week, but first some ponderings.

I was penning some thoughts relative to the current state of accreditation and a common theme kept reasserting itself: the recent changes are going to absolutely nothing to help decrease the number of findings in the physical environment and, in fact, are much more likely to increase the number (and probably types) of findings experienced during regulatory inspections. Now, I suppose this is rather an extension of the alignment with CMS (I mean, whoever received a visit from those folks and escaped completely unscathed? Perhaps some, but not a whole bunch, I’d venture to guess) and how that philosophy (scorched earth seems like a particularly apropos descriptor—at least at the moment) aligns with the idea/sense/concept that perfection is a noble goal, but not particularly obtainable on this particular space-spinning blue sphere. I’ve said it before, I’ll (no doubt) say it again: they are going to find “stuff” when they visit you—they have to! But that brings me back to the age-old question of what value does this level of attention to minutia bring to the process. I don’t think there’s anyone among us that believes that we have achieved a level of perfection of heretofore untold proportions—has a lot to do with why we have to show up at work every day, n’est-ce pas? There has got to be a better way to facilitate improvement in the management of the healthcare environment without brandishing the regulatory equivalent of a sharp stick (if not a cattle prod). So, as we wind down the 2016 season, those one-off OFIs have now been converted into a cluster of regulatory middle fingers—ouch! Okay, hopping down from the soapbox.

In the December 2016 issue of Perspectives, there is a fair discussion on how the Interim Life Safety Measures (ILSM) process is going to be utilized (perhaps even evaluated) during the survey process. In the October Perspectives, there was coverage of how a completed project (that involved ILSM implementation) would be reviewed to evaluate the effectiveness of the ILSM process. There was also discussion indicating that construction-related deficiencies would not be cited as specific RFIs but rather as a function of the ILSM performance elements. But the December publication offers yet another nuance to the process—when you have a Life Safety Code® deficiency identified during survey, there will be a resultant “discussion” of the deficiency and an inquiry as to which ILSM will be implemented to protect building occupants until such time as the deficiency (or deficiencies) is corrected. I think the important thing to keep in mind here is that the requirement is to implement your ILSM policy, which would then provide criteria for determining what, if any, of the ILSMs would be implemented. I also think that now would be a really good time to dust off your ILSM policy and run it through a couple of test deficiencies to ensure that your policy supports a reasonable approach to ILSM implementation. Finally (on this subject), in the days when clarification of findings was a worthwhile endeavor, it never “paid” to fix stuff during the survey (fixing a condition was tantamount to admitting that you had messed up), but now that everything gets cited, the simplest ILSM to implement is “none at all because we fixed the condition.” Can somebody give me a “that’s a pain in the posterior”? Amen!

As a final thought (or perhaps thoughts) for the week, I think we have to treat any construction or renovation activities as an invasive procedure, so we need to come up a process akin to the Universal Protocol adopted by the folks in surgery to make sure that everyone is on the same page before the activity starts (and that especially includes contractor staff—I am absolutely convinced that we could do a better job with that process).  As an offshoot of this, I think it might be time to adopt a process for periodically evaluating the construction/renovation management process, much as we evaluate the 6+1 EC/EM functions. I can’t think of a single “normal” process that has more potential for disruption, angst, chaos—you name it—than the construction and renovation process. Some folks are fortunate enough to have in-house resources for the management of these activities, but even then there can be opportunities for improvement–the communications process springs to mind as being frequently flawed.

Until next time, I bid you as much holiday cheer as you can tolerate!

History shows again and again how standards (and EPs) point out the folly of men…

It’s beginning to look like the proofreaders in Chicago must be enduring some late nights watching the Cubs! I don’t know about you folks, but I rely rather heavily on the regular missives from The Joint Commission, collectively known as Joint Commission E-Alerts. The E-Alerts deliver regular packages of yummy goodness to my email box (okay, that may be a little hyperbolic) and yesterday’s missive was no exception. Well, actually, there was an exception—more on that in a moment.

While it did not get top billing in the Alert (which seems kind of odd given what’s been going on this year), the pre-publication changes to the Life Safety chapter of the accreditation manual have been revealed, including comparison tables between what we had in January 2016 and what we can expect in January 2017. Interestingly enough, the comparison tables include the Environment of Care (EC) chapter stuff as well (though the EC chapter did not merit a mention in the E-Alert), so there’s lots of information to consider (which we will be doing over the course of the next little while) and some subtle alterations to the standards/EP language. For example (and this is the first “change” that I noted in reviewing the 112 pages of standards/EPs), the note for EC.02.02.01, EP 9 (the management of risks associated with hazardous gases and vapors) expands the “reach” to specifically include waste anesthetic gas disposal and laboratory rooftop exhaust (yes, I know…very sexy stuff!). It does appear that at least some of the changes (tough to figure out the split between what is truly “new” and what is merely a clarification of existing stuff—check out the note under EC.02.03.05, EP 1 regarding supervisory signal devices because it provides a better sense of what could be included in the mix). Another interesting change occurs under EC.02.03.05 (and this applies to all the testing EPs) is that where previously the requirement was for the completion dates of the testing to be documented, now the requirement actually states that the results of the testing are to be documented in addition to the completion dates. Again, a subtle change in the language and certainly nothing that they haven’t been surveying to. Oh, and one addition to the canon is the annual inspection and testing of door assemblies “by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.” At any rate, I will keep plowing through the comparison table. (Remember in the old days, it would be called a crosswalk. Has the 21st century moved so far ahead that folks don’t know what a crosswalk is anymore?)

The top billing in yesterday’s All Hallows Eve E-Alert (making it an Eve-Alert, I suppose) went to the latest installment in that peppiest of undertakings, the Physical Environment Portal. Where the proofreaders comment comes into play is that the Alert mentions the posting of the information relative to LS.02.01.30, (which happened back in August) but when you click on the link, it takes you to the update page, where the new material is identified as covering LS.02.01.35, so there is updated material, though you couldn’t really tell by the Alert. So, we have general compliance information for the physical environment folks, some kicky advice and information for organizational leadership, and (Bonus! Bonus! Bonus!) information regarding the clinical impact of appropriately maintaining fire suppression systems (there is mention of sprinkler systems, but also portable fire extinguishers). I’d be interested to see if anyone finds the clinical impact information to be of particular use/effectiveness. I don’t know that compliance out in the field (or, more appropriately, noncompliance) is based on how knowledgeable folks are about what to do and what not to do, though perhaps it is the importance of the fire suppression systems and the reasons for having such systems (Can you imagine having to evacuate every time the fire alarm activates? That would be very stinky.) that is getting lost in the translation. I have no reason to think that the number of findings is going to be decreasing in this area (if you’re particularly interested, the comparison table section on LS.02.01.35 begins on p. 80 of that document—any changes that I can see do appear likely to make compliance easier), so I guess we’ll have to keep an eye on the final pages of survey year 2016 and the opening of the 2017 survey season. Be still my beating heart!

I wanna know: Have you ever seen the rain?

In our intermittently continuing series on the (final!) adoption of the 2012 Life Safety Code®, we turn to the one area about which I have still the most concerns—the magic land of NFPA 99. My primary concern is that while NFPA 99 contains lots and lots of references to risk assessments and the processes therein, I’m still not entirely convinced that the CMS oversight of the regulatory compliance process is going to embrace risk assessments to the extent that would allow us to plot our own compliance courses. I guess I will have to warily keep my fingers crossed and keep an eye on what actually occurs during CMS surveys of the physical environment. So, on to this week’s discussion…

When considering the various and sundry requirements relating to the installation and ongoing inspection, testing and maintenance of electrical system components, one of the key elements is the management of risk associated with electrical shock in wet procedure locations. NFPA 99 defines a wet procedure location as “(t)he area in a patient care room where a procedure is performed that is normally subject to wet conditions while patients are present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff.”

Typically, based on that description, the number of areas that would “rule in” for consideration as wet procedure locations is pretty limited (and depending on the nature, etc., of the procedures being performed maybe even less limited than that). But in the modern age, the starting point for this discussion (and this is specifically provided for under section 6.3.2.2.8.4 of the 2012 edition of NFPA 99) is that operating rooms are to be considered wet procedure locations—unless a risk assessment conducted by the healthcare governing body (yow!) determines otherwise (all my yammering over the years about risk assessments is finally paying off—woo hoo!). By the way, there is a specific definition of “governing body”: the person or persons who have overall legal responsibility for the operations of a healthcare facility. This means you’re going to have to get your boss (and your boss’ boss and maybe your boss’ boss’ boss) to play in the sandbox on this particular bit of assessmentry.

Fortunately, our good friends at ASHE have developed a lovely risk assessment tool (this is a beta version) to assist in this regard and they will share the tool with you in exchange for just a few morsels of information (and, I guess, a pledge to provide them with some useful feedback as you try out the tool—they do ask nicely, so I hope you would honor their request if you check this out—and I really think you should). Since I’m pretty certain that we can attribute a fair amount of expertise to any work product emanating from ASHE (even free stuff!), I think we can reasonably work with this tool in the knowledge that we would be able to present it to a surveyor and be able to discuss how we made the necessary determinations relative to wet procedure locations. And speaking of surveys and surveyors, I also don’t think it would be unreasonable to think that this might very well be an imminent topic of conversation once November 5 rolls around and we begin our new compliance journey in earnest. Remember, there is what I will call an institutional tendency to focus on what has changed in the regulations as opposed to what remains the same. And I think that NFPA 99 is going to provide a lot of fodder for the survey process over the next little while. I mean think about it, we’re still getting “dinged” for requirements that are almost two decades old—I think it will be a little while before we get our arms (and staff) around the ins and outs of the new stuff. Batten down the hatches: Looks like some rough weather heading our way!

At any rate, here’s the link to the wet procedure location assessment tool.

Hope everyone has a safe and festively spooky (or spookily festive) All Hallows Eve!