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Forever in debt to your priceless advice…

Continuing on with our discussions of the unusually revelatory April issue of Perspectives, we shall now turn to the life safety-related items, starting with the sweetness of suites (though this may result in some tart-y findings).

One of the most anticipated elements related to the adoption of the 2012 edition of NFPA 101 Life Safety Code® was the full-on acknowledgement of suites. One of things I still find curious/amusing about the whole suite designation thing is there have classically been any number of patient (and other) spaces in healthcare that were clearly designed within the suite concept—even going back to design elements present in the ’70s (yes, I am that old—the ED in the first hospital in which I worked was an area of open patient “positions” with, I think, a trauma room that had a door). The postanesthesia care units (PACU) is the example that springs most quickly to mind—I don’t know that there was ever a time when PACUs were subdivided into individual rooms. From an operational standpoint, the design of a suite makes perfect sense for such care locations. Another area that was frequently “suite-ified” was the critical care unit, though those often had doors, but not necessarily doors that positively latched.

At any rate, one of the primary clear benefits of the suite design is the subtle shifting of “corridors” into “communicating spaces” (and now, as indicated in the April Perspectives, “aisles”), allowing for a fair amount of operational flexibility when it comes to the management of equipment, supplies, etc.  I guess there is something of a quandary when it comes to how much of this information is shared with staff at point of care/point of service—mostly based on the “if you give them an inch…” logical fallacy (more info on that sequence can be found with a web search; I wouldn’t advise it, though, as it is rather a rabbit hole). At any rate, the latest issue of Perspectives is (more or less) throwing down the survey gauntlet when it comes to clear width of spaces within a suite, invoking NFPA 101-2012, which sets a minimum width of egress at 36 inches in all facilities or portions of facilities classified as a healthcare occupancy. Soooooo, any spaces in which there are fewer than 36 inches of clear width are probably going to be cited; my gut instinct tells me that this will be most relevant to emergency department spaces, where the activities of the day tend to lean towards more blurry lines when it comes to egress paths. The other thought that popped into my head, based on the “portions of facilities classified as a health care occupancy,” is that there may be some patient rooms that might not make the 36 inches between the foot of the bed and the adjacent wall. That may not be an issue, but in my mind’s eye, I can see some tight squeezes…

The other life safety-related item in the April Perspectives deals with the (perhaps final) curtain call for the Building Maintenance Program (BMP) strategy for maintaining certain life safety components. While I can’t necessarily refer to the BMP as an anachronism, it’s been more than a decade since there was an particular survey benefit, though I believe—at least it was the last time I was able to look—the electronic Basic Building Information does include a question asking if the organization is using a BMP. Is anybody willing to hop on their TJC portal to see if the question is still there? That said, I don’t think CMS ever really accepted the concept of the BMP as an alternative means for managing life safety deficiencies (much as the PFI process was eventually kicked to the curb). I just checked the JCR portal for the standards manuals, and the BMP entry is still there, so I guess it’s taking a couple of bows before the curtain comes down for good.

As always, I trust that you all are well and staying safe. I just received my second dose of the vaccine the other day, so hopefully this will make traveling a simpler proposition. I guess every day brings us another day closer, so let’s keep the party going!

Doing the waive: Categorical waivers are still in the mix…

In preparation for last week’s missive on the transmission of fire alarm signals during fire drills (more on that in a moment), I ran across a CMS categorical waiver that was posted early last fall (September 25, to be exact) that provided some relief for folks wishing to use corrugated medical tubing in certain circumstances, rather than the rigid copper tubing required under NFPA 99-2012, due what CMS might consider an unreasonable hardship as corrugated medical tubing can be installed more efficiently and economically than rigid copper. The basis of the waiver is due to a more recent version of NFPA 99 (the 2018 edition) in which there are provisions that provide for installation of the corrugated. At this point, we all know the drill: You have to read the whole thing very carefully to ensure you don’t step on any regulatory toes, but if you’ve got some tricky installations coming up, this might be something of a relief. You can find all the details here.

Now, the reason I bring up the transmission of fire alarm signals deal is that the most recent edition of NFPA 101 (2021) includes some clarification in this regard (a shout out to Grant Finch out in Oregon for his detective skills on this). As noted last week, the current language indicates transmission of a fire alarm signal (with no additional information to be found as defining what that means, leaving things in the hands of the interpretive dance masters). The 2021 edition, in section, requires fire drills to include the simulation of emergency for fire conditions (much as it does now), but it goes on to say “include activation of the fire alarm system notification appliances.” Section still provides for the coded announcement between 2100 and 0600 hours, so that piece of it remains the same.

At any rate, I am hopeful that, with this current version clarification, even if there is no categorical waiver forthcoming, the accreditation organizations will stop fussing about the fire alarm signal transmission and move on to other things. After all, the truly applicable code for testing fire alarm signals is NFPA 72, so why would need to include signals in our fire drills—which reminds me, you still need to document the elapsed time of the fire alarm signals generation to its receipt at the central monitoring service, etc. I’ve been running into a spate of vendors that are not including that in their documentation, so you probably want to give your latest testing documentation a look. And while we’re on the subject, I personally think it’s bogus for your testing vendor to just give you a printout of the month’s alarm activity in which the test occurred; they should either highlight it on the sheet or pull the dates/times/results off the printout. I suspect that they are being more than adequately compensated for their services, which (to my mind) includes a summary of the results, particularly any deficiencies. I don’t think you should have to hunt for the deficiencies and now with the rollout of the virtual survey process (something on that next week), surveyors will have more time than ever to comb through your reports for those funky little missed devices, etc. Your fire alarm (and sprinkler system) ITM vendor should be highlighting the “to do” list so you can get it “to done.”

Hope you’re having a safe and productive week. See you on the flip side!

Are you transmitting? Late night fire drills and alarm signals…

I think we can safely say that sometimes it is tough to pinpoint specifics when it comes down to what performance elements are cited during regulatory surveys, be they virtual or actual. In this regard, I really couldn’t say to what extent this particular item is being cited, but I know that it happens and often that happening results in some level of consternation of the “How am I supposed to do that?” variety.

The Life Safety Code® (LSC) NFPA 101-2012 requires that: “(f)ire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7 (section, to be precise) goes on to indicate that “(w)hen drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.” I suspect that, over time, a lot of folks have ended up equating the transmission of a fire alarm signal and the use of a coded announcement as being equivalent, but that really isn’t the case. allows you to conduct a fire drill without disturbing patients, etc., but, as it turns out, you still have to include the transmission of the fire alarm signal (that’s the signal that actually “leaves” the building and goes to the central monitoring service, 911 call center, etc.). If you need further indication, I submit to you the “opinion” (or you could call it an interpretation) of one of our favorite AHJs. I think this gives you a good sense of the separation of what happen inside your facility versus making sure that pesky alarm signal finds its way outside.

But the question then becomes, how does one accomplish this if one has a fire alarm system that doesn’t provide an easy way of turning off the internal signals and still allowing for the transmission of the signal? This question bounced my way recently and I decided to do some poking around to see if there were any scholarly works, etc., and I came across some guidance published back in 2016 (the document is dated June 2016, so it would precede the official adoption of the 2012 LSC by CMS), that outlines some of the particulars of fire drills to be conducted in Minnesota.

One of the interesting elements is a note that deals with today’s discussion: “Note: When a coded announcement is used instead of audible alarms on the night shift, the fire alarm should be sounded first thing in the morning the following day to meet the requirement that each drill include ‘transmission of a fire alarm signal.’” Now I recognize that AHJ interpretations are many and varied (to an almost frightening degree), but I was wondering if anyone had been able to negotiate this type of process with their AHJ. It certainly makes sense to me that you could “extend” completion of the fire drill a few hours to ensure proper operation of the fire alarm system, but I also suspect that you’d probably be reticent to go that route without getting some sort of permission and you’d probably need to write it in to your policy or management plan as a standard practice or procedure, but it seems a rather elegant solution to me ( as a non-AHJ). What say you all?

Hoping this finds you well and staying safe; I figure every week brings us closer to whatever’s coming next, so let’s get there together!

If you’re the AHJ, it really isn’t an “interpretation,” is it?

I’m sure we all have stories about Authorities Having Jurisdiction (AHJ) whose “sense” of what is required by code was less operationally friendly than one might have preferred. The instructor at my first educational program at NFPA headquarters indicated that there is a single response to any question than can be asked regarding compliance with (in this case, but it applies fairly universally) the Life Safety Code®: “It depends.” There may be some that think that that was a rather flippant thing to say, but in my experience it holds way more truth than hyperbole, pretty much to the point of embracing it as a central concept for pursuing compliance. The corollary that extends from that is one of the other compliance “truths”: Any AHJ can disagree with any decision you’ve made, or, indeed, anything that they or another (competing) AHJ might have told you in the past. A good example of this is when you run into a state surveyor who is not particularly inclined to “honor” an existing waiver or equivalency. If I’ve learned anything over the past X number of years, it’s that results of previous encounters have little bearing on future encounters.

At any rate, I recently received a question regarding the audibility of occupant notification appliances as a function of NFPA 72 and the interpretation of an AHJ that there is no such thing as an “average ambient sound level.” It would seem that this particular interpretation is based on the “sense” that “average ambient sound level” (and it’s cousin “ambient sound level”) are unrelated to any measurements taken by a contractor or through the AHJ’s office. As we know (being the stewards responsible for ensuring that care environment is as functionally quiet as possible), NFPA 72 does indeed invoke (for audible public mode appliances) that the sound level of those appliances must have a sound level of at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds, whichever is greater, etc. NFPA 72 also stipulates a process for making that determination, calling for sound pressure level being measure over the period of time any person is present, or a 24-hour period, whichever time period is lesser. And to be honest, I don’t know that I’ve ever seen (perhaps because I never asked for it, but I may start) any documentary evidence of that measurement when determining the sound levels for a fire alarm system.

So, the thought occurs to me that it is entirely possible that, based on his observations and experience, his statement regarding the measurement of ambient noise levels is accurate to the extent of that experience, etc. He may know the contractor that installs fire alarm systems in his jurisdiction and received feedback that the process stipulated under NFPA 72 is not routinely included in acceptance testing of a system. Or it may be that, in his determination, the standard industry practice in his jurisdiction is not sufficiently consistent to allow for the use of the ambient noise levels as a determining factor and has identified an acceptable range for his jurisdiction (75 to 110 dB). He also knows that his office is not performing this measurement, so his statement, while perhaps a bit hyperbolic, is accurate from his standpoint. But I know there are areas in which even 75 dB can make quite a racket (I’m thinking recovery rooms, ICUs, etc.), which leads me to a closing anecdote.

Back when I was responsible for day-to-day operations, I had (on a number of occasions) tried to convince my local AHJ that we could reduce the volume of the notification appliances in the PACU (which, of course, begs the question of why anyone would spec audible devices in the PACU, but sometimes…) and still achieve the same level of safety in the event of fire, etc. (primarily based on staffing levels), but I couldn’t sell that scheme. This went on over the course of several years until one day I happened to find out this individual was coming in for surgery and darn if there wasn’t a fire alarm activation when he was in the PACU. Long story, short: His next visit resulted in him signing off on reducing the volumes on the appliances (I couldn’t get my boss to sign off on replacing them—lean budget times, but sometimes you have to take what you can get).

Hope you’re staying away from any exceptionally pesky AHJs, but if you’re dealing with an unbending presence, I hope you get the opportunity to cast some illumination on your “interpretation.”

Take care and stay safe!

And it makes me wonder…sure does!

And it’s not just a bustle in your hedgerow, so alarm might be warranted…

Lately, I’ve been using this space to muse on the potential for changes to the survey process, particularly as a function of the inclusion of outpatient clinic settings and the impact of life safety surveyor attention to these facilities might have on survey results. If your immediate thought was “more findings in the physical environment,” I fear you are more correct than you might have wanted to be.

While I don’t have access to the official results just yet (the wheels of bureaucracy grind ever slowly), I was able to be front and center last week for a full federal Conditions of Participation survey. The most notable aspect of the survey (for me) was the attention paid to outpatient clinics being managed as business occupancies by the life safety portion of the survey process. There was a lot of focused document review for these offsite locations, with the expectation that the degree/level of exactitude in the documentation for your main campus is to be extended to the outpatient settings. Inventory lists of devices, making sure sensitivity testing is being done (with specific values—not just a pass/fail note for each); focused attention on how spare sprinkler heads are being managed—including ensuring that the correct wrench or wrenches are in place; quarterly fire drills (and yes, you read that correctly; it seems that the days of annual fire drills in business occupancies is drawing to a close), etc.

Those of you managing your outpatient settings through your own processes will have a leg up on the process, but if you rely on documentation provided by landlords, etc., you probably want to start kicking those tires and having the discussions now. The other piece of this is that the expectation is that any requested documentation would be readily (pretty darn close to immediately) available for review by the surveyor, so you may want to consider how you are managing that process. Do you have site-based binders or do you provide electronically? The surveyors definitely don’t want to hear that (for whatever reason) the documentation is not available.

As a final thought for this week, in light of this week’s coverage, you may want to give some thought as to how you might memorialize the ligature resistance risk assessment in the outpatient areas (don’t forget to make it thoughtful). As you can see from the link, the FAQ is aimed at the “hospital and hospital clinics” settings, so I think we can see where this could (and, let’s face it, probably will) go.

Until next time, I hope this finds you well and somehow managing the current currents—not sure what it will look like when we finally get past these rapids, but I hope that we all get through together!

Do you still BBI? Also, how do you spell survey finding?


While I am not convinced it every truly went away, next month marks the official return of one of the most (in)famous acronyms in surveydom: BBI, which we all know stands for Basic Building Information (details can be found here). So, for those of you for whom survey is imminent, you might (if you have not already done so) want to hop on to your online Statement of Conditions portal to make sure that all your information is up to date, all required responses are in place, etc. Since this is nominally a “new” requirement, I think it best to presume that the Life Safety surveyors are going to be reviewing the contents, so you want to make sure you have a good read on your square footage numbers and all the rest of it. I don’t see this representing a particularly great risk of survey exposure, but I’d hate to see somebody out there in the audience to get tapped for something so simple.

In other news (and I would consider this more troubling in the long term), back in September, the updates to some of the Environment of Care performance elements for office-based surgery practices were published (details here). While the updates relate mostly to invocation of the 2012 edition of the Life Safety Code® and the applicable reference documents, it also (and this may me being a touch paranoid—’tis always the season) may be indicative of a shift in focus for what documentation might be requested for care locations that are nominally business occupancies. I have definitely seen this (though I wouldn’t yet call it a trend, though it’s getting there) in state surveys of larger healthcare organizations, so it may just be a matter of time before evidence of compliance is requested for all the various life safety systems in place at your offsite locations (remembering that this does not mandate the presence of fire alarm systems, sprinkler systems, etc.—it only requires you to appropriately maintain any existing systems).

On a final note for this week, it would seem that some folks are using their work order system to provide evidence of scheduled activities like monthly testing/inspections of battery-powered lights, exit signs, task lighting, etc., and I just wanted to let you know that in the absence of an inventory of devices by location, there are some surveyors (and perhaps even more than just some surveyors) that will not accept a completed/closed out work order as evidence of compliance for these activities. Recognizing that the standards-based requirement for the “inventory” (in all its glory) has not specifically been extended to utility systems equipment (though I have anticipated that extension for a while), I think it may be time to start including the same level of detail as required for life safety systems inspection, testing and maintenance activities:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

I suppose to a fair degree it makes sense for inspection, testing, and maintenance documentation to have a standard format and it certainly helps to establish compliance in a fashion that is recognizable to surveyors. I guess we’ll just have to keep a watchful eye on this one…

One size fits all…or one size fits none

In a world in which the economies of scale don’t always economize, I keep running into situations and/or conditions that result from trying to make something do too much. The classic example (other than those one-size-fits-all bunny suits in ORs across this great land of ours—I always end up looking like late-model Elvis, Vegas edition) is the temperature log that is used for food refrigerators, medication refrigerators, etc. As a general rule of thumb, unless the temperature range for each of the refrigerators being monitored is the same (and never mind trying to mix Fahrenheit and Celsius), then you are just asking for trouble. “Pushing” staff to have to discern between competing “out of range” temperature values requires an almost infinite amount of attention, and while there is, in certain instances, some overlap (food is usually 33-40 degrees F and medication 36-46 degrees F, so 36-40 works for both), it just makes so much more sense to limit confusion to the extent possible. And, to my mind, that means individualized temperature logs. One quick note regarding temperature logs for freezers, if your log doesn’t have a temperature “safe” range clearly indicated, I’ve been seeing a lot of mix-ups regarding those pesky negative numbers. For instance, if you establish a target of -15 degrees or colder, -10 degrees would be considered an -out-of-range value, but in talking with the folks doing the monitoring, they “think” of “10” being less that “15,” kind of missing the whole negative number dynamic. I won’t say that this is happening everywhere, but I have run into it in a couple of instances, so that’s something to keep an eye on.

Turning to the Oddities page, I was cruising through The Joint Commission’s FAQ page (admittedly, looking for blog fodder) and came across something of a puzzle; in the text of the FAQ dealing with the “old” requirement of the building assessment as a function of the Statement of Conditions (the old Part 3, which is no longer available) and has not been since 2007. But if you look at the text of LS.01.01.01, the second performance element indicates that a building assessment is required (at time frames to be determined by each organization) to determine compliance with the Life Safety chapter of the Joint Commission manual. I guess the thing that struck me about this happenstance is that the FAQ would have a good opportunity to indicate that the building assessment has evolved (or mutated—your pick) into its present day purpose  as an exercise in assessing your building for compliance with the LS chapter. Maybe they just haven’t gotten around to updating this FAQ (it is a ways down the FAQ page), and I suppose it is no more than a curiosity.

Walls and Bridges: Managing construction projects large and small

As you might guess, part of my approach when I’m doing onsite client work is to review the process for managing construction projects, inclusive of the risk assessment process (infection control, life safety). To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas. And with the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.

One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks. For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).

Similarly, if you remove the suspended ceiling in a project area, you have impaired the smoke detection/sprinkler protection in the area. Now it may be that the impairment is sufficiently minor in nature to not require implementation of ILSMs, based on your policy, but you still have to indicate that such is the case. You can’t say there was no impact or impairment, because the condition you have represents an impairment and so, there’s got to be some level of impact.

I think perhaps the way to look at this is much in the vain of our emergency management Hazard Vulnerability Analysis (HVA) process. There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible (and I do see pre-construction risk assessments that seem to be aimed at a de minimis implementation strategy). But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your “packaging” is a little tidier than it was previously.

As a final note on this subject, I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be. You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations (yeah, I know there’s no rule that says you have to, so chalk this up to a best practice invocation), so better to have visible postings.

Please let me close things out with best wishes for a joyous and restful (Can you combine those two? I think you can!) Thanksgiving to you and your families. 2018 whipped along at a pretty good clip and I suspect that the holidays will launch us into 2019 before too long, so take a few deep breaths and enjoy the day.

I may not be perfect, but I’m perfect for you: CMS rates the accreditation organizations!

Another mixed bag of stuff for you this week, leading off with a quick spin through CMS’ report card to Congress.

While the numbers have shifted around a little, infection control is making a move on the outside, but the physical environment is still the big point of focus, though you can see where the two are starting to cross over at a greater frequency. I think issues relating to ligature risks are going to be a very sharp focus, particularly with CMS surveys. Although it is interesting to note that (at least at the moment) when ligature risks come up in the CMS survey process, those risks have been cited under the Patient Rights Condition of Participation (each patient has a right to receive care in a safe setting), so we may see Patient Rights at the top of the heap next year. One way you can avoid that little dance of ignominy is to make sure that you have completed a comprehensive ligature risk assessment in those areas in which you are managing behavioral health patients, including mitigation strategies for items that cannot be immediately corrected and solid anticipated completion dates. They are taking ligature risks very seriously because of the potential for harm to patients and you don’t want to have a whole lot of open-ended plans of correction. It almost comes down to a sense that everything that exists is a potential risk to be managed and while I am hopeful that cooler heads will prevail, right now this is a very, very hot topic.

One other thing to note with the report card is a section that deals with an analysis of survey disparity relating to Life Safety Code® compliance and health and safety considerations. I’ve looked at the contents of this section, including their conclusions and recommendations, and I have a hard time thinking that this is ever going to go away as a survey focus. While I tend not to rely on absolutes when it comes to periods of time, I can say quite confidently that there will always be stuff to find during a survey. You can look today and find stuff, you can look tomorrow and find different stuff, you can look the day after and—you guessed it! Stuff happens; people do stuff we don’t want them to, including unauthorized field modifications. The list is literally and figuratively endless. I know they have to find something, but as a collective, I think most hospitals are very well maintained and managed as a function of the physical environment. But if the big “C” knocks on the door (and I guess we have to include the minions as well), there’s going to be a list of stuff. Our job is to keep that list to a minimum. Good luck with that!

Everybody here comes from somewhere: Leveling the post-survey field

Well, if the numbers published in the September Perspectives are any indication, a lot of folks are going to be working through the post-survey Evidence of Standards Compliance process, so I thought I would take a few moments to let you know what has changed since the last time (if ever—perhaps your last survey was a clean one) you may have embarked upon the process.

So, what used to be a (relatively) simple accounting of Who (is ultimately responsible for the corrective action), What (actions were taken to correct the findings), When (each of the applicable actions were taken), and How (compliance is going to be sustained) has now morphed into a somewhat more involved:

  • Assigning Accountability (for corrective actions and sustained compliance)
  • Assigning Accountability – Leadership Involvement (this is for those especially painful findings in the dark orange and red boxes in the SAFER matrix – again, corrective actions and sustained compliance)
  • Correcting the Non-Compliance – Preventive Analysis (again, this is for those big-ticket findings – the expectation is that there will be analysis of the findings/conditions cited to ensure that the underlying causative factors were addressed along with the correction of the findings)
  • Correcting the Non-Compliance (basically, this mashes together the What and When from the old regimen)
  • And last, but by no means least, Ensuring Sustained Compliance

This last bit is a multifocal outline of how ongoing compliance will be monitored, how often the monitoring activities will occur (don’t over-promise on those frequencies, boys and girls; keep it real and operationally possible), what data is going to be collected from the monitoring process, and, to whom and how often, that data is going to be reported.

Now, I “get” the whole sustaining correction “thing,” but I’ve worked in healthcare long enough to recognize that, while our goal may be perfection in all things, perfection tends not to exist within our various spheres of influence. And I know lots of folks feel rather more inadequate than not when they look at the list of findings at the end of survey (really, any survey—internal, external—there’s always lots to find), which I don’t think brings a ton of value to the process. Gee thanks, Mr. Surveyor, for pointing out that one sprinkler head with dust on it; gee thanks, Ms. Surveyor, for pointing out that missing eyewash check. I believe and take very seriously our charge to ensure that we are facilitating an appropriate physical environment for care, treatment, and services to be provided to patients in the safest possible manner. If I recall, the standards-based expectation refers to minimize or eliminate, and I can’t help thinking that minimization (which clearly doesn’t equal elimination).

Ah, I guess that’s just getting a little too whiny, but I think you see what I’m saying. At any rate, be prepared to provide a more in-depth accounting of the post-survey process than has been the case in the past.

The other piece of the post-survey picture is the correction of those Life Safety Code® deficiencies or ligature risk items that cannot be corrected within 60 days; the TJC portal for each organization, inclusive of the Statement of Conditions section, has a lot of information/instruction regarding how those processes unfold after the survey. While I know you can’t submit anything until you’ve been well and truly cited for it during survey, I think it would be a really good thing to hop on the old extranet site and check out what questions you need to consider, etc., if you have to engage a long-term corrective action or two. While in some ways it is not as daunting as it first seems, there is an expectation for a very (and I do mean very, very) thorough accounting of the corrective actions, timelines, etc., and I think it a far better strategy to at least eyeball the stuff (while familiarity is said to breed contempt, it also breeds understanding) before you’re embroiled in the survey process for real.