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Is there anybody out there?

I’ve yapped away here for a couple of months now. The warmth of the summer has faded, up here in the Northeast the vivid hues of autumn have also faded, and there are way more leaves on the ground than there are in the trees.


We’ve gone from a fair amount of certainty relative to all things safety to a pretty much wide open expanse of hope, denial, angst, expectation, questions, and answers. Our relatively calm little pool has been whipped into a froth of the unknown. So how are you going to spend the holidays?


When we started this little blogopoly (the spirit of M. Colbert lives), the intent was always to foment (or ferment–sometimes the vernacular gets a little fruity) a conversation for which I would periodically pitch some bon mots to keep the conversation going.


I have heard from some of you (keep those cards and letters coming), but it’s time to see if we can draw some folks a little more out into the light of the blogosphere.


Earlier this month during an audioconference about the known Joint Commission EC changes afoot, we asked folks what they thought their most challenging issues would be in 2008. Now it’s your turn.


What’s turning what little hair you have left to gray? What makes you linger almost lovingly in the antacid section of the big-box warehouse store?


See that little “Comments” link below my post? Click and register, and then you’ll be set up to post your thoughts to my query or any other topic I write about. It’s time to stand up and be counted, heard, and recognized. We want this space to be yours, too.


Let’s get ready to grumble!

Temporary partitions, permanent expectations

Watch your temporary partitions during construction and renovation. Make sure the contractor understands the expectations, such as:

  • “Smoke-tight” means, for all intents and purposes, no holes
  • “Debris removal” means removing the debris, not piling it up until it’s in the way

Yes, I know that there are allowable gaps in certain circumstances, but do you want to split hairs with the construction folks over stuff like that? Me neither!

ILSM approaches should change with project phases

My experience has been that sometimes activities that result in Life Safety Code problems have an ebb and flow to them. As a broad example, how you ensure safety during a demolition phase is different (maybe not substantially different, but different) than what you do during a construction phase, which can be different than what you would do when the project is finishing up.

When you do the assessment for a project of a fairly lengthy duration (and no, I’m not going to tell you how long that is–you have to figure it out), phase your ILSM plan. Maybe you start with additional fire drills throughout the house and maybe finish with drills in the immediate area.

Or maybe you can change the “arc” of your surveillance round process: Start out with daily (or even more frequently during demolition) and maybe end with weekly. The language of EC.5.50 provides all the opportunity you need to make these determinations for yourself, so take full advantage.

EC standard conspiracy or coincidence?

Just when I’ve memorized all the EC numbers, The Joint Commission proposes to change them in 2009.

Evidence of a vast regulatory conspiracy or merely coincidence? You decide.

Don’t get tied down with event-specific emergency management plans

You will find surveyors who look for specific emergency response plans for each of your vulnerabilities identified in the HVA, which is not really a standards-based requirement.

That’s not to say there wouldn’t be a certain benefit to having some event-specific response plans–there are, after all, standards-based requirements for having specific plans relating to utility systems disruptions and medical equipment failures.

Only develop emergency response plans for specific events in a manner that makes sense to the organization. For instance, those hospitals in the northern half of the country probably don’t have to do a ton of planning relative to winter weather. Do you really need to have a documented policy or procedure to deal with a snow storm? I’d be inclined to think not.

As with just about anything in the EC that doesn’t involve specific requirements, what you do (or choose not to do) should be based on your risk assessment and then discussion at your safety committee or disaster planning committee.

The Joint Commission expects you to:

  1. Look at the risks involved
  2. Identify strategies for appropriately managing those risks
  3. Implement those strategies
  4. Monitor performance to make sure that everything turns out as you thought it would

When The Joint Commission reconfigured the emergency management standards, it moved towards a performance improvement model. I think we’ll see more of that kind of thing as the commission rolls out future standards revisions.

Bush veto delays TB fit-testing

Our colleague David LaHoda was good enough to point out on Tuesday afternoon an AHA News Now report that indicated President Bush had vetoed a fiscal year 2008 budget for labor and health and human services.

It’s within this proposed budget that the OSHA annual fit-testing provision for tuberculosis exposure resides. As it stands now, the proposal would allow OSHA to enforce annual respirator fit-testing for TB, which Congress has disallowed for several years.

The veto probably just delays the inevitable when it comes to fit-testing, but for now, OSHA still can’t enforce annual fit-tests for TB respirators.


Scott Wallask

EC standards are grounded in regulation, albeit sub-rosa at times

When it comes to looking beneath the surface of an EC standard, I think we can stipulate that anything approaching a specific requirement is grounded somewhere in a code or regulation (e.g., NFPA, OSHA, EPA, etc.).

While it would certainly be nice to see the code reference right there in a given EC standard (sometimes it is, sometimes it ain’t), it defaults to us, as professionals, to make sure we understand the intricacies of compliance.

The Joint Commission’s building maintenance program may change in 2009

Hi everyone — It’s Scott Wallask over at HCPro.

Well, it looks like The Joint Commission’s building maintenance program-long heralded as a useful tool for facilities to use in complying with certain life safety maintenance requirements-may become less prominent in 2009.

However, don’t expect The Joint Commission to let up on fire equipment inspection, testing, and maintenance, which has proven to be a heavily reviewed area by the accreditor’s life safety surveyors.

The BMP’s scoring advantages that facilities enjoy today may not stay in effect in proposed new life safety standards for 2009, consultant William Koffel told us this week. Koffel–owner of Koffel Associates, Inc., in Elkridge, MD–is familiar with the proposed standards, which will likely fall into a new life safety chapter in the Comprehensive Accreditation Manual for Hospitals.

The proposed revisions may undergo field review by the end of the year, according to The Joint Commission. Full details on how the revisions affect the future of the BMP will come out during the field review, Koffel said.

The new chapter will include standards for the electronic Statement of Conditions, life safety assessmsents, and managing the Life Safety Code, according to The Joint Commission. There will also be scoring changes.

As of Wednesday afternoon, The Joint Commission had not returned a request for further comment.

Watch for further details in upcoming issues of Healthcare Life Safety Compliance.

Please post comments to us if you have any thoughts.

When a Joint Commission EP goes “ghost”

Suppose we have a pre-Nixon-era building in which we have not yet introduced emergency power into the patient rooms (no recent renovations of significance, etc.), but we do have emergency power outside each of the rooms.

The area complies with EC.7.20, EP #11 (providing emergency power for areas where electrically powered life-support equipment is used) because patients in this location don’t require ventilators and the usual run of life-support type equipment. If we had to provide emergency care, the defibrillator is plugged into emergency power out in the hall and, if really pressed, we could run an extension cord on a temporary basis into the room until the patient was stable enough for transport.

I mean, after all, we do have emergency power in this area “where electrically powered life-support equipment is used,” according to EP #11, so we-re on solid ground here–yes? Also, we’ve identified as a PFI plans to address this improvement opportunity, so again, we seem good to go.

Ah, not so fast grasshopper! It appears that, from a compliance standpoint, EP #11 is a veritable onion of a standard, with several layers of requirements that come into play.

Note EC chapter references to the American Institute of Architects’ Guidelines for Design and Construction of Hospitals and HealthCare Facilities (2001 edition) and NFPA 99, Standard For Healthcare Facilities (1999 edition).

Both of these august tracts reference a section of NFPA 70, National Electric Code, that requires hospitals to provide one duplex emergency power outlet per bed, connected to the critical branch of the emergency power distribution system, in general care patient rooms.

You might argue that when this building was constructed, these codes referenced above weren’t in effect, and you would be correct. But in a similar real-life case that I’m familiar with, an intrepid Joint Commission surveyor did not quite see it that way, resulting in an RFI under EC.7.20.

It took several back and forths with The Joint Commission before the determination was made that we had been in compliance with the EP as it was written in the standards, but the underlying NFPA 70 requirements had “caused” the noncompliance. Further relief came as the result of grandfathering this area’s configuration due to it not having been updated, since adoption of the applicable codes came long after the condition had been established.

So, the take-home lesson? It is in your best interest to use The Joint Commission’s clarification process and always:

  • Look at what the surveyor has identified as the issue
  • Lock at which EP is cited as the result of that identification
  • Keep at it until you get relief

When a survey ends and you have any number of RFIs, start the clarification process as quickly as possible. Work with your organization’s survey coordinator, your Joint Commission account representative, even engage the assistance of a consultant–the important thing is to leave no stone unturned.

The last thing you want to have to do is to fix something that is not broken. In the long run, you have enough other things that legitimately require your attention.

You can post comments to Mac’s blog now

Hi folks —

It’s Scott Wallask checking in. I just wanted to let all of you know that the “comments” function is finally up and running for Mac’s Safety Space.

To post a comment, you need to log in as a subscriber or trial user to the Hospital Safety Center, though anyone can read the comments without logging in.

Please let us know what you think of Mac’s postings by submitting a comment or share your experiences on a particular topic.


Scott W.