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Are the surveyors always correct?

In looking over various survey results from the past six months or so, I keep running into instances in which the surveyors either:

  • Over-interpreted a standard, usually in the form of requiring a process that is not specifically called for in the standard or,
  • On at least one occasion, the surveyor “ignored” (I use quotation fingers for this as I wouldn’t want to unjustly accuse anyone of ignorance) instructions given to them by The Joint Commission

A close review of the standards reveals a fairly limited number of prescriptive standards–including annual program evaluations, the frequencies for the various life safety equipment inspections, hazard surveillance rounds, and so on.

The rest of the elements o performance involve such matters as:

  • “The hospital ensures that a process exists . . .”
  • “The hospital controls access to and egress from . . .”
  • The all-purpose “The hospital identifies and implements ________ procedures”

Thus, it’s up to you, as the person designated by leadership to oversee safety, to decide what “ensures,” “controls,” and “identifies and implements” mean for your organization.

I have a number of sayings that, if truth be told, are probably as much clich

Welcome to the jungle…

I had planned on jumping right in on a favorite subject of mine (the infallibility of Joint Commission surveyors), but upon reflection it seemed a bit precipitous to leap without some words of introduction and maybe a quick look at the ol’ crystal consulting ball before we roll on the serious subjects.

That said, the first order of business ought to be the tenor this new forum is likely to take. While the subjects we will discuss are nothing but serious, please don’t mistake my lightness of tone for a lack of respect or a lack of understanding of how these things impact your every day lives.

I worked at an acute-care hospital in southeastern Massachusetts for some 23 years–starting out in environmental services and finishing my tenure as that organization’s safety officer. Since becoming a consultant six years ago, I’ve completed a number of interim staffing assignments at hospitals throughout the Northeast, in addition to the “regular” consultant-type assignments.

I know exactly the nature and intensity of the pains generated by day-to-day hospital safety operations (sometimes too exactly, but we’ll talk more about that on a slow news day).

I’m sure that over time this forum will evolve to one degree or another–hopefully with much participation from all of you. That said (and yes, I am absolutely aware that I use “that said” a lot, probably more than is necessary), if there’s something you guys would like to see covered in more depth, less depth, Johnny Deppth (alright, a cheap joke, but I couldn’t resist), then write to me. No topic is too obscure or too common to fall out of consideration.

So, bottom line–serious topics, somewhat irreverent responses and opinions, and rock-solid advice. This blog is your blog, this blog is my blog. Let’s make everything we can from it.

Trash containers in soiled utility rooms

There was a posting on Safety Talk recently about whether any regulations exist governing the size of trash containers in soiled utility rooms. In this particular case, the room had no trash chute, was one-hour-rated, and had sprinklers.

There are requirements in the Life Safety Code for this type of arrangement, based on, which sets size limits for soiled linen and trash containers.

However, also notes that facilities are exempt from these limits if containers are in hazardous areas protected by a one-hour fire barriers or sprinklers (see

So, in the Safety Talk poster’s situation, it appears that particular facility met the protection criteria for such a space.

On an unrelated note, please enjoy a most freewheeling 4th!

Beyond cell phones

I still hear a lot of discussion about whether to limit cell phone use within hospitals, but sometimes I think that cell phones are the least of our worries.

I still find that organizations haven’t really come to grips with the other communications technologies that are much more likely to result in electromagnetic interference–primarily two-way radios used by security officers, maintenance crews, etc.

Also, emergency response plans for communications system disruptions usually include provisions for a mix of cell phones and two-way radios as backups.

Now I’m not saying that’s a bad thing in and of itself, but you have to provide guidelines when staff members use these communication devices. Make sure all related policies and procedures are consistent in their application of any prohibitions, too.

New isolation guidelines are out

Don’t know if anyone else heard this yet, but maybe it’s of interest–the CDC released its updated isolation precautions guidelines, which you can view here:

One more thing about ratings of patient bedroom doors

Regarding my post yesterday about rated doors, perhaps a little clarification is in order. My note was aimed at exiting healthcare occupancies under Chapter 19 of the Life Safety Code.

In looking through the code for other occupancies for which this door requirement might be applicable in sleeping areas (e.g., dormitory/hotel, residential board and care), I could find no other mention.

Thanks to those who asked me about this.

Rating of patient bedroom doors

A colleague recently asked me whether patient bedroom doors should be 20-minute-rated-and the answer is yes, they should. But there are some qualifications on that answer, depending on sprinkler protection.

Under paragraph, the 2000 Life Safety Code requires doors protecting corridor openings to resist the passage of smoke and be constructed of the following:

  • 1 3/4-in. thick, solid-bonded core wood
  • Material that resists fire for at least 20 minutes

There are two exceptions to, though:

  • Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that don’t contain flammable or combustible materials don’t need to meet’s provisions
  • In smoke compartments protected by sprinklers, the door construction requirements of aren’t mandatory, but the doors must resist the passage of smoke