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Things that go bump (or don’t) in your egress stairwells

There has been a little increase in findings relative to various items (utility system components, security cameras, evacuation devices) being located in egress stairwells. NFPA 101-2000 Life Safety Code (e) gets pretty specific about what you can have in terms of penetrations into and openings through an exit enclosure assembly:

(1) Electrical conduit serving the stairway

(2) Required exit doors

(3) Ductwork and equipment necessary for independent stair pressurization

(4) Water or steam piping necessary for the heating or cooling of the exit enclosure

(5) Sprinkler piping

(6) Standpipes

This means, strictly speaking, that things like security cameras, water lines, phone/radio system repeaters, electrical conduit that does not serve the stairwell, etc. are pretty much off the table, particularly if they have been installed after March, 2003 (the official dividing line between new and existing construction).

There is an exception for existing penetrations as long as they are appropriately protected (firestopping, etc.), but if you’ve got newer than ’03 stuff in your egress stairwells, you may have some work ahead to square things away (I’d start with a conversation with either your state AHJ or maybe the engineers at TJC).

Keeping things cool in the hot lab

In reviewing “stuff” from the past few months (September and October were pretty busy on the regulatory front), I wanted to mention (in case this hadn’t crossed your path) the Government Accountability Office’s (GAO) report on the security of radioactive materials in hospitals as a function of the Nuclear Regulatory Commission’s (NRC) existing requirements. The GAO found the NRC requirements to be somewhat lacking, based on a sample of 26 hospitals and medical facilities.

According to the highlights of the report (you can find the whole megillah at:, the NRC did not agree or disagree with the findings of the report, feeling that existing security requirements are adequate. Some of the security lapses found during the GAO survey were such items as unsecured medical equipment containing radioactive material, unescorted access to radiological sources, even (darn it!) numerical keypad lock combinations inscribed on door frames.

Now I will tell you that this is all stuff I’ve encountered periodically during my consulting life (a boss of mine once told me “you can’t mandate intelligence”; then Ron White distilled that into “you can’t fix stupid”) and I will also tell you that sometimes all you can do is shake your head about this stuff. That said, I have no reason to think that the good folks at The Joint Commission (or indeed anybody else with a horse in the regulatory survey derby) are not abundantly aware of this report and it’s contents. So what follows is purely consultative in nature:

Read the report, look at the recommendations, perform a gap analysis at your facility, identify any improvement opportunities, present the risk assessment to your EOC committee and move forward. You may want to consider identifying the necessity for recurring review (which, natch, you should be doing as a function of your annual evaluation of the security management program), if you think you might lose track of this, but I think this should cover things quite nicely.

For those of you go-getters who’ve already run this race – what kind of stuff did you find? Any suggestions for the rest of the classes? Inquiring minds want to know!

And who do you think gave you permission to do that, mister man?

One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).

For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.

Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.

So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).

To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.

Make a connection with me – A U T O-matic

This is a question for those of you who have fire pumps; more specifically, those of you who have fire pumps with automatic transfer switches: How are you documenting that the transfer switch for your fire pump is being tested on a monthly basis in accordance with regulatory standards?

In any number of organizations, one of the automatic transfer switches (ATS) that can get lost in the shuffle is the ATS for the fire pump, as it is frequently located with the fire pump, not with the rest of the transfer switches on the docket for monthly testing. I’ve encountered any number of organizations that have “missed” the monthly testing for the fire pump ATS for just that reason, so I think we can safely say ensuring compliance with the monthly testing requirement calls for a little more forethought and planning. And remember, as an “A” performance element, if you miss a single monthly testing of the fire pump automatic transfer switch, that “earns” you a Direct Impact Requirement For Improvement, something that neither you nor I want to have happen. Well, at least me – I hope you don’t want one of those – they’re wicked icky, so to speak.

At any rate, I’ve seen this one popping up in recent surveys, so if this is not a topic to which you’ve given much thought, it might not be a bad idea to do a little checking. You might find the answers to be more surprising than you’d prefer.

The migratory habits of restroom waste containers

Now I will be absolutely candid in telling you that there are some things that I pay attention to that are probably way beyond the pale when it comes to normalcy; I suspect that this is going to be one of those topics, but here goes.

In my travels, I observe a great many things and one of the things I follow most closely is the hand-washing habits of my fellow (male) travelers. One of my fondest wishes would be to have the power to surreptitiously identify those who do not wash their hands when completing their restroom activities–a silent but obvious j’accuse, if you will. And my conclusion is that way, way too many folks are not washing their hands enough, and in so doing (or not so doing), they are increasing the risk of infection to not only themselves, but the rest of us.

Now, I’ve ranted in the past about manually-activated faucets in combination with automatic hand dryers, and how the arrangement does not promote good hand hygiene (Yeah, I know you can use your elbow or some other appendage to turn off the faucet, but not all faucets are so easily turned off).

I want to have a paper towel to turn off the faucet, but even more importantly, I want a paper towel to be able to open the door– because I can’t trust that the people using the door before me washed their hands! As a corollary to that, I also like to have someplace to dispose of the paper towel once I’ve opened the door and I am very pleased to note that there is a marked improvement in the availability of waste containers right next to the door. As far as I’m concerned, it gives me hope (not a ton, but some) for humanity.

Now I know that there is a carbon footprint aspect to all this (and I try to be as green as I can be: as I write this, I’ve been lugging a trash bag full of recyclable plastic around New Mexico, hoping to find a recycling bin for plastic. I’m still looking.), but this may be one that we have to tolerate, at least for the time being. Viruses, etc. appear to be on the rise again, so I want to make sure that we all make it through this at least relatively unscathed. End of rant.

Before they make me run…

One topic upon which I’ve not weighed in is the proposed changes to The Joint Commission’s Emergency Management and Leadership standards to more clearly reflect the responsibility of organizational leadership to provide oversight of the Emergency Management function in both critical access hospitals and “regular” hospitals. (Details can be found here:

The proposed changes have been open for comment since late October, but the field review process (which can – and hopefully has/will – include your thoughts and comments, boys and girls) is coming to a close (December 4, 2012 is the cutoff date) and I didn’t want you folks to miss out on the opportunity to shape the future (that’s probably a wee bit hyperbolic, but that’s me).

Now, to be completely honest with you, I hadn’t really looked too closely at the suggested changes, as much because I think there’s likely to be pushback from some folks to “soften” the language in the Leadership chapter regarding the anointing of an individual to be the “emergency manager” (that’s my euphemism). And after what happened in NYC post-Sandy, this could end up being a very interesting conversation.

I can’t honestly say that I disagree empirically with anything they’re proposing;  they still seem convinced that hospital leaders will not take this stuff seriously (unless they are well and truly “on the hook”). I suspect that there’s going to be a lot of up-selling at individual hospitals that the changes mean that someone must be hired specifically to handle emergency management, which will, in turn, cause consternation among those in healthcare who count the beans, which will, in turn, result in TJC having to clarify what they mean.

But again, I don’t think that what they are suggesting is out in left field, or– to any great extent–unreasonable. I’ve been to any number of hospitals where the leadership oversight of the EM program is one “hat” among many, but not every healthcare organization is in the crosshairs of crazy levels of emergencies (part of me can’t escape the thought that Sandy, like Katrina, was an event above and beyond what they could normally expect to experience, based on past history), so there will always be some level of variability. In looking back at the last 18-24 months, we’ve had a lot of catastrophic events directly impacting hospitals. For whatever reason, hospitals had never really taken a direct hit from a tornado until last year; so, does what happened in Joplin last year change how you have to look at things, particularly in tornado country? Absolutely, but that’s how you have to manage risk – focus on what you know has happend/can happen, and then work on the rest of it as time permits.

At any rate, I would encourage any of you folks out there who have not taken advantage of the field review to weigh in and raise the conversation to an ever-more-thoughtful level. You folks, as I like to say, are living the dream– and your stories/challenges are invaluable to this process. Make yourselves heard, lads and lassies, make yourselves heard!

I ain’t missing you (are you sure about that?)

As much as I had hoped for a reduction in findings relative to EC.02.03.05 (maintaining fire safety equipment and fire safety building features), that hope is being dashed on the rocks of reality. And once again, it appears that a lot of it has to do with the quality of the documentation provided to us by our fire alarm and sprinkler testing vendors.

Where this has been cropping up most recently is in the realm of ensuring that each of the applicable devices is tested in absolute accordance with the requirements for frequency. For example (this from a recent survey), if you have your vendors doing 25% of your inventory each quarter (for the devices that need to be tested annually), then you need to make sure that the number of devices tested in the 1st quarter of last year matches up with the number if devices tested in the 1st quarter of this year, or you need to have a very clear understanding of why the numbers don’t match up. Maybe you installed and/or removed devices from service; maybe there are devices that they could get to in one quarter and couldn’t in the subsequent (more on this in a moment).

Ultimately, we need to make sure that each of the devices in our inventory is being tested at the appropriate frequency. A question for those of you who have your fire alarm testing done on a once-a-year schedule: If a device can’t be tested during the regularly-scheduled activity– say, for instance, a patient room is occupied and the smoke detector can’t be tested– how are you making sure that that device doesn’t fall out of the testing loop?

I know it’s just a single device, but if it’s in a place that’s tough to get to, the next thing you know, you’ve got a couple of years passing without that device being tested… and it becomes low-hanging fruit for a diligent surveyor. I’m just saying…

Temper Temper(ature)

In the continuing pursuit of every possible question that could ever be asked about eyewash stations, there’s been some chatter recently (as well as some field encounters) relative to what is involved with the weekly operational testing of emergency eyewash equipment, particularly whether or not you have to verify the temperature of the flushing fluid. The “good” news is that while there is a requirement to periodically verify the temperature of the flushing liquid, that period is one that is some 52 weeks in length, so we can put that down for an annual visitation. Having said that, I’m thinking this might be a fine opportunity to cover the basic goals of the weekly test (I find there is frequently a bit of a gap in terms of front-line staff’s understanding of the reasons behind the testing).

Let’s start with the ANSI standard. The intent of the weekly activation from the ANSI perspective is to ensure that there is a flushing fluid supply at the head of the device and to clear the supply line of any sediment buildup that could interfere with flow (that’s why you do the test with the caps on – if the pressure isn’t sufficient to “pop” the caps, then there may be some blockage). Running the water also helps to minimize any contamination due to stagnant water.

Another common question is, “How long should I run the water?” The answer is “It depends.” I think we’ve discussed this before, but once more unto the breach: You have to consider the amount of water contained in the eyewash itself, and the water which is in all the sections of piping that do not form part of a constant circulation (a “dead leg” in the plumbing, as it were). Since water tends to be stagnant in these sections until a flow is activated, you need to run the device long enough to flush out all the stagnant water. This may take a little bit of figuring, but once you’ve figured out the time period, you should be good to go.

You also want to make sure that the eyewash equipment is completely accessible, the protective caps are in place, and someone hasn’t installed a cabinet over the device close enough to result in a head injury if someone tries to use the eyewash (don’t laugh – I’ve whacked my head more than once trying to fit my noggin into a confined eyewash. Yes, I realize that head trauma probably explains a lot, but that is an entirely different topic of conversation). Ultimately, it’s about making sure that if someone gets some bad stuff in their eyes, they have an appropriate means of responding to that exposure. Hopefully, it’s not something we need to use very often, but if we have the eyewash stations, we have to properly maintain them.

96 Tears – 96 Hours – 96 Response Plans – You’re gonna cry – cry, cry, cry!

I was doing some work at a client facility recently and happened to be on site when these folks were entertaining the representative from their property insurer. While there was lots of discussion about processes for managing fire alarm and sprinkler system impairments (might be worth checking with your property insurer for their definition of an impairment – might be a little more restrictive than you might think, especially if you are using the 4-hour timeframe identified in the Life Safety Code / TJC standards), which I expected, there was a little more attention paid to emergency response plans, particularly in relation to utility systems failures, primarily as a function of business continuity.

The rep was really keen to see the organization’s detailed response plans for the normally-anticipated failures and it prompted the thought that, in these days of the (at least somewhat) monolithic 96-hour assessment/response plan dynamic, whether we’re best served by having really in-depth, specific response plans, or if we’re better off with what amounts to a bullet list of strategies for managing the risks and vulnerabilities inherent in a particular failure event. So my question to you is this: How “deep” do your response plans go? Are we talking lots of details or is it more or less a response framework that requires a little more intuition/familiarity on the part of your incident commander?

I know that the structure and content of response plans have evolved (mutated?) over the past 10 years or so, but I’d be hard pressed to be able to quantify the improvements (I’m certain that there have been improvements – but I can’t say how I “know” this). Or, in the vernacular of this year’s presidential race, if we are better off than we were 10 years ago – how can we “prove” that improvement?

What say you?

How long has this been going on?

We’re rounding the turn and headed for home – no squeeze play at the plate this time…I hope!

EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems (#16, with 24% of hospitals having been cited)

It seems to me that we’ve discussed this in the past as well, but it appears that, in this survey year, everything bears repeating.

Anything that your medical gas and vacuum testing activities generate as deficiencies/recommendations/hints from Heloise/etc. needs to be accounted for somehow. Maybe your medical air intake is right next to an isolation exhaust, or it’s nothing more than a leaky outlet, or the issue is non-compliant construction (a favorite is the medical gas zone shutoff valve in the PACU with no intervening wall) that can wait until you do a remodel/renovation project. Whatever it is, you need to say, “This is what we’re doing about that, based on our assessment of the involved risks.” And don’t wait to get ahead of the curve on the fixes: As soon as the activity is completed you are on the hook for the fixes, so you need to know what’s on that list even before you get the pretty report. The clock starts ticking upon identification of the condition, so if you have to wait a month or 45 days for the report, you (and more importantly, your patients) are at some level of risk.

The other thing to do is make sure that your vendor is not using this process to drum up work; I can’t tell you how many times I look at multiple years of testing documentation and find the same “deficiency” over and over again – and then find out, well, it’s not really a deficiency at all. You will get slapped during a survey for this – if it’s a critical fix, then fix it, if it’s not a critical fix, then dot the “I’s” and cross the “t’s” and make sure they are accounted for.

Another component of this is obstructed access to zone shutoff valves, as well as making sure that the labeling of valves is accurate (areas served, contents of piping – labels have to be accurate, accurate, accurate). Also, make sure that what you are calling the area of coverage is in some sort of accordance with what the staff calls the area. I can’t tell you how many times that I’ve seen zone valves labeled in accordance with the architectural drawings and find out that front line staff really doesn’t know which areas are served by the valves. Knowledge is very powerful, and certain knowledge is an invaluable commodity during surveys.

EC.02.05.07 – Inspection, testing and maintenance of emergency power systems (#17, with 23% of hospitals having been cited)

Emergency generators and automatic transfer switches have to be tested in accordance with the requirements of EC.02.05.07 – if you need me to tell you what those are at this point, you may be in the wrong line of work. However, I am more than happy to answer any questions you might have regarding this most important subject. 30%, 30 minutes, no closer than 20, no greater than 40 between tests, run it for 4 hours at a minimum 30% load every 36 months – these are a few of my favorite things.

EC.02.03.01 – Management of fire risks (#20, with 19% of hospitals having been cited)

Breathing a sigh of relief, we’re near the end of our little journey through time and (interstitial) space.

This is another of those findings that it becomes a question of how far one must look before one can encounter enough deficiencies to drive an RFI (the answer in this case being 2). The question I have for you is this – how many junction boxes do you have in your facility. 100? 1,000? 10,000? So, the follow-up question is: How many would an individual (say, a Joint Commission Life Safety surveyor) have to look at before they found two that didn’t have a cover? There are so many opportunities to drop the ball on this one – mechanical spaces, comms closets (it’s very rare that I find an open j-box in an electrical closet – but not impossible). You know they’re going to look above the ceiling – and they’re not just looking for penetrations – and cabling on sprinkler piping – and, and…

You need to enlist the efforts of everyone who does work above the ceiling in your facility; they don’t necessarily have to fix it, but if you know where it is, then you have a shot at being able to address it before it gets ID’d during a survey. The proactive approach works unbelievably well for stuff like this.

And on the horizon looms the specter of a return to focus for the prevention of surgical fires – including the participation of physicians. Too many (and my stance is that one surgical fire is too many) surgical fires occur for my (or anyone’s) liking, so it’s time to kick this process into high gear. I know they’re busy, and may not always seem to be the most cooperative bunch on the planet, but this I see as a moral imperative (and it appears that TJC is similarly inclined – so if you won’t do it for me, do it for them). We can do a better job of educating folks about the risks of surgical fires – and so, we must do just that.

One other related thought is to make sure that you are appropriately managing amounts of compressed gas – don’t go over 12 e-cylinders in an unprotected area. And make sure that your gas storage rooms (for amounts greater than 300 cubic feet of gas) are appropriately fire-safe, etc.

This concludes our test of the emergency survey broadcasting system – this was only a test. We now return you to our regular programming, which is already in progress. If you have any questions or concerns about this or any other topic, you know where I am…