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In 2011, set another place at the table

At the recent Joint Commission Executive Briefings Session held in New York, an announcement was made that will  infinitely increase the complexity of the Joint Commission survey process for all safety folks. And what, you might ask, is that? Beginning in 2011 (presumably January, but I don’t know that for certain), everybody within the sound of my voice and the sight of my words will be have a Life Safety Code surveyor in their facility for (at least) an additional day during a “triennial” survey.  If you had one day last time, now it’ll be two. Two last time, now it’ll be three for you, my friend. And so on.

The fact of the matter is that the data being collected during the survey process (four out of the top five most frequently cited standards are EC/LS related) demonstrates that we (collectively) are not doing a very good job when it comes to compliance with the standards, particularly when it comes to those pesky (and I use that term quite hyperbolically) Life Safety Code deficiencies. And, I have no reason to think that this is going to go away until there is a marked improvement in findings.


A balancing act – no nets, no problem!

I’m sure you’ve all been discussing the shooting that happened last week at Johns Hopkins, as I have. I don’t know that this changes the landscape all that much – we know this threat exists, and we know that there is only so much preventative medicine that we can employ without turning our facilities into armed camps.

At this point, I am not familiar with a lot of specific detail – sometimes a person’s parent can be the focus of a lot of ill feelings, and sometimes those feelings will prompt an action far in excess of normal behavior. That being said, I trust that you are all establishing a means of continuously identifying workplace violence risks, and establishing response plans with municipal law enforcement.


Meeting emergency management standards with escalating drill scenerios

Joint Commission standard EM 03.01.03 requires that healthcare facility conduct two drills to test their emergency preparedness plan twice a year. If an incident occurs in your facility (such as a fire) you can use that as an exercise, but some struggle to conduct their second drill involving and escalating event (for example, one particular person emailed me indicating that there aren’t many escalating events that could happen in rural western Maine). [more]

Can doors be propped open with a wedge?

Q: If we have doors to staff offices and staff kitchen that have an auto-closure device, but are not ‘fire doors’, is it allowed to prop them open with a wedge?

A: The answer to your question (unfortunately) is “it depends”, though I can tell you, as a general rule of thumb, there are no regulatory surveyors who are going to give you a big thumbs up for propping doors open.

The “problem” is that the Life Safety Code® requires existing corridor partitions to be fire-rated for 1/2 hour (the doors you describe sound an awful lot like they would be considered corridor doors) and doors required to be fire rated have to have self or automatic closing devices, which means propping them open is on the excluded list.

My best advice would be to work with the local fire department to determine whether or not there are considerations that can be made. Sometimes office doors with closers can be disabled so long as the door is only open when the space is occupied (somebody has to be there to close it if the fire alarm goes off). Staff kitchens are probably less likely to be able to go that route, but perhaps they can be tied into the fire alarm system through the use of magnetic hold-back devices that release upon activation of the fire alarm. Ultimately, this is one topic that’s going to have to be “negotiated” on a case by case basis (there are very few Life Safety issue for which “blanket” fixes will apply).

Implementing workplace violence policies

Howdy, safety profs!

I’ve received a number of inquiries lately looking for workplace violence policies. I figured if a few might have questions, then that’s enough indication to me that there may be some other folks as well looking for these elusive policies.

With all that said, to be honest, I don’t know that I would advise pursuing policy development. It’s more than likely that any policies you would need to support the management of risks associated with workplace violence are already in existence. The key to compliance is to follow the risk assessment recommendations in the SEA and, for all intents and purposes, conduct a gap analysis based on the elements identified in the SEA.


Will surveyors require an MSDS for Wite-Out?

I recently received a fairly common question with a slight twist to it. Many people wonder if common household items such as Wite-Out® need to have a material safety data sheet (MSDS) on file. Although OSHA doesn’t require an MSDS in this case, this particular person said that a Joint Commission surveyor indicated otherwise.

This is not only interesting from an empirical standpoint, it is also interesting from a pure standards-compliance standpoint. The surveyor that indicated that The Joint Commission requires a MSDS for such products was completely and utterly incorrect in that assertion. TJC is not in the business of increasing the scope of federal regulations, and has not, in fact, done so in this or any other similar finding. [more]

Determining what is considered life safety sustaining equipment

Q: I was wondering if you had a list of what should be and/or could be considered life safety sustaining equipment (i.e. ventilators/cardiac defibrillators). Is this specifically described by each organization or are there certain pieces of equipment that automatically fall into this category?

A: This is a very subjective undertaking and, consequently, brings with it a great deal of variability. The “defining” characteristic of a life support piece of medical equipment is that if it fails, it could have a direct impact on someone’s life. Ventilators and defibrillators are likely candidates, as are anesthesia machines, dialysis machines, certain infant monitoring equipment (for instance, apnea monitors), electrosurgical devices, etc. While these could loosely be described as frequent flyers on the life support list, sometime the utilization of the devices or the types of procedures they’re being used in can alter the final determination, which is (almost) completely up to the organization. [more]

“Means of egress” remains as a top Joint Commission citation

The Joint Commission released statistics this week on standards compliance through the first six months of 2010, listing the top five Joint Commission requirements that were most frequently identified as “not compliant.”

Hospital safety standards (including EC and LS) littered the top five for both critical access hospitals and the hospital setting (read Steve Mac’s reaction here).

So, it’s probably no surprise to any of you that LS.02.01.20 – in which hospitals are required to maintain the integrity of the means of egress –  made it’s way onto that list (fourth  among critical access hospitals, with 33% non-compliance, and second among hospitals, with 50% non-compliance). This has been a constant struggle for facilities, especially when safety officers are contending with tighter budgets and less storage space. [more]

The song remains the same – will it ever stop?

In the August 18, 2010 edition of Joint Commission Online (if you don’t subscribe already, click here to see the whole wretched mess), The Joint Commission lists requirements that were most frequently identified as “not compliant” in each healthcare setting, and if there is any surprise at all, it’s that EC/LS didn’t manage to sweep the top compliance headaches among hospitals (maintenance of complete and accurate medical records for patients took the #1 spot).

One particularly disheartening piece of information is that we (and I mean that in the most inclusive sense possible) haven’t quite gotten our arms around the documentation requirements for EC.02.03.05. Unfortunately, there’s no way to know at this point whether there is a particular EP(s) that is causing this breakdown or whether it is indeed spread over the continuum. (If anyone out there was cited under this standard during 2010, please share your story about what got you into hot water during survey).

I personally don’t like being able to pinpoint the vulnerabilities on this one. Is it something as simple as that ever-funky question of whether or not you need to have an inventory, by location, of your fire alarm devices? Or is it something else – a couple of missed monthly fire extinguisher checks perhaps? Inquiring minds want to know. [more]

Computerized work orders as records

While reviewing weekly fire pump test reports for a client recently, I came across a problem that I have seen before. This client relies on their new computerized maintenance management system (CMMS) to document that the fire pump is tested each week. The CMMS spits out a preventative maintenance (PM) work order each Monday, and the maintenance technician assigned to do this task goes about his job and completes the weekly test as specified. He turns in his signed and dated work order to the data entry person to have it completed in the CMMS.

However, this is where the problem begins. The data entry person may not get around to closing out the PM work order right away, and if it rolls over to the next week, he/she may enter the completion date incorrectly. On many CMMS programs, if you do not enter the actually completion date when closing a PM, it will default to the current date as the completion date. When a list of weekly tasks is generated, it could very well show that two or more weekly tests were completed in a single week, and some weeks did not have a test at all. [more]