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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.

Examples of immediate threat to life and safety, Joint Commission style

In my last posting, I talked about when surveyors invoked an immediate threat to life and safety. Let’s take a stroll through the list of “threats” we’ve encountered during client surveys, shall we?

Consider these:

  • Lack of master alarms for medical gas systems
  • An unreliable fire pump
  • Inoperable fire alarm system
  • Fire doors throughout the facility not closing and latching
  • Penetrations in fire walls not sealed with a fire-rated material
  • Main circuit breaker not tested or maintained and raw sewage leaking from pipes in a crawl space beneath a hospital
  • Lack of procedures to identify and maintain fire protection (i.e., lack of an effective means to transmit a fire signal to an external point and the responsible person not knowledgeable on the use of the fire alarm system)
  • No means of exit in an emergency and lack of implementation of interim life safety measures

Do you see a pattern developing? Well, neither do I–just kidding. Some of these situations seem fairly straightforward, but thinking about the fire doors and penetrations (not to mention how one would define an “unreliable” fire pump), there does appear to be some room for surveyor interpretation. As they might say here in the Boston area, that’s a shockah!

I think if I had to give you a piece of advice, it would be to make sure that everyone on your team has a pretty good understanding of how EC issues interrelate and how your organization ensures that all of these working parts come together and result in the safest possible environment for patient, staff members, and visitors.

And staff members may need to articulate this when you’re not around (unless you’re planning on no vacations until the next survey–I know I’d be tired).

If your survey will be between now and the end of the year, then start preparing now. If your survey was last week, start now. If your survey won’t be until at least 2009, start now. This is one of those things that is not at all well-served by procrastination.

Are you threatening me? Do I look like I’m threatening you?

One of the more precipitous aspects of the survey process is the invocation of an immediate threat to health or safety. This would the moment of a survey in which your entire world turns into manure.

Hopefully, such a plight will never darken the hallowed halls of your organization, but there is some indication that this problem has been occurring more frequently of late, so it seemed a good opportunity to cast a little light into this shadowy corner of accreditation lore.

Basically, the ball starts rolling when surveyors believe that they have encountered a situation that has, or may potentially have, a serious effect on someone’s health or safety, and thus requires immediate action to remedy the condition.

The survey comes to a screeching halt, your CEO gets to hear the fabulous news, Joint Commission headquarters near Chicago gets a call, even “appropriate government authorities” are in the loop-it’s all just too lovely. Of course, the impact on your accreditation status can be swift and painful, too. I’ll take root canals for $1,000 please, Alex.

Then there are the things you have to do to get out from underneath this damnation:

  • Take immediate action to completely remedy the situation
  • Prepare a thorough and credible root cause analysis
  • Adopt systems changes that prevent future recurrence of the problem

There are a number of conditions I’ve heard about in the environment of care that have resulted in the invocation of an immediate threat to life and safety. I’ll get into them in my next posting.

Stay safe,

Steve Mac.

Elevator problems cause a scare at a Seattle hospital

Hi everyone –

It’s Scott Wallask checking in here at the Hospital Safety Center.

Those of you who use ISIS model elevators manufactured by ThyssenKrupp should read this story about a hospital that had an elevator failure in Seattle. Luckily, the elevator’s safety brakes worked and no one was injured.

ISIS models use Kevlar ropes that don’t require a machine room. In a letter available at the link above, ThyssenKrupp has outlined a series of actions it will take across the country in response to the hospital mishap.