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Surprise, surprise, surprise

Just a few weeks ago I was involved with an unannounced survey by The Joint Commission (formerly JCAHO). I encountered one of those funny little happenstances that really isn’t that funny: a surveyor who expressed surprise when the data that he had recorded during the survey was sufficient to warrant a requirement for improvement (RFI) under EC.5.20.

For the record, I wasn’t surprised–and I don’t think it has anything to do with math skills.

Now for those of you who “believe” in the 95% rule based on the practical implementation of a building maintenance program (and especially to those who have disagreed with my interpretation of how the BMP gets surveyed), please consider this in the spirit of holiday giving. The following items added up to an RFI:

  • A single exit sign that the surveyor thought should be pointed in a different direction
  • A single smoke door with a gap greater than 1/8 inch and no astragal
  • A single penetration in a rated wall
  • A single location requiring fire-proofing of a steel beam

Oh, by the way, the exit sign, smoke door, and rated wall had all been repaired before the end of the survey.

Now I am very hopeful that these citations (with the possible exception of the beam) will be overturned on clarification. The folks in question have a solid BMP in place, but the numbers involved (1+1+1+1 = RFI) are important to keep in mind as you go through survey.

I’ve likened this, probably ad nauseum, to a death by a thousand cuts. But thing that really gets me: Do the surveyors really not understand how the scoring works? Was he really surprised at the RFI?

I know that the mark for just about any B or C element of performance is:

  • Zero to one instances of not meeting the EP means you fully comply
  • Two instances is generally partial compliance
  • Three or more instances is noncompliant

The above scoring is in effect during survey. Post-survey becomes a lesson in determining compliance percentages (90-100% for full, 80-89% for partial, and you know what happens when you go south of that point).

So where’s the surprise, especially with four instances of noncompliance under EC.5.20? Oy!

You need to do your presurvey assessments very carefully and keep a close eye on those mounting instances of noncompliance. All those supplementals of years past are living together in the land of the surprise RFI–and that’s one “foreign” land that doesn’t require a government-issue passport for entry.

It’s not 96 hours or bust for EC.4.12

Contrary to popular interpretation, EC.4.12, EP #6 does not require hospitals to be self-sustaining for 96 hours.

No, really!

There is a note following this EP that indicates an “acceptable response effort would be to temporarily close or evacuate the facility, consistent with their designated role in their community response plan.” And, interestingly enough, this is a “B” element of performance, so the burden of proof is on the organization to determine what they need to do to meet this EP.

So, what EP #6 does require is that each organization has some sense of how such an event (effectively being cut off from the outside world for 96 hours) would be managed. Some hospitals might be able to do a 96-hour solo standing on their heads, while others might struggle to do 24 hours.

One of the clear lessons learned during Katrina is that many (if not most) of the hospitals involved didn’t know that an “acceptable” part of their response plan would be to get out in the event that they could no longer safely care for patients. I think this is partially the result of the whole “defend-in-place” strategy that has always applied to hospitals from a fire and life safety perspective. I think somehow defend-in-place crossed over into the management of disasters and catastrophes.

It’s your turn to comment on the proposed life safety standards

Hi folks, it’s Scott Wallask up at HCPro logging in.

The Joint Commission opened its field review for the proposed life safety standards on Tuesday. You should check them out if you have the time. The final version of these standards will take effect in 2009.

I haven’t had a chance to talk to any of my sources or The Joint Commission (formerly JCAHO) yet, but here are some of my initial thoughts:

  • Currently, EC.5.20 (Life Safety Code compliance) has four EPs for hospitals. There are nine proposed life safety standards in the field review, with about 100 EPs. However, many of these EPs seem to stem from the current Part 3 of the Statement of Conditions, which makes me wonder whether Part 3 will simply fold into these new standards.
  • The Joint Commission indicates that there is a new process under development to ensure that scoring for all of these new EPs will not result in a sudden spike in bad accreditation decisions at hospitals.
  • As we first reported in early November, it does indeed appear on the surface that the building maintenance program’s scoring advantages have ceased in the proposed draft.
  • There are many specific references within the proposal to NFPA code requirements, which is helpful.

Let us know what you think by clicking the comments link below. I’ll be digging into this topic more in our newsletter, Healthcare Life Safety Compliance.

Thanks…Scott W.

In EC.1.10, a little can add up to a lot

Can inappropriate corridor storage be a requirement for improvement (RFI) all on its own? It can if it gets cited three times during a survey.

As noted in prior communiques, EC.1.10 has become quite the melting pot of survey torment. How do you like this for a trifecta:

  • Item X was stored in an exit hallway, which decreased the available width to less than 8 ft
  • Items Y and Z, which were not in use, were stored in exit hallways, which would possibly slow the evacuation of patients if required
  • Exit hallways are used to store devices other than the emergency cart

RFI? you ask. RFI, say I.

I always thought that this type of citation was rather more apropos of EC.5.20 and all things Life Safety Code. Such surveyor creativity–I am in awe!

ILSMs–your ticket to conditional accreditation

In reviewing recent survey findings, I’ve noted that surveyors (especially, but not limited to, the life safety specialists) have become very skilled at identifying exactly what elements of your ILSM policy were not implemented, making it almost impossible to get a favorable decision when seeking RFI clarification.

Your policy says “A,” but you didn’t do “A”–welcome to conditional accreditation.

The rest of your organization could be absolutely perfect in every other facet of the survey process, and you could still be in conditional accreditation because you got boxed into a corner on your ILSM policy. How unpleasant would that be?

And you get to have someone from The Joint Commission come back to resurvey you in six months or so, just to make sure that you’ve got everything under control. You’ve already waited the whole freakin’ year for them to come and now you have to wait for them to come again. That would be most stinky, don’t you think?

And so, to reflect briefly on compliance mantra:

  1. Do the right thing (and frequently common sense is a good indicator of the right thing)
  2. Do what you say (don’t shoot yourself in the foot with the policy gun)
  3. Say what you do (and please don’t make a policy that goes on and on and on and on–kind of like me)

Put it this way, if you have a policy that looks like it might be one of my blogs, you can probably simplify it a wee bit.

If you can get all those points covered in your practice, policy, procedure, and planning, your survey compliance is in better shape.

If your policy says you “must” use ILSMs, get out your highlighter

Now, you may be getting sick of hearing me talk about this, but I keep running into folks who are getting hammered during survey because their ILSM policy is so restrictive that they get cited for not following their own policy.

I happen to think, among Joint Commission (formerly JCAHO) survey indignities, that this is the greatest indignity of all.

We shouldn’t have to discuss the individual ILSM elements identified in EC.5.50. There are 11 of them–you know ’em, I know ’em–it’s all part of the firmament at this point. And there’s nothing that says you can’t come up with your own additional measures for your organization.

But you’ve just gotta have a policy, you’ve gotta include consideration of the effervescent 11 (I’m trying to come up with a sobriquet that will catch on), and then you have to follow your policy. It can be that your ILSM process is too prescriptive, which I continue to run into–sometimes before survey (I like it when that happens, big smile!), sometimes after survey (no smiles then, just wailing of souls and gnashing of teeth).

OK, right now, I want you to pull out your ILSM policy. That’s OK, I’ll wait . . .

Back? Good!

Now look at the first couple of paragraphs. At any point in the verbiage does your policy say that you “must” do anything? It does? Okay, so what is it that you must do?

If your policy says you must do anything other than to assess for the appropriate implementation of ILSMs, consider it a red flag. Regardless of the situation–construction, renovation, PFIs, any Life Safety Code issue–we assess and implement ILSMs as appropriate.

If your policy in any way speaks about mandatory implementation, then get out your yellow highlighter and earmark that language for extinction.

More on this next time. . . .

The Joint Commission doesn’t ban smoking

Smoking bans in hospitals have been a hot trend this year.

The Joint Commission (formerly JCAHO) has never required hospitals to outright prohibit smoking. While there is a clear expectation that a hospital manages smoking from a life safety and patient health standpoint, there are still instances in which patients can be allowed to smoke within the confines of the building (so long as the smoking area is environmentally separate, properly safe, meets relevant standards, etc.).

Certainly The Joint Commission doesn’t expect employees and visitors to be allowed to smoke inside the building (and I’ve seen some very interesting definitions of what constitutes “outside” and “inside”).

That said, smoking bans have generally been promulgated at the state or municipal level, in which case The Joint Commission would expect an organization to comply with applicable rules and regulations, etc.

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.