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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.

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.