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Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with Originally, this section of the LSC referenced which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.


I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

My heart is black and my lips are cold

Crash carts on flame with rock and roll!

I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.

On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!

Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…

As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.

So that’s the scoop for this week. I hope the new year is treating you well. See you next week!

A most excellent start…

Recently, the AORN Journal published an editorial penned by Kelly Putnam, the managing editor, highlighting the role nurses play in preventing surgical fires (see here for detail). The piece raises a lot of interesting points about some of the operational considerations that come into play when it comes to appropriately managing fire risks in the surgical environment. But what really caught my eye—and my imagination—was the conclusion, which goes a little something like this: “Perioperative nurses are integral to a team approach to fire safety. Nurses are responsible for performing preoperative risk assessments and informing other team members of the risks associated with each procedure, identifying potential fire hazards, helping to find system fixes that improve patient safety, and conveying the details of fire-related incidents to other stakeholders at the institution.”

Now those of you who’ve been following this space for a while will no doubt note the presence of one of my favorite (okay, pretty much #1 on the hit list) phrases: risk assessment. And not only does the risk assessment get a shout out, it’s within the framework of a team approach to managing fire safety in surgery. As I pondered this, I was thinking, wouldn’t it be cool if we could use this as a jumping off point for nursing involvement in a team approach to risk assessment that focuses on the management of the whole darn care environment? I’ve been yammering at just about every opportunity my “sense” that one of the desired end products of the current focus on the care environment by regulatory surveyors is the demolition of the “barrier” that exists (in smaller doses than formerly, to be sure, but not entirely gone) between the “clinical” and “non-clinical” functions of any healthcare organization. It is my firm belief that the organizations that will most effectively manage the survey process are those organizations that have developed a true collaboration of staff across the care continuum. In a very real sense, everyone in your organization is taking care of patients—directly or indirectly, everyone influences the “patient experience.” And at the end of the day (and yes, I recognize that the Urban Dictionary refers to that little turn of phrase as a “rubbish phrase used by many annoying people…”): CARING FOR THE PATIENT IS CARING FOR THE ENVIRONMENT!

Start printing up the t-shirts and bumper stickers…

Smoking is smoking is smoking is smoking

In the February 11, 2015 issue of Joint Commission Online, there’s an interesting piece recommending organizations review their smoking policies to ensure that the risks associated with electronic cigarettes are being properly managed. The primary risk identified in the article relates to the potential for fire events, including issues with rechargeable batteries, though it does touch on potential issues with the vapor/smoke generated by the devices (and I can tell you from a close-up encounter with the vapor cloud during a hospital visit, the smell is kind of noxious) and the importance of environmental separation (ventilation, etc.). As a final inclusion, the article reasserts (so to speak) that Joint Commission standards do not require hospitals to be smoke-free (allowing provisions for smoking in specific circumstances), so those of you who have gone that route (and may be experiencing a bit of a struggle—particularly if your community is not quite ready to embrace the smoke-free environment) may be interested in the brochure provided by The Joint Commission (you can find the brochure here). It certainly can’t hurt to check it out; and adopting it as a reference in your policy might be enough to dodge a finding during survey. I mean, come on, it’s all about best practices, n’est-ce pas?

Waivering my magic wand

Season’s Greetings to you all and please accept my very best wishes for a safe and fulfilling New Year.

And speaking of the holiday season (please excuse my tardiness on this one—probably should have come up with this before Halloween came and went—oh well…), I was wondering how folks had been coming to grips with the allowances contained within the CMS Categorical Waiver on combustible decorations, now that we are in the midst of our third end-of-the-year-holiday-timey-wimey period since the waiver was issued back in March 2012.

I can anecdotally speak to a fair amount of reluctance on the part of safety and facilities folks in running too far with the decoration waivers (or, to be a wee bit more precise, running too far in terms of communicating the changes to frontline staff; to a degree, I share the horror of what might happen, but I also believe that there is a therapeutic value in making the place look festive during the holidays, but I digress).

So has anybody come up with some creative decorating ideas or are you still embracing your inner Scrooge? You know me, I’m always curious about such things…

And who drills the drillers?

Another email question asked whether there were any specific Joint Commission education requirements for the folks who conduct quarterly fire drills. The short answer to that question is no, TJC does not require any specific education for the folks conducting the fire drills. But you know that I rarely rest upon the short answer, so I would certainly think that from a practical standpoint, it might not be a bad idea to have a little education package gathered together for that purpose. Ultimately, there is a responsibility to ensure that folks are competent in whatever they’re doing and you would certainly want to make sure that any folks assessing the competencies of others (which is nominally what you’re doing when you conduct fire drills) are themselves competent in that process. Again, not a bad idea to have something, but it’s not specifically required. I would suggest including some accounting of the process in your Fire Safety Management annual evaluation. Is anybody else working on this type of thing? I suppose there are lots of points in which staff interactions are evaluated for compliance—how do you make sure the folks doing the oversight have got the goods? I, for one, would be interested to hear any stories about this.

Documentary evidence: More you need to know…

Another perpetually sticky wicket in the survey process (and we’ve discussed this, oh, once or twice before) is the timeliness of documentation from maintenance and testing vendors and the expectations of how that process has to be managed. During an ASHE-sponsored webinar last fall, George Mills posited the scenario in which there is a delay (delay times can vary, but you probably have a pretty good idea of how long you have to wait for reports to come back from your vendors) in receiving a report for fire alarm testing in which a handful of devices failed during routine testing. If you don’t receive the failure information immediately upon its identification by the vendor, what you are saying, in effect, is that it’s okay for me not to “know” (there’s that word again) how reliable my fire alarm system is for a month while I’m waiting for the report. If any of you think that it is indeed “okay” not to know might want to think about another line of work. From an empirical standpoint, a failed fire alarm device puts the building occupants (patients, staff—you know, those folks) at a greater risk, which is never, never, never a good idea. And what if you don’t get the report for six weeks, the failed devices haven’t been replaced, and now you’re looking at the possibility for having to manage the deficiency with a PFI, ILSM assessment—the whole magillah. Truthfully, you have better things to do with your time.

Mr. Mills’ suggestion (and I think it’s a good one, having made the suggestion at least once or twice in the past) is to ensure (either contractually or otherwise) that any deficiencies identified are in your possession before they “complete” their work. You can set it up so they let you know at the end of each testing day (that would be my preference) or at the end of the engagement. But you have got to have that information in your possession as soon as it can be made available to you. The occupants of your building depend on each and every element of your systems—fire alarm, fire extinguishment, medical gas and vacuum, emergency power—you know that list by heart and it’s your responsibility that they are managed appropriately.

PFI – Pretty Freaking Important – you’d better believe it!

I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.

It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.

So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:

PFI = ILSM Assessment

Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?

I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…

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).

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.