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You probably already knew this…

I know we talked a bit about fire drills not so long ago, but somehow I seem to have missed this particular “clarification” while I was dodging the COVID-19 virus last summer and I wanted to make sure that you folks who may not have had much time for bedtime reading last (last) summer, I figured it couldn’t hurt to get this one out there (especially since these clarifications seem to be generating some findings).

In the July 2020 issue of Perspectives, there is an article that discusses some of the “asks” (OK, I suppose they’re somewhat more authoritative than asks…) that could come into play during survey when your fire drill program is being evaluated. One of the items applies particularly to folks who are using the two-shift model (as opposed to a three-shift model) with the enjoinder to schedule drills when administrative staff are on site so they can participate in the drill(s)—and have the opportunity to respond acceptably to the drill. So that’s something that could be queried during a survey (if you’ve adopted the two-shift).

The next item concerns the scheduling of drills across quarters. Now I think that this kind of flies in the face of the whole randomized scheduling, but, for example, if you conduct a first-shift drill in February, then the expectation is that the subsequent drills would be in May, August, and November, using the “every three months, plus or minus 10 days” definition. So, if you were to conduct a first-shift drill in January and then a first-shift drill in June (with the intent being to “mix things up”), that would result in a finding. It’s been a long time since I’ve conducted a fire drill, but I suspect I would have been in arrears relative to this expectation.

The Perspectives article also includes some guidance relative to what things to look at during fire drills. For instance, making sure that (when the fire alarm system is activated) locked egress doors unlock appropriately; as well as making sure that you evaluate the component of your fire response plan that deals with the management of visitors, particularly at the point of origin for the fire.

In the end, I don’t know how helpful it was to “release” this particular information when a lot of folks were trying to figure out how to ensure staff didn’t lose sight of the importance of fire drills while still maintaining the social distancing norms of the day. I think we’ve all come to grips (more or less) with the whole hour of separation between drill times, but it almost seems like a case of moving the compliance target just out of reach every time you think you’ve “grasped” the brass ring (somehow the whole “compliance as carousel” vision seems to be more telling every time I think about it). I guess there’s always an opportunity or two floating around, but sometimes I wish they floated within the immediate field of vision…

Now that this has come to light, I think I’m going to go back and check some of those issues of Perspectives to see if there’s any more revelatory content. Until next time!

Deck the halls with boughs of noncombustible construction…

It hardly seems possible that we are rushing headlong into the depths of November (October being almost as I write this), though I will note (as you would no doubt verify) that some of the big box stores have had “those” decorations out on the showroom floor for a couple of weeks. Strange that they don’t have a section of trimmings for hospitals…mayhap one day some illustriously inventive individual will come out with a line of Life Safety Code®-compliant holiday decorations for the healthcare market. To sleep, perchance to dream…

At any rate, it would seem that once again it is time to prepare for the onslaught of non-UL-listed trees and lights and all manner of unauthorized décor modifications (if you don’t believe me, check this out). I think that if I were in a position of waiting on a survey that’s more than 45 days late, I would very much plan on seeing our friends from Chicago before the end of the year and I would spend a wee bit of time coaching the more festive members of your organization in the do’s and don’ts of noncombustible decorations. As I’ve maintained right along, I absolutely understand that there is a therapeutic value (and perhaps never more so than this upcoming season) in having our places look festive during the holidays. Folks are exhausted and are probably not going to react well to any overly Scrooge-y dictates—work with them—if you have any money in your budget, maybe put together some examples of what can be done with code-compliant materials. I think, sometimes, the most powerful message of all is the one you show—and leave the telling to others…

To close the thought on those well within the survey window—the goal of the survey process is to generate findings, particularly in the physical environment—if you have a circuit breaker labeled as “spare” and it’s in the “on” position, they’re gonna find it and write it. If you have some schmutz on a sprinkler head, they’re gonna find it and write it. Something parked in front of an electrical panel—yup! Something parked in front of a fire alarm pull station—you betcha! Doors not latching—oh yeah! There are no perfect buildings and if all they can find are these types of imperfections, that’s what your survey report will look like.

Effective rounding is the only thing that’s going to keep these types of things under control; I’m sure there’s lots of rounding going on—make sure they’re effectively managing the conditions that are most likely to be discovered during survey. You know what to look at (everything!). Get folks out of the habit of looking “for” things—it sometimes leads to missing other things that didn’t make the “checklist.”

Someone’s in the kitchen, but there are no banjos involved…

In the never-ending quest for generating new and challenging survey findings, our friends in Chicago have thrown down the gauntlet (or perhaps more aptly, the oven mitt) for a new focus area: the kitchen! Certainly, the kitchen has always been part of the fabric of most regulatory survey visits. If you think about it, kitchens are among the most risk-laden environments in healthcare. You’ve got all the classic physical environment risks—slips, trips, falls, fire, sharps, heat, humidity, chemical hazards, sanitation/cleaning, a lot of entry-level positions—the list goes on and on. You could make the case that the kitchen environment is among the least risk-free environments in any healthcare organization. I will stop short of calling it dangerous, but it sure is hazardous.

To that end, this week’s Joint Commission blog posting outlines some of the major focus areas for the survey process as it relates to the kitchen; the blog also includes a link to a checklist for reducing fire and other risks in the kitchen. If you don’t have a formal process for doing rounds in your kitchen(s), might be work kicking the tires on this one.

Hope you all are well and staying safe. While I think we’re starting to make the adjustments to the “new normal,” the post-Thanksgiving spike (if there is one, and there’s no reason to think there won’t be) should be arriving shortly, so keep up the good work and we’ll get through this!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

Brother/Sister, can you spare a sprinkler head?

This week, I continue my ruminations on all things relating to outpatient care sites (Quick question: Is there anyone out there who doesn’t have responsibility for any outpatient care locations? I hope not, because this is probably getting a little tedious, though I guess in that hope it means that your existence has become more complicated over time, but if you don’t, you probably will). At any rate, this week’s tidbit revolves around the requirements for all (and I do mean “all”) properties having sprinkler heads to have a list of the sprinkler heads installed in the property, with the list being posted in the sprinkler cabinet. I think everyone is familiar with the requirements to have a stock of spare sprinklers, which would include all the types and ratings installed, with the number of spares guided by the following algorithm:

6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows (this also shows up in NFPA 25-2011 in Chapter 5) :

(1) For protected facilities having under 300 sprinklers – no fewer than 6 sprinklers

(2) For protected facilities having 300 to 1000 sprinklers – no fewer than 12 sprinklers

(3) For protected facilities having over 1000 sprinklers – no fewer than 24 sprinklers

By the way, the information contained in this week’s missive is sourced from the 2010 edition of NFPA 13 Standard for Installation of Sprinkler Systems, which came into play when CMS adopted the 2012 edition of the Life Safety Code® (LSC). As a cautionary note, now this information “lives” in NFPA 25 Standard for the Inspection, Testing & Maintenance of Water-Based Fire Protection Systems, so if you happen to have a state authority having jurisdiction that’s using a more recent edition of the LSC, then NFPA 25 is where you’ll find this stuff.

At any rate, back to that all-important list (and kudos to those of you who have your lists in place), bopping back to NFPA 13, we find the following:

6.2.9.7.1* The list shall include the following:

(1) Sprinkler identification number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating

(2) General description

(3) Quantity of each type to be contained in the cabinet

(4) Issue or revision date of the list

The Appendix provides a little more info:

A.6.2.9.7.1 The minimum information in the list contained in the spare sprinkler cabinet should be marked with the following:

(1) General description of the sprinkler, including upright, pendent, residential, ESFR, and so forth

(2) Quantity of sprinklers to be maintained in the spare sprinkler cabinet

Where the rubber meets the road, so to speak, is the requirement for an annual verification of all this stuff:

NFPA 25-2011: 5.2.1.4 The supply of sprinklers shall be inspected annually for the following:

(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5

(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.5.6

5.4.1.5* A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.

A.5.4.1.5 – A minimum of two sprinklers of each type and temperature rating installed should be provided.

5.4.1.5.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.

5.4.1.5.2 The sprinklers shall be kept in a cabinet located where the temperatures will at no time exceed 100 degrees F.

5.4.1.4.2.1 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

So that’s the partial skinny on sprinklers; the primary reason for plunking this down in front of you is because this showed up as a finding (mostly the list, but the other stuff is fair game) in a recent survey (not The Joint Commission, but these things tend to move through the various regulatory tribes).

I did want to leave you with a final thought for the week. I subscribe to a weekly email newsletter from James Clear (the following lives here); I find the newsletter interesting and much more often than not, useful, so I give you:

“What is the real goal?

  • The real goal is not to ‘beat the market.’ The goal is to build wealth.
  • The real goal is not to read more books. The goal is to understand what you read.
  • Don’t let a proxy become the target. Don’t optimize for the wrong outcome.”

Stay well and stay safe—that’s all I need you to do!

In the grand scheme of things, this helps—but how much?

A few weeks back we chatted about efforts to engage the 1135 Waiver process as a function of fire and life safety systems inspection, testing & maintenance, particularly as a function of ASHE’s efforts to facilitate a coordinated response. Apparently, this part of the waiver picture was not a priority for the folks at regional CMS, so there were a number of rejection notices sent to folks.

I’m not exactly sure what may have transpired (other than the passing of time, but if there were folks with access to CMS ears that continued to advocate, a debt of gratitude is owed), but some items related to certain inspection, testing & maintenance activities have finally made it to the slate of blanket waivers. You can find the information here, on page 23 of the linked document. Unfortunately, it appears that the blanket waiver announcement is being released in cumulative form, so you have to dig a little bit to find the applicable passage. Because of that, I’ve copied and pasted the information below.

As near as I can tell, the areas of greatest concern for the moment are those activities for which waivers were not granted:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency.

In looking at the list, I think that it is both reasonable and very practical from a safety perspective. Clearly, as busy as it is, there are critical processes/protections that need to be assured, so hopefully you haven’t missed any of those noted activities and, if you have, you probably need to start working on preparing your organizational leaders for some likely survey findings.

As a closing thought, lately while walking I’ve been checking out some new (to me) podcasts, one humor-based (Conan O’Brien Needs A Friend—generally pretty good—a couple of good “laughs out loud” per episode) and one not so much so, which is my shareable moment for you. Lately, the Freakonomics Radio podcast has been covering subjects relating to the pandemic, with the episode I listened to today being “How Do You Reopen A Country?” One of my favorite aspects of this program is their tendency to come at topics in a calm, measured fashion, but generally from a somewhat unusual angle, but I don’t want to spoil it for you be jabbering too much. If you’re interested in something thoughtful, but not crazily scary, you might enjoy the episode.

Hope this finds you safe and well – until next time…

CMS Blanket Waiver Information

Inspection, Testing & Maintenance (ITM) under the Physical Environment Conditions of Participation: CMS is waiving certain physical environment requirements for Hospitals, CAHs, inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and potential exposure/transmission of COVID-19. The physical environment regulations require that facilities and equipment be maintained to ensure an acceptable level of safety and quality.

CMS will permit facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

  • Specific Physical Environment Waiver Information:

o 42 CFR §482.41(d) for hospitals, §485.623(b) for CAH, §418.110(c)(2)(iv) for inpatient hospice, §483.470(j) for ICF/IID; and §483.90 for SNFs/NFs all require these facilities and their equipment to be maintained to ensure an acceptable level of safety and quality. CMS is temporarily modifying these requirements to the extent necessary to permit these facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

o 42 CFR §482.41(b)(1)(i) and (c) for hospitals, §485.623(c)(1)(i) and (d) for CAHs, §482.41(d)(1)(i) and (e) for inpatient hospices, §483.470(j)(1)(i) and (5)(v) for ICF/IIDs, and §483.90(a)(1)(i) and (b) for SNFs/NFs require these facilities to be in compliance with the Life Safety Code (LSC) and Health Care Facilities Code (HCFC). CMS is temporarily modifying these provisions to the extent necessary to permit these facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. The following LSC and HCFC ITM are considered critical are not included in this waiver:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.

o 42 CFR §482.41(b)(9) for hospitals, §485.623(c)(7) for CAHs, §418.110(d)(6) for inpatient hospices, §483.470(e)(1)(i) for ICF/IIDs, and §483.90(a)(7) for SNFs/NFs require these facilities to have an outside window or outside door in every sleeping room. CMS will permit a waiver of these outside window and outside door requirements to permit these providers to utilize facility and non-facility space that is not normally used for patient care to be utilized for temporary patient care or quarantine.

The place of working dangerously: The importance of kitchen safety

Recently, I fielded a question regarding fire response plans for food services and got me to thinking about the importance (and challenges) of good safety practices in the kitchen.

My firm belief has always been that,  for all intents and purposes, the kitchen is among the most “dangerous” locations in the hospital (when you think of pretty much all the classic safety “risks”, the kitchen has them—fire, slips, trips, cuts, chemical exposures, etc.) and also possesses among the most (if not the most) transient work forces in healthcare. Add to that the frequency of the entry-level folks being new not only to healthcare, but sometimes the working world, success really rests on the effectiveness of education, from the point of onboarding through regular department education, including the conduction of fire drills.

In poking around on the web, I came across some information provided by the Lafayette (Indiana) Fire Department relative to commercial kitchen fire safety that I think is well worth checking out for some cues in how to work with the Food & Nutrition folks to ensure the education process is all that it can be. I have noticed over the years (my wife is a big fan of cooking shows) that the celebrity chefs don’t focus as much on fire safety as they do on food safety (though I suspect Gordon Ramsey might have a few choice words if one of his restaurants had a fire). And I also know that some of the key components of fire response in a kitchen is a little counter-intuitive relative to how folks are trained in general, particularly the activation of the suppression system before one tries to use an extinguisher. I think these folks deserve a fair amount of focused support and the information contained here. It really provides you with a good road map for ensuring that your kitchen areas are as safe as they can be.

Shine on you crazy fire response plan!

On the things I’ve been doing over the past couple of weeks has been reading through the EC/LS/EM standards and performance elements to see what little pesky items may have shown up since the last time I did a really thorough review. My primary intent is to see if I can find any “Easter eggs” that might provide fodder for findings because of a combination of specificity and curiosity. At any rate, while looking through the fire safety portion of the manual, I noticed a performance element that speaks to the availability of a written copy of your fire response plan. That makes sense to me; you can never completely rely on electronic access (it is very reliable, but a hard-copy backup seems reasonable). The odd component of the performance element is the specificity of the location for the fire response plan to be available—“readily available with the telephone operator or security.”

Now, I know that most folks can pull off that combo as an either/or, but there are smaller, rural facilities that may not have that capacity (I think my personal backup would be the nursing supervisor), so it makes me wonder what the survey risks are for those folks who don’t have 24/7 switchboard or security coverage. At the end of the day, I would think that you could do a risk assessment (what, another one!?!?!?) and pass it through your EC Committee (that kind of makes the Committee sound like some sort of sieve or colander) and then if the topic comes up during survey, you can push back if you happen to encounter a literalist surveyor (insert comment about the likelihood of that occurring). As there is no specific requirement to have 24/7 telephone operator or security presence (is it useful from an operational standpoint to do so, absolutely—but nowhere is it specifically required), I think that this should be an effective means of ensuring you stay out of the hot waters of survey. For me, “readily available” is the important piece of this, not so much how you make it happen.

At any rate, this may be much ado about nothing (a concept of which I am no stranger), but it was just one of those curious requirements that struck me enough to blather on for a bit.

As a closing note, a quick shout-out to the folks in the areas hit by various and sundry weather-related emergencies the past little while. I hope that things are moving quickly back to normal and kudos for keeping things going during very trying times. Over the years, I’ve worked with a number of folks down in that area and I have always been impressed with the level of preparedness. I would wish that you didn’t have to be tested so dramatically, but I am confident that you all (or all y’all, as the case may be) were able to weather the weather in appropriate fashion.

No one told you when to run: Closing out one year, embarking on another…

Every once in a while, I like to poke back through recent missives from our friends in Chicago and elsewhere to see if there was anything that I missed on first review or something that didn’t really “pop” out at me at the time. And, somewhat typically, the really pressing hard news stories are in rather shorter supply as we get closer to year’s end. Truth be told, the whole ligature picture has really held sway in recent weeks, almost to the exclusion of everything else.

At any rate, in looking at the most recent (I think) slate of pre-publication standards, I noticed a couple of “new” requirements that gave me a little bit of pause. Due to some editorial constraints, I won’t identify the standards and EP numbers, but I will try to give you a sense of where there “live”: they are identified as “new” on the webpage, so that may be enough for you to find them (you’re a pretty smaht bunch and I have every confidence in your detective-ing abilities). This week we’ll cover the Environment of Care changes and hit the Life Safety changes next week (where did the year go!?!):

 

  • The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information. (Safety Management)
  • Management of smoking materials for patients receiving respiratory therapy. (Smoking Policy)
  • Periodic evaluations of fire hazards during surgical procedures (don’t forget to define that period!) (Fire Safety Management)
  • Process for reducing risks when flammable germicides or antiseptics are using during “hot” surgical procedures (electrosurgery, cautery, lasers) (Fire Safety Management)
  • The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15. (Fire Safety Management)
  • Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (Inspection, Testing & Maintenance of Life Safety Systems equipment)
  • Hyperbaric facility safety, including labeling of equipment used in oxygen-enriched atmospheres (we covered this a couple of weeks ago, with a couple of folks weighing in with questions on how far to go with Chapter 14 of NFPA 99; if the past is any indicator of the future, I would be moving towards adoption of the whole thing and probably start to extend the labeling of equipment out to all oxygen equipment—this is where they start digging into this—we know the targets will move over the next survey years, so better to be ahead of the game than behind). (Medical Equipment Inspection, Testing & Maintenance)
  • Inspection, testing, and maintenance of anesthesia apparatus, including gas flow and oxygen concentration verification; no oil, grease or flammables for oxygen equipment. (Medical Equipment Inspection, Testing & Maintenance)
  • ORs are wet locations unless you have a risk assessment that says otherwise and has been approved by the governing body (it appears that risk assessments done in “isolation” will no longer meet the mark—organizational leadership has to be involved in the process. Written record of the risk assessment is available for survey review. We covered this before.  (Utility Systems Management)
  • Risk level identification of electrical distribution; we did this one before as well.  (Utility Systems Management)
  • Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.  Keep an eye on those pediatric locations, particularly areas that can “swing” – tamper-resistant receptacles could well become a moderate risk of harm during survey. (Utility Systems Management)
  • Power strips must be appropriately listed for use in patient care vicinity, patient care rooms, etc. Focus on this has already started, so you better start working with your IT folks to make sure everything is going in the right direction. (Utility Systems Management)
  • Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was intended. I predict that this is going to keep this standard at the top of the most frequently cited standards list. (Utility Systems Management)
  • Areas designated for administration of general anesthesia using medical gases or vacuum are in accordance with NFPA 101-2012 and NFPA 99-2012 (Utility Systems Management)
  • Electrical system critical branch supplies power for specific needs (task illumination, fixed equipment, select receptacles, and select power circuits) in areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum. The EES equipment system supplies power to the ventilation system. (Utility Systems Management)
  • New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (Utility Systems – Emergency Electrical Power Source)
  • Equipment designated to be powered by emergency power supply are energized by the hospital’s design. Staging of equipment startup is permissible. (Utility Systems – Emergency Electrical Power Source)
  • For deemed status hospitals, battery lamps and flashlights are available in areas not serviced by the emergency supply source. (Utility Systems – Emergency Electrical Power Source)
  • Line isolation monitors are tested in accordance with NFPA 99-2012. (Utility Systems Inspection, Testing & Maintenance)
  • Risk level identification of medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems. (Inspection, testing & maintenance of medical gas system components)
  • All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (Inspection, testing & maintenance of medical gas system components)
  • Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012. (Inspection, testing & maintenance of medical gas system components)
  • Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” (Inspection, testing & maintenance of medical gas system components)
  • A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders. (Inspection, testing & maintenance of medical gas system components)
  • More cylinder storage stuff (I suspect you know the drill)—NFPA 99-2012 has a great deal of detailed requirements—and I have no reason to think that they won’t be kicking the tires pretty diligently. (Inspection, testing & maintenance of medical gas system components)
  • Also, transfilling of liquid oxygen is a process with very, very specific requirements; if you’re not transfilling liquid oxygen in your facility, you could count yourself fortunate, but be on the lookout for any evidence of liquid oxygen being transferred inside your “house”; NFPA 99-2012 is your guide. (Inspection, testing & maintenance of medical gas system components)
  • Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training. (Staff Competency & Education)

I know this is a lot of stuff to consider, but I wanted to put it out in front of you folks on the off chance that your bedtime reading hasn’t strayed into the realm of the 2018 standards changes. I have every reason to think that some of this stuff will show up again in this space (and what a space!), but if someone wants to start a particular conversation before we kick off (kick at?) 2018, please feel free.

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 19.3.5.7. Originally, this section of the LSC referenced 19.3.5.1 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…