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Suites for the sweet

Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”:  The management of suites.

So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).

In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.

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 7.1.3.2.1 (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).

I ain’t missing you (are you sure about that?)

As much as I had hoped for a reduction in findings relative to EC.02.03.05 (maintaining fire safety equipment and fire safety building features), that hope is being dashed on the rocks of reality. And once again, it appears that a lot of it has to do with the quality of the documentation provided to us by our fire alarm and sprinkler testing vendors.

Where this has been cropping up most recently is in the realm of ensuring that each of the applicable devices is tested in absolute accordance with the requirements for frequency. For example (this from a recent survey), if you have your vendors doing 25% of your inventory each quarter (for the devices that need to be tested annually), then you need to make sure that the number of devices tested in the 1st quarter of last year matches up with the number if devices tested in the 1st quarter of this year, or you need to have a very clear understanding of why the numbers don’t match up. Maybe you installed and/or removed devices from service; maybe there are devices that they could get to in one quarter and couldn’t in the subsequent (more on this in a moment).

Ultimately, we need to make sure that each of the devices in our inventory is being tested at the appropriate frequency. A question for those of you who have your fire alarm testing done on a once-a-year schedule: If a device can’t be tested during the regularly-scheduled activity– say, for instance, a patient room is occupied and the smoke detector can’t be tested– how are you making sure that that device doesn’t fall out of the testing loop?

I know it’s just a single device, but if it’s in a place that’s tough to get to, the next thing you know, you’ve got a couple of years passing without that device being tested… and it becomes low-hanging fruit for a diligent surveyor. I’m just saying…

96 Tears – 96 Hours – 96 Response Plans – You’re gonna cry – cry, cry, cry!

I was doing some work at a client facility recently and happened to be on site when these folks were entertaining the representative from their property insurer. While there was lots of discussion about processes for managing fire alarm and sprinkler system impairments (might be worth checking with your property insurer for their definition of an impairment – might be a little more restrictive than you might think, especially if you are using the 4-hour timeframe identified in the Life Safety Code / TJC standards), which I expected, there was a little more attention paid to emergency response plans, particularly in relation to utility systems failures, primarily as a function of business continuity.

The rep was really keen to see the organization’s detailed response plans for the normally-anticipated failures and it prompted the thought that, in these days of the (at least somewhat) monolithic 96-hour assessment/response plan dynamic, whether we’re best served by having really in-depth, specific response plans, or if we’re better off with what amounts to a bullet list of strategies for managing the risks and vulnerabilities inherent in a particular failure event. So my question to you is this: How “deep” do your response plans go? Are we talking lots of details or is it more or less a response framework that requires a little more intuition/familiarity on the part of your incident commander?

I know that the structure and content of response plans have evolved (mutated?) over the past 10 years or so, but I’d be hard pressed to be able to quantify the improvements (I’m certain that there have been improvements – but I can’t say how I “know” this). Or, in the vernacular of this year’s presidential race, if we are better off than we were 10 years ago – how can we “prove” that improvement?

What say you?

Wait there’s more – three men in black said don’t report this…

So, we’ll start this week’s coverage with that pesky little Infection Control (IC) finding (yes, I do recall saying that I would make sense of this as a function of the EC/LS continuum):

Managing the risks of infections associated with medical equipment, devices, and supplies (#5 on the list of top-cited standards, with 39% of hospitals having been cited – IC.02.02.01)

This primarily has  to do with the various and sundry methods of disinfection that are used in the healthcare environment, from low-level disinfection (EP 1), which includes the presence of expired product (i.e., spray disinfectant, disinfectant wipes) to ensuring that staff are knowledgeable of how long they have to keep the surface wet in order to disinfect said surface. And that’s not just the folks in EVS, that’s everybody who wipes something down with a disinfectant. If the goal is to disinfect the surface (which is different than cleaning – cleaning doesn’t take as long), then everyone who uses the stuff has to know how long the surface has to stay wet.

The next component is the intermediate- and high-level disinfection and sterilization processes, particularly when it comes to the manual disinfection of medical equipment. We’ll be chatting about this more in the future, but (and I will eventually reiterate – but don’t I always?), if there are folks in your organization who are performing manual disinfection of patient care devices/instruments, most frequently using an OPA product – you need to make sure that the process has been evaluated  as a function of what is actually required by the manufacturer.  This is a very complicated process (with lots of steps to go awry), and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…did I say perfect? Indeed, I did!

You also have to make sure that you are properly disposing of medical equipment, devices, and supplies – which means it is vewwy vewwy important that everyone understands what constitutes medical waste – how bloody, etc. do things have to be before they go into the red bag.

Finally, this one deals with the storage of medical equipment, devices, and supplies. This could be any number of things, one of which is not particularly negotiable – outdated stuff – no real defense there. But it could also be any one of those bugaboos – storage under the sink, uncovered linen carts, cardboard, non-solid bottom shelves of storage carts, etc. If I’ve said this once, I’ve said it a million times – there are no (nationally promulgated – check your local listings for regulations near you) rules about these. Each of these is a case of self-determination on the basis of a risk assessment – each represents an infection control risk. Our obligation is to identify the most effective means of managing those risks.

So, as you can see, this is all stuff that fits ever so neatly into the EC world – always more to keep an eye on, don’t you know.

LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke (#7 on the top-cited list, with 36% of hospitals having been cited)

As the list of non-surprise issues continues, we find ourselves facing non-intact smoke barriers (Can you say “penetrations” again? Good!) and door issues. Hopefully, you all are starting to become familiar with the specifics (you’d better be); EP16 – 23 are providing the most compelling fodder for survey findings. Also, findings relative to the protection of hazardous areas – once again, door latching issues, doors that don’t self- or auto-close and latch (maybe because they’ve been wedged open or had a latch taped over), maybe the odd penetration – pretty basic stuff, all in all.

LS.02.01.35 – Fire extinguishing system requirements (#8 on the list, with 35% of hospitals having been cited)

Eighteen-inch storage leads the parade, but other things to keep an eye out for are:

  • Cabling and other materials draped over/attached to sprinkler piping (including the supports) – chances are you’ve got some of this somewhere in your building – it’s up to you to find it before TJC does.
  • Dust and/or other materials (including grease) on sprinkler heads – gunked-up sprinkler heads don’t work nearly as effectively as those that are pristine. By now, you (or your sprinkler contractor) should have a pretty good idea of which heads are susceptible to build-up of ca-ca.
  • Missing escutcheons – if we only knew where the blessed things went. It’s like some sort of black hole or extraterrestrial event – they disappear and we’re on the hook.

And look, we haven’t even quite finished with the top 10 yet , but rest assured…

Mac’s Safety Space: Survey 2011–will we have to juggle more?

I probably spend too much time thinking about such things, but as I was pondering the expanding role (and presence) of the Life Safety Code® surveyors as we launch ourselves into the 2011 accreditation year, it occurred to me that this expansion might result in some scheduling conflicts during the conduction of the survey, particularly for smaller organizations in which folks (and you know who you are) don many hats within the confines of their work days.

I’m sure that the creation of individual survey schedules will be most thoughtful, but each organization organizes things a little differently (note to self: a new club – the Organization of Organized Organizations – the OOO, if you will), but the question becomes – do you have bench strength when it comes to managing the survey process? I’m thinking that it would mostly be the clinical folks that might be pulled in a couple of different directions during survey. What would you do if some of those folks had to forego the EOC/EM sessions because of “competing” clinical tracer activity?

Fortunately, we do get a little advanced notice when The Joint Commission provides a survey agenda ahead of time, but it might be worth checking to see if everything lays out in a manner that allows you to put your best foot forward. Again, probably too much thought, but it’s never a bad idea to have a strategy.