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There’s a light, a certain kind of light – and it’s not an oncoming train!

This one has the potential to be the game-changer we’ve been hoping (waiting) for – the emergence of the 2012 edition of the Life Safety Code® as a CMS-sanctioned regulatory standard.

Once you lay your hands on this plucky little document –  the official CMS memorandum – you will see that it appears) to represent a fair degree of flexibility when it comes to, among other things, corridor storage, and the amount of combustible decorations that are allowed. One thing this likely means is that everyone’s going to be inundating NFPA for their own personal copy of the 2012 Life Safety Code® – this is going to become a go-to resource from here on out.

Now, the first thing you will notice is that there’s a lot of mention of nursing homes, and not so much of hospitals, particularly on Page 1. To that end, let me direct you toward the bottom of page 2 of the document (under the section titled “Effective Date”), which specifically indicates that the memorandum and all its components are “in effect for all applicable healthcare facilities such as Hospitals and Nursing Homes.”

The other caveat, at least for the moment, is that it appears that the changes are only “accessible” through the CMS waiver request process, which will, in turn, result in a process in which “each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.” I’m not entirely certain whether this would drive anything more than a review of the waiver request, but I’m not entirely certain how they’d be able to ensure compliance with LSC requirements, etc., without eyeballing a facility. That said, there’s a whole heck of a lot of hospitals that would be pursuing this, so maybe there’s a process in place, maybe based on past TJC/DNV/HFAP and/or CMS survey results.

So, what it looks like we have here is some room for stuff in the corridors, including fixed furniture; and the presence of combustible decorations on “walls, doors and ceilings.”

That’s enough yapping from me for the moment; I encourage you to check out the document and let us know what you think. I think it’s very interesting.

Mac’s Safety Space: Life Safety Surveyor

Q: I was just wondering what your thoughts are on the expanding life safety surveyor. I am in a 42-bed hospital and on my last survey cycle I got my first Life Safety Surveyor. My next survey should be any time. My last surveyor spent about five to six hours with me and asked many different questions, went through the grid of questions on the fire equipment, and at the end of the day, I thought he could not possibly have any more questions. But now I will have a surveyor for two days. What will the surveyor look at?

Steve MacArthur: You pose an interesting question–one for which I have given a fair amount of consideration as my client work tends to be in smaller facilities–so I’ve had a number of conversations in this regard.

One thing (or I suppose a couple of things) I can say for sure is that the survey of the physical environment will be conducted primarily, if not exclusively, by the Life Safety Code® (LSC) surveyor, including the Emergency Management review and the Environment of Care document review, which historically has fallen on the other members of the survey team.

So, the management plans, EC minutes, annual evaluations, disaster critiques, etc. will all be reviewed by the LSC surveyor. I see this as an absolute plus for folks with well-organized programs as the review will be conducted by someone with rather more current expertise so the review will be conducted by someone who understands the practical/operational considerations, so I am hoping that this will result in less need for us to defend our rational decisions to “opinions” that are not germane, or even possible, in the current regulatory environment.

The LSC surveyors generally have regular jobs at hospitals, though I suspect with the broadening of the survey scope we may see more folks taking this on as a retirement job, but that may not be for a while. Conversely, folks with “squishy” programmatic elements are much more likely to have those vulnerabilities exposed during survey. I’m not sure if I’ve mentioned this previously in the blog, but there is a certain recognition that we do not exist in a perfect environment, so it is how we proactively manage those imperfections that will be the benchmark at the end of the day.

Another benefit is that we won’t have to “bond” with different folks during the survey, which, especially in smaller organizations with not a lot of bench strength, can be a challenge in a short survey. You’re getting pulled in a million different directions (I’m sure you know that feeling). The survey of your area of responsibility has become, in effect, a one-stop shop, which will allow you to exercise greater control over the process. Sure, there is a chance that they can dig a little deeper and find a few more things, but really, are they going to be able to find something about which you are unaware? I think not.

As a final “benefit”, if you will, is that the LSC surveyor will stick around long enough for you to discuss the findings and, ideally, make your case for compliance. Although the “marching orders” at the moment are for everything to go into the report, you can discuss the findings as a function of compliance with the standards, which will help you make full use of the clarification process. If you look at the standards that are being cited most frequently, there are lots of “C” performance elements in the mix, so lots of post-survey opportunities.

I suppose you could say that I’m looking at this whole change from a “glass half full” perspective, but it’s not going to go away any time soon, so we might as well look at this as a positive development.

Mac’s Safety Space: Medical completion non-life safety completion

Steve MacArthur, safety consultant at The Greeley Company, answers a question regarding medical equipment.

Q: What should our medical equipment non-life safety completion percentage monthly thresholds be? I have been using 90%, but was told 95%.

Steve MacArthur: This is kind of a trick question in that, to some degree, both responses can be correct (note the very wishy-washy use of “can” in that last statement). When looking at preventative maintenance compliance rates for non-life-support medical equipment, there are generally two not-quite distinct processes that come into play.

From a Joint Commission perspective, the performance element regarding the maintenance on non-life-support medical equipment (EC.02.04.03 EP #3), you will note that this is a “C” performance element, which ultimately means that the minimum compliance expectation would be a compliance rate of at least 90% (the 90% is specifically identified in the instructions for conducting the annual Periodic Performance Review; during a “real” survey, if you have two instances of non-compliance, then that would result in a Requirement for Improvement (RFI) – an RFI that you can remove from the final report via the clarification process). The 95% number is a vestige of the ancient days of the EC standards, though I believe that as a performance improvement target, 95% is a “better” number than 90%. That said, 90% is still an “A” and a passing grade for Joint Commission compliance.

I’ve been having a lot of discussions lately with clients about whether we should view the Joint Commission standards as a be-all, end-all proposition and I’ve been encouraging folks to look at the TJC standards as a baseline expectation and then identify improvement strategies that establish expectations that go beyond that. As another example of this minimum expectation, I frequently talk about hazard surveillance rounds and whether merely complying with the two per year in patient care areas and one everywhere else is really sufficient to appropriately manage the physical environments in our facilities. To my mind, compliance with regulatory standards is the least we can do, so to speak – but we always strive to be better than that.