Codes + Standards
Successful LSC surveys depend on documentation
Most health facilities professionals will admit that the Life Safety Code specialists’ intensive review results in more lost sleep than any other part of The Joint Commission survey process.
This is understandable when one considers the volume of material that is actually reviewed, documents that are carefully read and the probing questions that generally follow. These factors coupled with an unannounced survey process would make even the most meticulous hospital engineer a bit uneasy.
However, these concerns can easily be alleviated by properly organizing Environment of Care and Life Safety Code documentation and testing the system with practice tracers.
Preparation is key
We have all heard the saying that “practice makes perfect,” and preparing for your day or days with the Life Safety Code specialist is no different. Not only will it ensure that the proper documentation exists, but it will also ensure that those members of the organization who must speak about these items can do so fluently.
The most successful way to prepare for a Life Safety Code specialist is to begin thinking like one. Only then can health facilities professionals recognize the enormity of the specialist’s tasks and better understand ways to help him or her complete them. Understanding these needs begins with clearly understanding the standards that they survey—not only those found in the Environment of Care chapter, but also those found in the National Fire Protection Association (NFPA) documents that are referenced.
The Joint Commission references five separate NFPA documents under standard EC.02.03.05 alone. They are the 1998 editions of NFPA 10, 25, 96 and 1962, and the 1999 edition of NFPA 72. Additionally, the 1999 edition of NFPA 99 and the 1996 edition of NFPA 111 are referenced later. These documents are the driving force behind the Environment of Care and Life Safety standards. They outline the details and time frames for each test and it is imperative that health facilities professionals have a working knowledge of these documents.
More than one health care organization has received an unexpected Requirement for Improvement (RFI) simply because a key component of one of these tests had been overlooked. This has been particularly true when they rely on vendors to complete the tests without careful oversight. Even though a contract might clearly state that the vendor test in accordance with NFPA standards, it is the hospital’s responsibility to ensure compliance.
During a recent survey, for example, it was discovered that the fire alarm testing firm had never tested the air handler shutdowns. When asked about it, they responded that they only do so upon request from the health care facility, a fact that had never been discussed or included in a contract document.
Survey surprises such as these can be avoided with a bit of preparation. The best place to start is by using a checklist or a similar tool that summarizes the tests required and their intervals.
Many such tools exist within the public domain and health facilities professionals could certainly develop their own. However, one of the best I have seen was developed by Curt Hibbard, a former Life Safety Code specialist and past president of the American Society for Healthcare Engineering (ASHE) who is director of facilities management at St. Joseph Regional Medical Center in Lewiston, Idaho. This simple spreadsheet, which is available for free to ASHE members at www.ashe.org, contains information to ensure compliance and is currently being used by most Life Safety Code surveyors.
The checklist can be used to inventory a facility’s testing requirements. For example, many organizations do not have water tanks for their fire suppression systems; therefore, these tests do not apply. In such cases, it is a good idea to leave these items on the checklist but indicate that they are not applicable to the organization. This will help the health facilities professional and the surveyor feel confident that these were not simply overlooked. Once the inventory has been taken, the documents can be organized in a system that makes sense for the facilities professional. Remember, time will be of the essence during a Life Safety Code specialist’s review, so proper organization is imperative.
Getting organized
Most surveyors tend to review these documents at the end of the day, but it is their prerogative to do so at the beginning, dramatically compressing the timeline.
It can be particularly helpful to organize them in hanging files by order of the standard. This makes it simple to provide the reports to the surveyor as they typically ask for them in standard order.
Other useful “prework” includes flagging specific areas of lengthy reports where important information might be found, such as flagging the page of a detailed fire suppression report where the five-year standpipe test has been documented.
Once these documents are properly organized, the most important (but perhaps most often ignored) step begins—practice tracers. Just as the health care organization’s clinical personnel are out on the floors pulling charts and drilling staff, so should the facilities professional do the same with the Life Safety documents.
It will help a health facilities professional if he or she has a colleague periodically ask to go through these documents, looking carefully for items that may have accidentally slipped through the cracks. This process is also useful for preparing whoever may have to fill in should the facilities professional be unavailable during the survey. Health facilities professionals should go through this exercise at least twice each year and quarterly during the health care organization’s survey window.
During these tracers, facilities professionals should carefully review each document to make sure they fully meet the intent of the standard. Many organizations have received RFIs for tests that were properly performed but not well documented, such as monthly automatic transfer switch tests or recovery times for sprinkler main drain tests. It is equally important to ensure that any and all deficiencies noted on reports have been corrected and properly documented. Noting the corrective actions on the original reports is a good way to ensure that follow-up takes place and can be useful in locating more detailed documentation should it be requested.
Aside from the testing documentation, the Life Safety Code specialist will also review past and present Statement of Conditions (SOC). The quickest way to a conditional accreditation is to have not followed up on previous SOC items or fully implemented Interim Life Safety Measures (ILSM) for current deficiencies.
Element of performance three of EC.01.02.01 requires that the organization have a written ILSM policy that covers any deficiency that cannot be immediately corrected. These elements of performance are “decision rule” elements, meaning that noncompliance automatically results in conditional accreditation. A part of a facility’s routine tracer activity should be to review the current and previous SOCs, the ILSM policy and how well the ILSM policy has been implemented and documented.
In addition, the facilities professional should also ensure that accurate Life Safety drawings are available. These will help avoid confusion during the building tour and can serve as an excellent tool for orienting the surveyor to the facility.
Additionally, if the organization has been granted an equivalency by The Joint Commission, a copy should be available for review prior to beginning the tour. A word of caution: Although the local authority having jurisdiction may have given the facility an equivalency, one still must be requested and approved by The Joint Commission prior to the surveyor’s visit.
Narrow testing band
Unless the facility is a critical access hospital, where the surveyor will review the entire Environment of Care, the Life Safety Code specialist will be looking at a narrow band of critical testing items.
Using the LSC specialist’s process prior to their visit will almost certainly ensure a successful outcome.
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Steve Spaanbroek, SASHE, is managing director of MSL Healthcare Consulting Inc., McMurray, Pa. He focuses primarily on regulatory compliance consulting in multiservice health care facilities. He can be reached at sspaanbroek@mslhealthcare.com. |
| Sidebar - What are LSC specialists looking for? |
The items currently being surveyed by the Life Safety Code specialists at non-critical access facilities include the following:
The National Fire Protection Association (NFPA) documents discussed in the main article are available for purchase at www.nfpa.org. They are also available online to NFPA members for viewing only. Each health care facility should have them available. Other helpful resources can be obtained from the American Society for Healthcare Engineering’s (ASHE’s) Web site at www.ashe.org. Many of these resources are available as free downloads for ASHE members. |
This article 1st appeared in the February 2009 issue of HHN Magazine.
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Life Safety Code specialists are expected to be a part of all Joint Commission surveys this year. The specialists will spend two days in health care facilities larger than 750,000 square feet and one day in smaller facilities. Furthermore, if an organization is classified as critical access, the specialist will spend one day reviewing all of the standards in the Environment of Care, Life Safety and Emergency Management chapters.