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Surveyors Can Hold CEOs Accountable for Fire Protection Vendors' Poor Work

Scott Wallask, for HealthLeaders Media, April 13, 2009

As Joint Commission citations increase for Life Safety Code® (LSC) violations, many of you are becoming more aware of these problems. A further twist may put this concern in an even brighter spotlight.

The Joint Commission's life safety specialists review LSC compliance during all hospital surveys. While the specialists concentrate on five physical environment standards during their intensive, day-long reviews, they can also look for related compliance in a trio of Joint Commission leadership (LD) standards.

The LSC sets a variety of fire protection provisions for hospitals and other healthcare facilities. The National Fire Protection Association in Quincy, MA, publishes the LSC; however, it is up to authorities such as The Joint Commission to enforce the code.

The relevant LD standards and specific elements of performance (EP) to watch for include:

  • LD.04.01.05, EP 4, which requires hospital leaders to hold staff members accountable for their responsibilities
  • LD.04.01.11, EP 5, which mandates that leaders provide for adequate equipment and resources
  • LD.04.04.01, EP 2, which requires leaders to give priority to problematic processes for the purposes of performance improvement

HealthLeaders Media caught wind of a recent example of one of these LD standards in action. During a review of fire protection equipment documentation at one hospital, a life safety specialist said a contractor had not completely tested all of a protection system's components.

As a result, the surveyor issued a citation under LD.04.01.05, EP 4, because the hospital worker assigned to monitor the contract did not adequately review the report to verify system components were properly documented, according to a former surveyor who spoke on condition of anonymity.

Typically, fire protection equipment inspection, testing, and maintenance falls under a Joint Commission environment of care standard, but in this case the life safety specialist believed the crux of the problem resided with leadership's oversight.

The issue of vendor contracts is on the radar of George Mills, FASHE, CEM, CHFM, senior engineer at The Joint Commission. Mills oversees interpretation and enforcement of life safety requirements for the commission.

At the 2008 annual conference of the American Society for Healthcare Engineering in National Harbor, MD, Mills told attendees that he was frustrated by hospital managers who blame vendors for not having fire equipment testing results available for surveyors.

In such cases, it is up to facilities to monitor vendor performance, and a lack of such diligence points to a problem with a hospital's leadership style, he added.

Other life safety deficiencies that might lead to an LD standard citation include unrealistic completion dates for projects and administrators pulling back budgets for improvement plans previously approved by The Joint Commission.

The Joint Commission introduced its life safety specialists to survey teams in January 2005 following a U.S. Government Accountability Report that concluded Medicare validation surveys at hospitals uncovered serious fire safety deficiencies that Joint Commission surveyors hadn't identified in earlier visits. The Joint Commission has deeming authority to accredit hospitals as being compliant with the Centers for Medicare and Medicaid's Conditions of Participation.


Scott Wallask is senior managing editor for the Hospital Safety Center. He can be reached at swallask@hcpro.com.