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Hospitals Should Verify Safety Inspections Now

Scott Wallask, for HealthLeaders Media, March 24, 2010

The upcoming end of the first quarter may be a time to reflect on your financial performance, but from a building safety perspective, that timeframe also triggers several recurring inspection and testing activities that The Joint Commission mandates.

Most of these requirements fall under the hospital accreditation manual's "environment of care" chapter, which is a series of standards that address how to manage occupational, fire, and building system risks.

Perhaps the biggest quarterly concern that Joint Commission surveyors will zero in on is whether a hospital has successfully completed fire drills. The accrediting group requires hospitals to conduct at least one drill per shift each quarter, which can add up to a sizable task depending on the amount of employees.

At least 50% of required quarterly drills must be unannounced, meaning only selected drill organizers should know about an upcoming exercise. Finally, you must critique your drills, with an eye toward not only how well staff responded, but also whether fire protection features worked properly.

Be sure to check whether any interim life safety measures (ILSMs) are in place that could require extra quarterly drills, given that ILSMs are also high on surveyors' minds. ILSMs help offset life safety deficiencies by providing temporary alternatives to keep staff and patients safe.

Fire safety devices to note

Other environment of care concerns with a quarterly review component include:

  • Testing fire protection supervisory signal devices, such as valve supervisory switches or water level indicators

  • Testing fire alarm notification devices for off-site responders, such as the fire department or an alarm monitoring company

  • Inspecting fire department water supply connections

  • Testing stored emergency power supply systems, which can take the place of or supplement generator-provided emergency power

There may also be more informal needs to check on a quarterly basis.

For example, some hospitals require the submission of reports every three months to the safety committee from the safety officer or biomedical engineer. Such reporting contributes to monitoring the environment of care, although these reports are not required by The Joint Commission each quarter.

Also, facilities may employ a building maintenance program to track life safety problems that often crop up, but are easily correctable, such as burnt-out exit signs or fire doors that are out of alignment.

A building maintenance program will set specific inspection intervals for problems areas, and quarterly inspections are a common time frame to consider. If your facility has such a program in place, verify that quarterly reviews are being completed as expected.


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

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