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Treat Life Safety PFIs as Contracts with Joint Commission

Scott Wallask, for HealthLeaders Media, April 27, 2009

In the business world, we generally respect the sanctity of contracts and expect repercussions if we breach such agreements.

Well, there's a Joint Commission contract of sorts regarding fire safety that you might not be familiar with—though if there's ever an infringement of this contract, you'll quickly become aware of it in terms of potential conditional accreditation status.

This contract is known as the "plan for improvement," or PFI. The PFI falls under The Joint Commission's electronic Statement of Conditions (SOC), which hospitals must complete under the life safety standards.

If your facilities or safety managers discover a Life Safety Code® deficiency within the hospital, The Joint Commission allows three options to pursue:

  • Correct the problem immediately
  • Enter it into a facility work order system and complete the repair or correction within 45 days of discovery
  • Add a PFI for the deficiency

A PFI is essentially a pact with The Joint Commission indicating the hospital's intent to fix a life safety deficiency, says Brad Keyes, CHSP, a safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

A PFI involves opening a line item for the deficiency within the e-SOC and indicating:

  • What type of corrective work is necessary
  • The potential cost for the project
  • An estimated completion date

PFIs are accepted by surveyors when they review your e-SOC during a survey. The Joint Commission requires you to finish PFI projects within six months of the completion date or to formally request an extension of that deadline. If you don't complete a previously accepted PFI within the six-month grace period and haven't requested an extension, your organization faces potential conditional accreditation status from The Joint Commission—a penalty that the commission has in fact meted out over the past few years.

PFIs also have financial implications, Keyes says. CEOs don't have the option of not funding a PFI previously approved by The Joint Commission.

Should funds get pulled for a PFI project in the pipeline, the organization could again risk conditional accreditation, he says.

An important point to keep in mind is that PFIs are only to correct Life Safety Code deficiencies. For example, although it is probably a sound idea to install a new sprinkler system in an existing hospital wing currently without sprinklers, under the Life Safety Code, such action isn't required because the code allows existing healthcare occupancies to not have sprinkler protection.

Trying to incorrectly put this work on a PFI, perhaps to leverage funding for the new sprinklers, might be taken by surveyors as mismanagement of your e-SOC, Keyes says.


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

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