A major accrediting organization for hospitals released data on its most-cited standards for the first half of the year.
By Steven Porter
This article was originally published in Hospital Safety Insider, August 31, 2017.
The Joint Commission released survey data from the first half of the year showing that the overwhelming majority of hospitals are struggling to demonstrate compliance with certain fire hazard provisions of the Life Safety (LS) chapter.
About 86% of the 763 applicable hospital surveys conducted in January through June revealed deficiencies under the most-cited standard, LS.02.01.35, which addresses the provision and maintenance of fire-extinguishing systems, according to the September edition of Perspectives.
The second-most-cited standard, LS.02.01.30, deals with features designed to protect people from fire and smoke hazards. About 74% of surveys found deficiencies on that front.
There’s nothing terribly new or tricky about these two standards, says HCPro’s resident hospital safety expert Steve MacArthur, safety consultant for The Greeley Company in Danvers, Mass. It’s the lack of leeway that seems to be behind such high citation rates.
“What is now required for everything in the physical environment is perfection, and that is really tough to pull off under the best conditions,” MacArthur says.
A violation under LS.02.01.35 could be as simple as dust found on a sprinkler head or a box stored within 18 inches of a sprinkler deflector, he says.
The days of emerging from a survey without findings under the LS and/or Environment of Care (EC) chapters are “pretty much gone forever,” so rather than looking to assign blame, hospitals should focus on managing their performance data, identifying weak spots, and taking steps toward corrective action, MacArthur adds.
Two other standards from the LS chapter made it into The Joint Commission’s Top 10 list: LS.02.01.10, which addresses features that aim to hamper flames, smoke, and heat in the event of a fire; and LS.02.01.20, which governs means of egress.
There were four standards from the EC chapter in the Top 10 list, too: EC.02.05.01, EC.02.06.01, EC.02.02.01, and EC.02.05.05. The remaining two standards came from the Infection Control (IC) and Record of Care, Treatment, and Services (RC) chapters.