In a culmination of efforts to better review fire protection features in acute care facilities, Life Safety Code violations became the top cited standard in all surveyed hospitals in 2008, reports The Joint Commission.
According to the July 2009 Joint Commission Perspectives, 45% of surveyed hospitals received a citation for EC.5.20, the old 2008 standard for Life Safety Code compliance. That standard has since expanded into 10 life safety standards introduced in 2009.
The National Fire Protection Association publishes the Life Safety Code, while The Joint Commission and Centers for Medicare & Medicaid Services enforce the year-2000 edition of the document. EC.5.20's top ranking isn't a surprise to Brad Keyes, CHSP, life safety consultant for The Greeley Company, a division of HCPro in Marblehead, MA.
Life Safety Code violations are more prominent "not only due to the high emphasis The Joint Commission places on life safety, but also due to the general lack of understanding by facility managers of the code and the interpretations made by [The Joint Commission]," said Keyes, who is a former life safety specialist with the accreditor.
Life safety specialists, who have working knowledge of the Life Safety Code and often have experience as facilities professionals at hospitals, joined survey teams back in 2005.
The specialists tour the building from roof to basement, checking how well the facility complies with the various provisions in The Joint Commission's life safety standards and related Life Safety Code requirements.
The addition of the life safety specialists was prompted by a U.S. Government Accountability Office report issued in 2004 that concluded Medicare validation surveys at hospitals uncovered serious fire safety deficiencies that Joint Commission surveyors hadn't identified in earlier visits.
Other problems make the list
In addition to Life Safety Code deficiencies, the old EC.5.40, which sets a variety of provisions for the inspection, testing, and maintenance of fire protection equipment, was the sixth most-cited standard last year, affecting 26% of hospitals. EC.5.40 has since been renumbered EC.02.03.05.
Here is the top 10 list of cited standards in 2008, along with the percentage of hospitals cited, as published by Perspectives:
- EC.5.20 (45%)—Life Safety Code compliance
- IM.6.50 (43%)—Qualified staff members transcribing verbal or telephone orders
- MM.2.20 (37%)—Properly stored medications
- National Patient Safety Goal 2C (37%)—Improving timeliness of reporting and receiving critical tests and results
- IM.6.10 (31%)—Keeping complete and accurate medical records
- EC.5.40 (26%)—Maintaining fire protection equipment
- National Patient Safety Goal 3D (25%)—Labeling medications and medication containers
- HR.1.20 (22%)—Ensuring staff member qualifications are consistent with job responsibilities
- Universal Protocol 1C (21%)—Conducting time-outs immediately before starting procedures
- National Patient Safety Goal 8A (19%)—Comparing a patient's current medications with those ordered for the patient