August 2017
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Greetings from the Healthcare Facilities Leadership program at OCTC. In this newsletter, I would like to hit on a very specific industry trend that is impacting every healthcare facility professional from front line technicians to top leadership. It started out a couple of years ago with fire and smoke door inspections and has now expanded to ALL life safety equipment and features. The issue revolves around the “immediate” requirement to address life safety deficiencies. Gone are the days of 12 years to take care of life safety deficiencies on your Statement of Condition with a PFI.
With the removal of the Plan for Improvement, light has quickly been shed on how healthcare facilities routinely defer the repair of life safety equipment and features. This is clearly represented in the following Joint Commission Standard-
- LS.01.02.01 EP 2 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24 hour period in an occupied building. Notifications and fire watch times are documented.
The term immediate has been clarified to mean the shift the deficiency is found plus one more shift. While this is easily understood, the bigger issue is the historical behavior of delayed documentation after inspections or routine rounds. Following are a couple of examples-
- Security identifies a burnt out exit sign during rounds on the weekend.
- Maintenance needs to order a battery after identifying a failed 90 minute egress light test.
- A contractor sends you a report of deficiencies days after inspection.
All of these would result in an immediate failure to comply unless an ILSM had been put in place immediately.
We must educate and train everyone responsible for identifying and correcting life safety feature issues. We must also train and educate more people on how to put in an effective and practical ILSM protocol. I believe our current ILSM documentation is too cumbersome to meet operational efficiencies. I am sure many of you are working on this already.
In future issues, I will address the now required 100% PM completion rate for equipment, Competency Based Training, ASHRAE 188, and Preventive Maintenance Checklist strategies. Hang in there and know that you are making a difference.
Looking forward to future updates.
Warmest Regards,
Mike
Mike Canales mike.canales@kctcs.edu phone #270 852 8142
Mary Kinney mary.kinney@kctcs.edu phone #270 686 4434
