Compliance News: Fire Protection Systems Testing Revisions by TJC

By Dean Samet, CHSP

In the May 2011 edition of The Joint Commission Perspectives, TJC an­nounced a change effec­tive July 1, 2011 for Envi­ronment of Care Standard EC.02.03.05, EP 2 and introduced a new EP 25. The standard, “the hos­pital maintains fire safety equipment and fire safety building features” remains unchanged.

EP 2 has been changed and will require quarterly testing of water-flow devices. TJC stan­dards previously required testing every six months or semi-annu­ally in accordance with NFPA 72, 1999 edition. EP 2 will read as follows: “For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly, the hospital tests wa­ter-flow devices. Every six months, the hospital tests valve tamper switches. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 25, 1998 edition (Sections 2-3.3 and 3-3.3) and NFPA 25, 1999 edition (Ta­ble 7-3.2). For hospitals that do not use accreditation for deemed status purposes: Every six months, the hospital tests valve tamper switches and water-flow devices. The completion date of these tests is documented.”

Compliance News: Disinfection Note Revision for TJC Infection Prevention and Control Standard

By Dean Samet, CHSP

Effective April 1, 2011, The Joint Commission made a slight revi­sion to the Note for Standard IC.02.02.01, EP 2. The following lan­guage has been deleted: “Intermediate level disinfection is used for items such as specula.”

The standard and note now read as follows: “The [organization] implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.* (See also EC.02.04.03, EP 4.)

Note: Sterilization is used for items such as implants and surgi­cal instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes.

* For further information regarding performing immediate and high-level disinfection of medical equipment, devices, and sup­plies, refer to the web site of the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/hicpac/Disinfection_Ster­ilization/acknowledg.html (Guide for Disinfection and Sterilization in Healthcare Facilities, 2008).

Compliance News: Emergency Management - Exercises

By Susan McLaughlin, MBA, FASHE, CHSP

The Joint Commission requirements for emergency exercises have been relatively static over the past several years. But there have been several minor changes, primarily in the notes to ele­ments of performance in EC.03.01.03, that merit taking a closer look at what is needed.

First the schedule, which hasn’t changed in and of itself. Hospi­tals must do two “live” exercises per year (as opposed to tabletops) to include the following three scenarios: Influx of patients (EP 2), Sustainability (EP 3), and Community integration (EP 4).

The twice a year requirement comes out of EM.03.01.03, EP 1, which contains Note 2, “Staff in freestanding buildings classified as a business occupancy (as defined by the Life Safety Code®) that do not offer emergency services nor are community designated as disaster receiving stations need to conduct only one emergency exercise annually.” Conversely, if there are business occupancies that DO offer emergency services and/or ARE disaster receiving stations, the implication is that these facilities are under the same exercise requirements as a hospital.

Compliance News: ECRI's Top 10 Health Technology Hazards for 2011

By David Stymiest, PE, FASHE, CHFM


Emergency Care Research Institute (ECRI) recently published a Health Devices guidance article entitled “Top 10 Technology Hazards For 2011” listing ten sources of potential danger that ECRI believes warrant the greatest attention in 2011 for protecting patients and staff. The article, available on www.ecri.org, provides detailed guidance for each of the following issues.

1.  Radiation Overdose and Other Dose Errors during Radia­tion Therapy* - Stating that this can take the form of deliver­ing the wrong dose, treating the wrong site on the patient, or treating the wrong patient, ECRI included specific recom­mendations for support, training, installation, commissioning, maintenance, procedures, oversight, and implementation of corrective actions. 

2.  Alarm Hazards* - Discussing alarm-related adverse incidents typically involving staff being overwhelmed by the number of alarms, alarm settings not being restored, and alarms not being properly relayed to ancillary notification systems, ECRI made specific recommendations for examining the entire alarm environment, establishing protocols for settings and response, implementing and monitoring policies to control alarm silencing, modification, and disabling. 

Notifying TJC about Significant Changes

What is the maximum amount of time after an addition is made to a hospital does the hospital have to notify TJC of the change?

Managing the Impact and Costs of Emergency Power Testing on Hospital Operations: A Case Study

By David L. Stymiest, PE CHFM FASHE; Jack W Dean, PE; and Anand K. Seth, PE CEM 
(This white paper was first presented at ASHE's 35th Annual Conference, July 1998.  It has not been updated for 2011 and is provided here as an historical reference only.)

Introduction

Hospitals are required to have an emergency power testing program in place to meet the requirements of NFPA 70, NFPA 99 and NFPA 110, as well as standards established by accreditation organizations such as JCAHO. The goal of the emergency power testing program should be to comply with regulatory requirements without adversely affecting the operation of the hospital or the well-being of the patients. The specific requirements to be met are referenced by the forerunner to this paper. That technical document addresses the importance of simulating actual loading conditions during the testing period and the necessity of following up on the test results to identify problems and take corrective action. This paper builds upon that publication by detailing a case study of emergency power testing occurring over a significant period of time at the Massachusetts General Hospital (MGH), issues uncovered (which might be described as second order consequences of the emergency power testing effort) and the steps taken to eliminate problematic issues.

Emergency power testing programs involve transferring the power sources of operating systems from utility power to the emergency generators and back. This action can cause disruption to increasingly more complex clinical and building equipment, building automation systems, and hospital operations. When managed properly and proactively followed through, these disruptions are valuable learning experiences and provide opportunities to improve the hospital infrastructure, improve hospital operations and reduce the hidden costs of testing. This case study presents a number of lessons learned and offers proactive strategies for managing the process. The lessons learned also illustrate areas where future system designs should be improved.

Read entire article here: Managing the Impact and Costs of Emergency Power Testing 

Medical Records Protection

One of the bullet points in IM.2.20,EP 6, mentions protecting records in a manner that minimizes the possibility of damage from fire or water. How can we protect our records from both fire and water when we are mandated to have sprinklers in the chart room in case of fire? We will have a problem with water if the sprinklers go off.

Using Load Profiles to Determine EPSS Peak Demand Load

David Stymiest, PE CHFM FASHE, DStymiest@ssr-inc.com

The author has used load profiling to determine EPSS peak demand load for more than 20 years.  The discussion below is intended to highlight some of the lessons learned.  For a full discussion, refer to the author’s 2009 ASHE Management Monograph, “Managing Hospital Emergency Power Systems – Testing, Operation, Maintenance and Power Failure Planning” available at http://www.ashe.org/.

NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at www.nfpa.org.

Hospitals should document their actual EPSS peak demand load.  It is not enough to assume that the highest emergency generator kilowatt (kW) demand during an early-morning monthly test represents the true peak EPSS demand load.  This is a poor assumption due to the variability of mechanical, building, and clinical process loads during a typical hospital workday.  If an EPSS test time is chosen due to low clinical activity, then that avoided clinical load will not be reflected in the EPSS test loading.  Additionally, some equipment, such as smoke control systems and fire pumps, will not operate except during atypical situations.

Life Safety Essentials: Coverings and Decorations Applied to Fire Doors

Learning Objective: To review the standard for materials on fire doors.
 
By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

The Joint Commission’s 2011 Hospital Accreditation Standard for Life Safety LS.02.01.10 Element of Performance 7 states “Doors requiring a fire rating of 3/4 hour or longer are free of coverings, decorations, or other objects applied to the door face, with the exception of informational signs”. (For full text and any exceptions, refer to: NFPA 80-1999: 1-3.5) According to NFPA 80 Standard for Fire Doors and Fire Windows informational signs are permitted to be installed on the surface of fire doors but the total of area of all attached signs are not to exceed 5 percent of the area of the face of the fire door to which they are attached. Signs must be attached to fire doors using adhesive, mechanical attachments such as screws or nails are not permitted. Signs are not to be installed on glazing material in fire doors. Signs should not be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation of the fire door. 

45 Day Deficiencies Time Line

What is the time frame that the Joint Commission permits before a deficiency to a life safety feature must be entered in the SOC? In other words, does The Joint Commission allow an organization to manage the resolution to a life safety deficiency through a work order system if it can be resolved quickly?

Locks on Patient Room Doors

What is the NFPA code that discusses locks on Patient Room doors?  Are they allowed?

Fire Watches

Does The Joint Commission have any standards that cover fire watches, i.e., designating an employee to watch for fire dangers when fire-prone conditions occur, such as hot work being performed near insulation?  

Pressurized Stairwells

What is the criteria that determines if a building will have a pressurized stairwell?  What about elevator shafts?

Storage in Elevator Areas

A hospital has an elevator bank where the smoke doors close off the area, making the path of egress at the stairs in the hallway prior to the smoke doors.  Is it acceptable to put beds or wheelchairs in the elevator area as there is limited storage space elsewhere? 

Emergency Power - Crash Carts

Do you know of a regulatory citation that requires crash carts to be plugged into a red outlet?  There is a local policy that requires life support systems (not sure if the definition applies to a crash cart but it does apply to the defibrillator) to be plugged into a red outlet.

Storage in Alcoves

A small, 4 shelf book cabinet has been placed in a little shallow alcove (not in any pathway) in one of the elevator lobbies.  Is it legal by NFPA standards to keep the shelf unit where it is?

Life Safety Essentials: Emergency Responder Radio Coverage

Learning Objective: To identify if radio coverage is adequate for emergencies and disasters.

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

During emergencies and disasters the emergency responding agencies must have sufficient radio coverage to conduct and direct interior and exterior operations. Many buildings throughout the country that are made of concrete and steel can shield or hamper radio communications.  Recognizing the need for emergency responder radio coverage, the 2009 International Fire Code® says that “All buildings shall have approved radio coverage based upon the existing coverage levels of the public safety communication systems of the jurisdiction at the exterior of the building”.  

Two exceptions to the requirement are a wired communication system and a determination by the local authority having jurisdiction that the radio coverage is adequate.  In addition, there are specific requirements for the minimum signal strength into the building and out of the building. Where radio coverage or a wired communication system is not provided, the local authority will determine if such system is needed and establish a time frame for compliance. Healthcare organizations should consult their local fire department to determine if radio communications are adequate and if these provisions of the International Fire Code® are locally adopted.

Toasters and Toaster Ovens

I know we are not to have anything with an open/exposed heating element.  What is the rule on toaster ovens in staff lounges? 

Fire Department Notification

Is a General Contractor’s written statement (ex. in meeting notes or a memo) that they notified the fire department sufficient documentation, or should the hospital insist on getting copies of the Fire Department notification?

Electrical Rooms and Closets

What issues could a TJC or CMS surveyor cite in electrical rooms and electrical closets? 

Self-Preservation

What is the revised reference statement from CMS on the classification of an ambulatory occupancy as defined by one or more patients being incapable of self preservation?