Eliminating Immediate Threat to Life Situation Time Limit

Is there a time limit to eliminate an “immediate threat to life” situation for all TJC accreditation programs?

It is always expected that organizations will take immediate action when discovering, encountering, or facing any immediate threat to life situations. However, in some cases, TJC is allowing organizations up to 23 days maximum to resolve issues if the immediate threat cannot be corrected within 72 hours.

If after discovery by a surveyor followed directly by an expedient internal TJC review process, TJC believes an immediate threat to life exists, their president or a designee will issue an expedited Preliminary Denial of Accreditation (PDA) decision. The organization will be notified and the PDA decision will be posted on The Joint Commission’s Quality Check® Web site, and appropriate governmental agencies will be notified at that time. The organization is given five days to notify TJC if it wishes to appeal the PDA decision.

After notification of the PDA decision, an organization has up to 72 hours to do the following:

• Eliminate the immediate threat to life situation entirely (example: removing adult medication doses from a pediatric unit); or
• If the situation is such that it will take the organization additional time to fully eliminate (example: something involving building construction), then they must implement interim life safety measures (ILSM) to abate the risk to patients (example: cease performing a certain procedure and implement additional life safety measures) within 72 hours. If the situation is not fully eliminated or resolved within 72 hours, the organization will have, at a maximum, up to 23 days to do so.
• Note: In a footnote in the above referenced Joint Commission Perspectives® article, TJC states that “interim life safety measures” now refer to any safety measure(s) implemented to preserve life, whether related to the traditional Life Safety Code® deficiencies, renovation or construction activities, or some other immediate threat to life situation. (See Standard EC.5.50 in HAS manual for previously defined ILSMs.)

Once The Joint Commission has been notified by the organization that it has abated the immediate threat to life situation, TJC will conduct an “abatement” survey to validate the abatement. If the abatement survey confirms the absence of the immediate threat to life situation, TJC will remove the PDA decision. Therefore, it behooves organizations to respond as quickly and effectively as they can to remove or resolve the immediate threat to life situation.