TJC Redefines “Quarterly” and “Every 3 Years” for 2014

 By David Stymiest, PE, CHFM, CHSP, FASHE

Take a close look at your 2014 schedules for quarterly requirements such as fire safety system testing found in several elements of performance (EPs) under Standard EC.02.03.05.  The brand new 2014 TJC definition of QUARTERLY can be found on page EC-3 at the beginning of the EC Chapter in the 2014 Hospital Accreditation Standards.  The previous definition allowed quarterly activities to be accomplished anytime during a calendar quarter.  The 2014 definition, however, is “every three months, plus or minus 10 days.”  We recommend that you interpret this new requirement conservatively as three months from the date of the previous activity, plus or minus 10 days.


Also look at quarterly fire drill schedules in accordance with Standard EC.02.03.03, EP-1.  Although it is not clear if an EC-chapter definition would extend to a related LS-chapter requirement, we recommend that a safe approach would be to look also at the additional quarterly fire drills scheduled to comply with the Standard LS.01.02.01, EP-11 Interim Life Safety Measure.  We recommend that you take a close look at the new definition and check the schedule dates for the first day shift drills in each quarter, the second day shift drills in each quarter, the first evening shift drills in each quarter, etc.

And for those organizations that have a stored emergency power supply system (SEPSS), the Standard EC.02.05.07 EP-3 requirement for SEPSS quarterly testing is another area to review.

We recommend that organizations look at the actual dates for quarterly testing in 2013-Q4 and make sure that the 2014-Q1 dates will be in compliance with the new definition.  And then take a close look at the entire 2014 testing calendar as well.

The other 2014 change in how TJC defines time between testing and inspection activities is the 3-Year test.  The new EC chapter definition is 36 months from the date of the last event, plus or minus 45 days.”  This is a change from the previous “plus or minus 30 days” requirement and is a minor relaxation of the rule that applies to the generator 4-hour tests required by Standard EC.02.05.07, EP-7.