Joint Commission discusses Fire Safety Equipment Inventories at ASHE Conference

 By David Stymiest, PE CHFM CHSP FASHE

The Joint Commission (TJC) Engineering Director George Mills addressed the issue of fire safety equipment inventories at his 2013 ASHE Annual Conference plenary in July.

Mr. Mills stated that with respect to Standard EC.02.03.05, Elements of Performance (EPs) # 1 through # 20 inclusive, every device required to be tested must be documented in an inventory. He further stated that TJC surveyors will expect the facility to be able to identify specific variances in devices tested from year to year, and that simply having the total quantity of devices without more specific definition will not be adequate. Finally, Mr. Mills stated that lack of a written, electronic, or other form of inventory addressing the devices covered by any of the 20 EPs could result in a finding against that EP. Needless to say, Organizations who have yet not finalized their EC.02.03.05 inventories can be subject to numerous RFIs during survey.

TJC Addresses CMS Categorical Waivers

 
By David Stymiest, PE CHFM CHSP FASHE

 ASHE recently discussed in its Listserv TJC’s response to the CMS categorical waivers.

According to ASHE, TJC requested that organizations indicate in the eBBI’s Additional Comments field the acceptance of any categorical waivers as well as so noting those decisions in the EOC Committee minutes. TJC Life Safety Code surveyors will field-verify that the CMS conditions are being met for any accepted waiver, similarly to the CMS onsite field-verification approach.

TJC Provides Tips for Meeting Problematic Life Safety Compliance Requirements 

By David Stymiest, PE, CHFM, CHSP, FASHE

TJC Director of Engineering George Mills provides tips for meeting problematic life safety compliance issues in the July 2013 of The Joint Commission’s EC News.  This valuable multi-page article addresses the following elements of performance (EPs) and related types of survey requirements for improvement:

TJC Strengthens Leadership Accountability for Emergency Management

By David Stymiest, PE, CHFM, CHSP, FASHE

In the July 2014 issue of Joint Commission Perspectives, TJC officially issued new and revised leadership requirements intended to provide “a clearer description of leadership-level oversight of emergency management.”  The new and revised elements of performance are all effective January 1, 2014. 

TJC Issues 2014 National Patient Safety Goal on Clinical Alarm System Safety

By David Stymiest, PE, CHFM, CHSP, FASHE

In its Joint Commission Online article dated June 26, 2013 (available at http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf) The Joint Commission announced a new 2014 National Patient Safety Goal NPSG.06.01.01 on clinical alarm safety for both hospitals and critical access hospitals.  The July 2013 issue of Joint Commission Perspectives discusses the new NPSG in detail.

Opening Day - Transitioning from construction to survey-ready operation

Opening Day

Transitioning from construction to survey-ready operation

This article first appeared in the May 2010 issue of HFM Magazine.

By David l. Stymiest, P.E., FASHE, CHFM

Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.

Click here to go to article at the HFM Magazine website.