2013
THE HEALTHCARE ENVIRONMENT
Anne M. Guglielmo
Engineering Department
The Joint Commission
© Copyright, The Joint Commission
UPDATE
Risk
RISK ICON
•
•
•
•
Proximity to patient
Probability of harm
Severity of harm
Number of patients at risk
 Integrated into the Manuals, E-dition, AMP, & FSA Tool
for three risk-focused categories:
1. National Patient Safety Goals
2. Accreditation program-specific risk area standards
3. Selected direct/indirect impact standards
 In addition, the FSA Tool will use the R icon to identify
the fourth risk category:
4. RFI standards from current cycle survey events.
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 All products will display a single icon at the EP level
RANKING RESULTS: 11 OUT OF 21 IN 2012
Standard
2012
RFIs
2011
RFIs
2
LS.02.01.20
51%
56% Means of Egress
3
LS.02.01.10
46%
52% General LSC Requirements
5
EC.02.03.05
40%
40% Features of Fire Safety
6
LS.02.01.30
39%
45% Life Safety Protection
7
EC.02.06.01
35%
31% Built Environment
9
LS.02.01.35
34%
29% Fire Suppression Systems
10
EC.02.05.01
33%
23% Utility Systems (Ventilation)
11
EC.02.02.01
30%
25% Hazardous Materials & Waste
15
EC.02.05.09
23%
22% Medical Gases
17
EC.02.05.07
22%
26% Emergency Power
21
EC.02.03.01
19%
21% Fire Safety
Subject
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Top
20
Rank
#2: LS.02.01.20 51%
egress.
 EP 13 Corridor Clutter
 Also scored
 EPs 16 – 21 Suites issues
 Boundaries & Size defined
• Sleeping Suite <5000 sq ft
• Non-sleeping suite <10,000 sq ft
 EP 22: Patient sleeping room is not locked
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 The hospital maintains the integrity of the means of
CORRIDOR STORAGE
“If the corridor looks cluttered…it probably is”
 Carts Allowed:
 Crash Carts
 Isolation Carts
 Anything in the egress corridor more than 30
minutes is storage
 Dead end corridors may be used for storage
 Less than or equal to 50sqft space
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 Chemo Carts
SUITES
 Not identified on drawings
Boundaries
Dimensions
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Exits
LS DRAWING INFORMATION
 A legend that clearly identifies features of fire safety

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



building is partially sprinklered)
Locations of all hazardous storage areas
Locations of all rated barriers
Locations of all smoke barriers
Suite boundaries, including the size of the identified
suites—both sleeping (max 5,000 sq ft) and non-sleeping
(max 10,000 sq ft)
Locations of designated smoke compartments
Locations of chutes and shafts
Any approved equivalencies or waivers
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 Areas of the building that are fully sprinklered (if the
#3: LS.02.01.10 46%
designed and maintained to minimize the
effects of fire, smoke, and heat.
EP 9 Fire Barrier Penetrations
EPs 5 – 7 Door issues
EPs 1 & 2 Building Type issues
EP 8 Duct issues
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 Building and fire protection features are
#5: EC.02.03.05 40%
 The hospital maintains fire safety equipment
Risk Icons:
EP4: Audio/Visual Alarms
EP11: Water flow alarm to fire pump flow test
EP19: Automatic shutdown of AHU
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and fire safety building features.
Features of fire protection
NEED FOR INVENTORY
 EC.02.03.05 EP 1 – 20:
documented in an inventory
 If x devices were tested last year, and x-1 were tested
this year, which device was missed?
• Each device must be on the inventory to identify
which device was missed
• Total number of devices (quantity) is not adequate
 Lack of an inventory (written, electronic or other)
results in a finding at the EP
 Findings solely for lack of inventory is not scored at
EC.02.03.05 EP 25
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 Each device that is required to be tested must be
EC.02.03.05
reviewed
 If the documentation for a specific EP is not
available a finding is written as non-compliant
for that EP
 The documentation should be readily
available
 If the organization clarifies after survey:
 Joint Commission Engineers will review and
evaluate compliance
 LD.04.01.05 EP 4 remains
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 During survey specific documentation is
EPs 1 -20:
 Missing documentation: score the EP as noncompliant
 Also write a finding at EP 25 for documentation
not being readily available to the AHJ
• If acceptable documentation appears, finding
at EP 1 – 20 might be removed during survey
• EP 25 remains
 LD.04.01.05 EP 4: Staff held accountable
 If 3 or more findings at EC.02.03.05 EP 1 – 20
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EC.02.03.05
EC.02.03.05 EP 25
 For hospitals that use Joint Commission accreditation for
deemed status purposes:
 Documentation of maintenance, testing, and
inspection activities for fire alarm and waterbased fire protection systems includes the
following:
Note: For additional guidance on documenting activities:
 NFPA 25, 1998 edition (Section 2-1.3)
 NFPA 72, 1999 edition (Section 7-5.2)
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Below for Contents
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Name of the activity
Date of the activity
Required frequency of the activity
Name and contact information, including
affiliation, of the person who performed
the activity
NFPA standard(s) referenced for the
activity
Results of the activity
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EC.02.03.05 EP 25
#6: LS.02.01.30 39%
The hospital provides and maintains
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building features to protect individuals
from the hazards of fire and smoke.
EPs 16 – 23 Smoke Barriers & Doors
EP2 Hazardous Areas
#7: EC.02.06.01 35%
patient population and are safe and
suitable to the care, treatment and
services provided
The organization must provide a safe
environment
 Unsecured oxygen cylinders
 Outdoor safety is scored at
EC.02.01.01 EP 5
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 EP 1 Interior spaces meet the needs of the
EC.02.06.01
temperature and humidity levels suitable for the care,
treatment and services provided
 Ventilation:
• i.e. doors held open by air pressure; odors
 Temperature:
• Hot / Cold calls
 Humidity
• Primary concern is for areas >60%RH
− Mold growth is possible
 EP 20: Patient care areas are clean and free of
offensive odors
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 EP 13 The organization maintains ventilation,
#9: LS.02.01.35 34%
Risk Icon:
EP 1: monitor authorized automatic sprinkler system
EP 2: water flow alarm
maintained below the sprinkler deflector to the
top of storage.
NOTE: Perimeter wall and stack shelving may
NFPA 13-1999, 5-6.6
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 There are 18” or more of open space
Perimeter
Shelving
18” RULE
Perimeter
Shelving
Ceiling
18”
18”
Wall
OK
Wrong
OK
OK
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Wall
#11: EC.02.05.01 33%
 EC.02.05.01 EP 1: Improper system design
achieve required results
 EC.02.05.01 EP 4: Lack of written inspection,
testing & maintaining frequencies
Continuous monitoring by a building
automation system (BAS) is acceptable
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Inability of the mechanical system to
EC.02.05.01
appropriate pressure relationships, air-exchange rates and
filtration efficiencies
 Specific areas lack
 negative or positive pressures in relationship to
adjacent areas
• i.e. Endoscopy Processing Room should be negative
to the egress corridor
 the correct number of air changes per hour
 Improper filtration
• MERV = minimum efficiency reporting value
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 EC.02.05.01 EP 6: Ventilation system is unable to provide
#11: EC.02.02.01 30%
 EP’s 3 – 5: Personal Protective Equipment
and the process to manage hazardous
materials and waste handling and
exposures
EP 4 is a RISK ICON
 EP’s 6 – 7: Hazardous energy sources
 Escorts to Hot Lab based on organization
policy
 Perspectives, July 2012
 EP 7 is a RISK ICON
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
#15: EC.02.05.09 23%
 Medical Gas Systems
 EP 1: Inspection Testing and Maintaining
 EP 2: Test when modified, installed or repaired
 EP 3: Obstructions
 EP 3: Labeling
 Areas served
• Accuracy
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 Contents of piping
EPs 4 – 7
 Missed Generator & Automatic Transfer
Switch (ATS) Tests
12 times per year between 20 & 40 days
 Each emergency generator must be
tested with a load of at least 30% of
nameplate
 Each ATS must be tested
 Missed triennial 4 hour test
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#17: EC.02.05.07 22%
#21: EC.02.03.01 19%
 Fire Plan (EP 9 & 10)
 Lack of fire safety training as per fire plan
 Surgical site fires
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 Fire Safety (EP 1)
 Open junction boxes
 More than 300cuft of nonflammable medical
gases (i.e. oxygen) per smoke compartment,
open to the egress corridor
LIFE SAFETY CODE SURVEYOR
 LSCS Background
Facilities or Environment of Care based
All HAP and CAH will be surveyed for a minimum
of 2 days by a LSCS
Greater than 1.5 million sq ft will be
surveyed for a third day by the LSCS
An additional day is added for every three
buildings that are classified as healthcare
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Prefer CHFM certification
LIFE SAFETY CODE SURVEYOR
 Interfaces with survey team member(s)
 LSCS Survey Focus
 Life Safety Chapter
 EC.02.03.05
 EC.02.05.07
 EC.02.05.09
May conduct the EC Session
 May conduct the EM Session
 Other “Observations”
 May also survey
 LD.04.01.05 EP 4 Accountability
 LD.04.04.01 EP 2 Hi-Priority
 LD.01.03.01 EP 5 Resources
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
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
 Significantly compromised fire alarm system
 Significantly compromised sprinkler system
supply system
 Significantly compromised medical gas master
panel
 Significantly compromised exits
 Other situations that place patients, staff or
visitors at extreme danger
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 Significantly compromised emergency power
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
 CONT01
The Immediate Treat to Health or Safety has
been successfully abated and verified through
the direct observation or other determining
method.
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 PDA01
An Immediate Threat to Health or Safety exists
for patients or the public within the hospital.
AFS 10 IS RELATED TO THE
SOC AND PFIS
accepted PFIs (LS.01.01.01 EP 2)
 Failure to develop ILSM policy and implement
appropriate ILSMs (LS.01.02.01 EP 3)
 Failure to manage previously accepted PFIs affects the
Joint Commission
 Both organizations are aware of deficiencies that
have been managed using the PFI process
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 Failure to make sufficient progress on previously

Resolution to a deficiency:
 Resolve it immediately
 Correct it within 45 days:
 Management process that documents the
deficiency and actions to resolve
 ILSM must be considered
 Plan For Improvement located in the Statement
of Conditions™
 Corrected within 6 months of the Projected
Completion Date
 ILSM must be considered
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DEFICIENCY RESOLUTION
45 DAY CORRECTIVE ACTION
 Documented
 Origination date
 Completion date
 Kept available for rolling 3 years
 Life Safety deficiencies
 Must not exceed 45 days
(PFI)
If originally a work order, close out as complete and
generate the PFI
 Must be made available to the Joint Commission
 During survey to confirm management of the deficiency
 Upon request by the Joint Commission
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 If greater than 45 days create a Plan For Improvement
HOW MANY OPEN PFIS
ARE TOO MANY?
self assess and create a Plan for Improvement
 The self disclosure has never defined how many is too
many
 The ILSM process was created to allow both the
organization and The Joint Commission to be aware of
Life Safety Code deficiencies
 Failure to make progress on previously accepted PFIs,
including failure to implement ILSMs results in
Conditional Accreditation
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 The PFI process was created to allow organizations to
HOW MANY OPEN PFIS
ARE TOO MANY?
 Survey Process:
 There is no limit to the number of PFIs
View All screen
 Spot check during building tour both some closed and
open PFIs to evaluate how well the organization is
managing the PFI process
 Evaluate the scope of PFI entries
 Are there life safety deficiencies
 Are they greater than maintenance items (i.e.
screws missing from a door hinge)
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 Evaluate both closed and currently open PFIs in the
STATEMENT OF CONDITIONS: PFI
 PFIs should be related to the LS Chapter
 PFIs should provide specific information
 No blanket statements
“…penetrations on 3rd floor”
 Specific references to Life Safety Drawings is
acceptable
 32 penetrations as identified on LS Drawing
3rd Floor, Center Tower dated 3/3/2010
 Projected Completion Date is for all listed
items (i.e. “32 penetrations”)
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
TWO FORMS OF EQUIVALENCIES
 Fire Safety Evaluation System (FSES)
deducting any deficiencies, with the outcome determining
if the building is equivalized based on the FSES
 Traditional Equivalency
 A process of field verification identifying alternative
methods of fire safety that off-set the identified deficiency
 Field verification from one of the following:
 Registered Architect
 Fire Protection Engineer
 Local AHJ responsible for fire safety
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 A process of calculating the features of life safety and
HISTORY AUDIT TRAIL
when considering extensions or other activities
related to an organization
 Prior to surveying, the surveyor must preview the
History Audit Trail to discover if equivalencies or
other actions have occurred by SIG Engineers
 When surveying, brief but accurate information
entered in the File Room is important
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 The History Audit Trail is used by SIG Engineers
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2012 LIFE SAFETY CODE
1.Means of Egress Enhanced
 Patient lift & transport equipment may be
stored in the Means of Egress, provided
 5ft clear corridor width is maintained
 Fire plan addresses management of
storage
 Accommodates current “equipment in
use”
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NFPA 101-2012
NFPA 101-2012
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2. Fixed seating permitted
 provided 6ft clear width
 < 50sqft with 10’ between groupings
 Groupings must be on same side of
the egress corridor
3. Cooking Facilities
 One cooking area may be open to the egress corridor
per smoke compartment
 Any additional cooking areas must be in protected
room similar to hazardous areas
 Provisions:
 No deep fat fryers
 Safety equipment to de-activate fuel supply
 Grease baffles installed
 No solid fuel (i.e. charcoal)
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NFPA 101-2012 CORRIDOR COOKING
4. Fireplaces in smoke compartments with patient
sleeping rooms
 Section 18/19.5.2(2), (3) and (4)
 Allow the installation of direct vent gas
fireplaces
 In smoke compartments containing patient
sleeping rooms
 Installation of solid fuel burning fireplaces in
areas other than patient sleeping areas
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NFPA 101-2012 FIREPLACES
5. Allow the use of Furnishings, Mattresses,
and Decorations including Section 18/19.7.5
Allows the installation of combustible
decorations on
 Walls
 Doors
 Ceilings
LSC Section 18/19.7.5.6
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NFPA 101-2012 DECORATIONS
BUILDING MAINTENANCE PROGRAM
(BMP)
All EPs related to the original
ten BMP items are ‘C’ categories
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The BMP is no longer available to offset
findings during survey, but is
considered “best practice”
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RISK ASSESSMENT
EC.02.01.01 EP 1 (A CATEGORY)
the environment of care that could affect patients, staff and
other people coming into the hospital’s facilities.
 NOTE: Risks are identified from internal sources such as
ongoing monitoring of the environment, results of root
cause analysis, results of annual proactive risk assessments
of high-risk processes, and from credible external sources
such as Sentinel Event Alerts. (See also EC.04.01.01 EP 14).
 Is there a risk assessment process?
 Quality of the risk assessment process
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 The hospital identifies safety and security risks associated with
EC.02.01.01 EP 3 (C CATEGORY)
 The hospital takes action to minimize or
eliminate identified safety and security
risks in the physical environment.
 Did the organization respond to the risk
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assessment and correct the identified risk?
Identify Safety &
Security Risks
Risk
Assessment
EC.02.01.01
Established
Process?
No
Yes
Yes
No
Resolved?
Yes
EP 1
No
Unsafe
conditions?
Consider
EC.02.06.01
EP 1
EP 3
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EP 1
Identify Risk?
EC.02.06.01 EP 1
 Interior spaces meet the needs of the patient
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population and are safe and suitable to the care,
treatment and services provided.
 Unsafe patient care areas
 Behavioral Healthcare Unit: Clinical or Physical?
• Ensure the risk is not being managed clinically
• Does not include non-patient care areas
WHEN TO CONDUCT A RISK ASSESSMENT
decision
 Educated guess that drives your assumptions
 Clearly document the process
 Determine when to re-assess the issue
 Problem solving approach to determine
appropriate response
 Preventive strategies to address potential issues
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 Use to evaluate any issue that lacks a clear
CONDUCTING A RISK ASSESSMENT:
SEVEN STEPS
2.
3.
4.
5.
6.
7.
Develop arguments in support of the issue
Develop arguments against the issue
Objectively evaluate both arguments
Reach a conclusion
Document the process
Monitor and reassess the conclusion to
ensure it is right conclusion
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1. Identify the issue
ENVIRONMENTAL TOURS
 The organization monitors conditions in the environment
of care.
 EP 12 Environmental tours
patient care areas every six months
 EP 13

Environmental tours
non-patient care areas annually
 EP 14
Ongoing monitoring of actual / potential risk
 EP 15
Evaluation of objectives, scope, performance
and effectiveness of all EOC management plans
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
EC.02.06.05 EPS 2 & 3
Preconstruction Risk Assessment (PRA)
Construction or renovation in occupied
healthcare facilities can result in environmental
problems such as:
 Noise
 Vibration
 Creation or spread of contaminants
 Disruption of essential services
 Emergency Procedures
 Air quality
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PRA
INTERIM LIFE SAFETY MEASURES
 Order of Standards (LS.01.02.01)
 EP 1 & 2 regardless of ILSM policy
including
 AFS 10 Process
 When to implement
 What to do to protect occupants
 Both construction related and noncompliance with the LSC
 EPs 4 – 14 align with policy and
implementation strategies
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 EP 3 must clearly define the ILSM policy
DEPARTMENT OF ENGINEERING
630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Director
Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
John Maurer, CHFM, CHSP
OPEN Engineer Position
OPEN Engineer Position
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Engineer
THE JOINT COMMISSION DISCLAIMER
reserves the right to change the content of the information, as
appropriate.
 These slides are only meant to be cue points, which were
expounded upon verbally by the original presenter and are not
meant to be comprehensive statements of standards
interpretation or represent all the content of the presentation.
Thus, care should be exercised in interpreting Joint
Commission requirements based solely on the content of these
slides.
 These slides are copyrighted and may not be further used,
shared or distributed without permission of the original
presenter or The Joint Commission.
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 These slides are current as of 5/1/2013. The Joint Commission