2011
Joint Commission
Findings , Impact & Update
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission
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Joint Commission & CMS:
Issue Resolution
Top 5 Most Cited
Standards in 2010
1. 62% RC.01.01.01
1. 47% EC.02.03.05
2. 50% LS.02.01.20
2. 44% LS.02.01.10
3. 44% LS.02.01.10
3. 40% EC.02.05.07
4. 38% EC.02.03.05
4. 33% LS.02.01.20
5. 37% LS.02.01.30
5. 27% EC.02.06.01
SIG Engineering 2011 - 2
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Hospitals
Critical Access
Hospitals
#2: LS.02.01.20 (50%)
of the means of egress.
EP 13 Corridor Clutter
EP 12 Projections
EPs 16 – 22 Suites issues
 Equivalize > 5000 sq ft
EP 1 Doors locked in means of
egress
SIG Engineering 2011 - 3
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 The hospital maintains the integrity
Corridor Storage
 “If the corridor looks cluttered…it probably is”
 Corridor clutter is not a PFI issue
 Carts Allowed:
Carts
 Isolation Carts
 Chemo Carts
 Based on a HITF Interpretation (TJC, CMS &
other AHJs) the following carts are not allowed:
 Linen Hampers
 Latex Carts
 Anything in the egress corridor more than 30
minutes is storage
SIG Engineering 2011 - 4
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 Crash
Corridor Storage
storage
Less than or equal to 50sqft space
 Converting patient room:
Long term include door closure
 Surge issue: based on policy patients
may be treated in the egress corridor
during surge conditions
SIG Engineering 2011 - 5
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 Dead end corridors may be used for
#3: LS.02.01.10 (44%)
 Building and fire protection features
are designed and maintained to
minimize the effects of fire, smoke,
and heat.
9 Penetrations
 EPs 5 – 7 Door issues
 EPs 1 & 2 Building Type issues
 EP 8 Duct issues
SIG Engineering 2011 - 6
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 EP
#4: EC.02.03.05 (38%)
 The hospital maintains fire safety
equipment and fire safety building
features.
of fire protection
NOTE: #1 for Critical Access Hospitals
SIG Engineering 2011 - 7
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 Features
#5: LS.02.01.30 (37%)
 The hospital provides and maintains
building features to protect
individuals from the hazards of fire
and smoke.
16 – 23 Smoke Barriers & Doors
 EP 2 Hazardous Areas
SIG Engineering 2011 - 8
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 EPs
Life Safety Code Specialist
 LSCS Background
or Environment of Care based
 Prefer CHFM certification
 LSCS Agenda
 On-Site Two Days
 Interfaces with survey team member(s)
 LSCS Survey Focus
 Life Safety Chapter
 EC.02.05.03
 EC.02.05.07
 EC.02.05.09
 Other “Observations”
SIG Engineering 2011 - 9
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 Facilities
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
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
Example: for a HAP organization with 2 million
square feet of healthcare occupancy and 5
buildings classified as healthcare occupancy:
the number of LSCS days would be 4
SIG Engineering 2011 - 10
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Life Safety Code Specialist
LD.04.01.05 EP 4: What to do when
the documentation isn’t there…
as non-compliant
 Also score LD.04.01.05 EP 4
 If the documentation becomes available later in the survey
to the survey team, the team can:
 Consider removing the previous finding if documentation
confirms the activity was completed as per the EP
 LD.04.01.05 EP 4 may also be removed during survey
 If the survey team would prefer not to evaluate the
documentation the organization can submit clarification
 If the organization clarifies after survey:
 SIG Engineers will review and evaluate compliance
 LD.04.01.05 EP 4 remains
SIG Engineering 2011 - 11
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 During survey specific documentation is reviewed
 If the documentation is not available write the observation
What Triggers ITL
(Immediate Threat to Life)
system
 Significantly compromised sprinkler system
 Significantly compromised emergency
power supply system
 Significantly compromised medical gas
master panel
 Significantly compromised exits
 Other situations that place patients, staff
or visitors at extreme danger
SIG Engineering 2011 - 12
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 Significantly compromised fire alarm
What Triggers AFS 13
accepted PFIs
 Failure to make sufficient progress
(LS.01.01.01 EP 2)
 Failure to 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
SIG Engineering 2011 - 13
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 AFS 13 is only related to 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
SIG Engineering 2011 - 14
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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
Improvement (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
 During CMS/Joint Commission validation process
upon request
SIG Engineering 2011 - 15
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 If greater than 45 days create a Plan For
How Many Open PFIs
Are Too Many?
organizations to 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
SIG Engineering 2011 - 16
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 The PFI process was created to allow
How Many Open PFIs
Are Too Many?
 Survey Process:
both closed and currently open
PFIs in the 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)
SIG Engineering 2011 - 17
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 Evaluate
Statement of Conditions: PFI
 PFIs should be related to the LS Chapter
clutter is not a legitimate PFI
 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”)
SIG Engineering 2011 - 18
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 Corridor
Equivalencies
equivalencies
 Traditional Equivalency
 A process of field verification identifying
alternative methods of fire safety that offset the identified deficiency
 Fire Safety Evaluation System (FSES)
 A process of calculating the features of life
safety and deducting any deficiencies, with
the outcome determining if the building is
equivalized based on the FSES
SIG Engineering 2011 - 19
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 The Joint Commission accepts two forms of
History Audit Trail
Engineers 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
SIG Engineering 2011 - 20
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 The History Audit Trail is used by SIG
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”
Contingency Planning




environment of care
Failure of utilities could directly impact patient
care delivery
Activities associated with managing utilities are
designed to ensure the reliability of the
systems day to day
Contingency plans are developed to ensure
reliability of utilities systems
Contingency plans address at least two issues:
 Utility/Equipment failure or disruption
 Emergency related failures or disruption
SIG Engineering 2011 - 22
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 Utilities exist to provide a safe and comfortable
Contingency Planning: Survey
contingency plans are current and
accurate
 Discuss the organization
Memorandum of Understanding and
its impact in the community
 Evaluate against Standards &
Elements of Performance
 Suggest the organization include
exercising these contingency plans
with their Emergency Exercise
SIG Engineering 2011 - 23
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 Organizations ensure their
EP 7 The hospital maps the distribution of utility
systems
EP 8 The hospital labels controls for a partial or
complete emergency shutdown
EP 9 The hospitals has procedures for responding to
utility system disruptions
EP 10 The hospitals' procedures address shutting off
the malfunctioning system and notifying staff in
affected areas
EP 11 The hospitals procedures address performing
emergency clinical interventions during utility
systems disruptions
EP 12 The hospitals procedures addresses the
following: How to obtain emergency repair services
EP 13 The hospital responds to utility system
disruptions as described in its procedures
SIG Engineering 2011 - 24
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EC.02.05.01 Utilities Mgmt.
Emergency Operations Plan identifies alternative
means of providing:
EP 2 electricity
EP 3 water needed for consumption and
essential care activities
EP 4 water needed for equipment and sanitary
purposes
EP 5 fuel required for building operations or
essential transport activities
EP 6 medical gas/vacuum systems
EP 7 Utility systems defined as essential, such
as
 Vertical & horizontal transport
 Heating & cooling systems
 Steam for sterilization
EP 8 Utility needs identified in the HVA
SIG Engineering 2011 - 25
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EM.02.02.09: Utility Disruption
Time Defined
NOTE 1: The above does not apply to required frequencies such as
emergency generator testing (see EC.02.05.07 EP 4 & 8)
NOTE 2: An alternative of developing either a unique, written
policy or adopting NFPA definitions when available is acceptable
SIG Engineering 2011 - 26
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The Joint Commission EC chapter defines time as:
 Daily, weekly, monthly and quarterly are
calendar references
 Semi-annual is 6 months from the last
scheduled event +/- 20 days
 Annual is 12 months from the last scheduled
event +/- 30 days
 3 years is 36 months from the last scheduled
event +/- 45 days
Semiannual: +/- 20 days
Annual: +/- 30 days
20
30
Scheduled
Month
Due
Date
+
20
20
30
Scheduled
Month
30
Semiannual
June
July
Aug
Sept
Oct
Nov
Annual
Jan
F M A M J J A S O N
D
+
20
30
Dec
Jan
Frequencies required by Code may not be modified
(i.e. EC.02.05.07 EP 4 & 8)
SIG Engineering 2011 - 27
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Due
Date
EC.02.03.05
 EP 13 Every 6 months the hospital inspects
any automatic fire extinguishing systems in
a kitchen. The completion date of the test is
documented.
 Every 6 months +/- 20 days
 EP 12 Every 12 months the hospital tests
visual and audible alarms, including
speakers. The completion date of the test is
documented.
 Every 12 months +/- 30 days
 At least monthly the hospital inspects
portable fire extinguishers. The completion
dates of the inspections are documented.
 Tested within the calendar month
SIG Engineering 2011 - 28
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Does Every mean Every ?
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
SIG Engineering 2011 - 29
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PRA
Interim Life Safety Measures
 Order of Standards (LS.01.02.01)
1 & 2 regardless of ILSM policy
 EP 3 must clearly define the ILSM
policy including
 AFS 13 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
SIG Engineering 2011 - 30
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 EP
Fire Watch
situation (4 out of 24 hours) must implement a
fire watch until the fire alarm system or sprinkler
system has been returned to service or is stable.
 In many situations, this distinction comes
down to whether an event or activity is
scheduled or unscheduled.
A scheduled activity would be an event known to
and under the knowledge of and control of
organization staff
 a construction project
 servicing or upgrading the fire alarm system
or sprinkler system.
SIG Engineering 2011 - 31
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An organization experiencing a compromising
Service Situation
Putting a shield over one smoke detector to prevent dust/false
alarms for more than 4 hours
Fire Watch ILSM Evaluation
Required?
Required?
No
Recommended
Rationale: Other features of fire protection are not compromised during the event, such as
additional smoke detectors or sprinkler heads in the affected area.
Covering all smoke detectors during a controlled event, such as
only during the time contractors are working in an affected
area, although after hours, the entire area is fully operational
No
Yes
Rationale: During a controlled event the organization is managing the deficiency. The area
would be continually monitored, and ILSM should be implemented as per policy.
● Scheduled event (that is, working on, servicing, or
upgrading fire alarm system or sprinkler system)
Not in all
cases
Yes (emphasis
on occupant
notification)
Rationale: During a controlled event, the organization is managing the deficiency. The area
would be continually monitored, and ILSM would be implemented as per policy.
● Unscheduled event (that is, shutting off a zone valve to
the sprinkler system or disabling a smoke zone for more
than 4 hours in response to a system failure)
Yes
Yes
SIG Engineering 2011 - 32
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Shutting off a zone valve to the sprinkler system or disabling a fire
alarm zone for more than 4 hours
EC.02.06.05 EP 1
recognize the Facilities Guidelines Institute (FGI)
Guidelines for Design & Construction of Health Care
Facilities
 ASHRAE 170 has been attached to the Guidelines
 Ventilation Table
 20 – 60 % RH requirement of relative humidity in
seven affected areas of the Surgical
Environment, and one in Diagnostic & Treatment.
 NOTE CMS has not adopted this, but remains
at 35 – 60%RH
 The established 60% upper range however
should be maintained for issues such as mold
growth.
SIG Engineering 2011 - 33
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 Effective 1/1/2011 the Joint Commission will
RH% Treatment Areas
 Class A Operating/Procedure room
 Class B and C operating rooms
 Operating/surgical cystoscopic rooms
 Delivery room (Caesarean)
 Treatment rooms
 Laser eye room
 Diagnostic & Treatment: Gastrointestinal
Endoscopy Procedure Room
SIG Engineering 2011 - 34
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 Trauma room (crisis or shock)
General Life Safety Interpretations
Associated with Building Water Systems
 This 29 page DRAFT document provides
guidance related to Legionella mitigation
 Site survey to identify risk points
 i.e. water towers
 Mitigation strategies
 Water treatments
• what to do if contamination occurs,
such as secondary treatment
SIG Engineering 2011 - 35
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 ASHRAE 188 Prevention of Legionellosis
Central Sterile Layout
 Physically separated soiled and clean work rooms
Soiled Work Room:
 Work surface, sink, washer/sterilizer decontaminators
 Soiled room is not to have direct contact with the OR
 Clean assembly /work room
 Hand washing station
 Sufficient workspace and equipment
 Self-closing door or pass through is acceptable between
soiled and clean work rooms
 Storage
 provisions for humidity, temperature, and ventilation
 Location of storage may be within the clean assembly/
workroom in a permanently designated space
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3
SIG Engineering 2011 - 36
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
Function
Pressure
Relationship
Min
Outdoor
ACH
Minimum
Total
ACH
All Room
Air
Exhausted
Directly
Outdoors
Equip.
Room
Negative
N/R
10
Yes
N/R
N/R
Soiled or
Decontam
Negative
2
6
Yes
N/R
72 – 78
Clean
Work
Room
Positive
2
4
N/R
Max 60
72 – 78
Sterile
Storage
Positive
2
4
N/R
Max 60
72 – 78
ANSI/ASHRAE/ASHE Standard 170-2008
Relative
Humidity
Design
Temp.
°F
Table 7-1
SIG Engineering 2011 - 37
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Ventilation (Table 7-1)
Changes to EC.02.03.05 EP 2
 Existing:
six months the hospital
tests valve tamper switches and
water-flow devices. The
completion date of the tests is
documented.
NOTE: for additional guidance on
performing tests see NFPA 721999 (Table 7-3.2)
SIG Engineering 2011 - 38
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Every
 Revised:
 EP2 For hospitals that use Joint Commission
accreditation for deemed status purposes: At
least quarterly the hospital tests water-flow
devices. Every 6 months the hospital tests
valve tamper switches. The completion date is
documented.
NOTE: For additional guidance on performing
tests see NFPA 25-1998 (Section 2-1.3 &
2.3.3) and NPFA 72-1999 (Table 7-3.2 and
Section 7-5.2).
SIG Engineering 2011 - 39
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Changes to EC.02.03.05 EP 2
EP 2 (continued) For hospitals that do not
use accreditation for deemed status
purposes: Every 6 months, the hospital
tests valve tamper switches and waterflow devices. The completion date of the
tests is documented. Note: For
additional guidance on performing tests,
see NFPA 72, 1999 edition (Table 7-3.2).
SIG Engineering 2011 - 40
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Changes to EC.02.03.05 EP 2
NEW: EC.02.03.05 EP 25
 For hospitals that use Joint Commission
accreditation for deemed status purposes:
of maintenance, testing,
and inspection activities for fire alarm
and water-based fire protection systems
includes the following:
Next Slide for Contents
Note: For additional guidance on documenting
activities:
 NFPA 25, 1998 edition (Section 2-1.3)
 NFPA 72, 1999 edition (Section 7-5.2)
SIG Engineering 2011 - 41
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 Documentation
Continued Text:
 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
SIG Engineering 2011 - 42
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NEW: EC.02.03.05 EP 25
NEW: EC.02.03.05 EP 25
 For hospitals that use Joint Commission
Note: For additional guidance on documenting
activities:
 NFPA 25, 1998 edition (Section 2-1.3)
 NFPA 72, 1999 edition (Section 7-5.2)
SIG Engineering 2011 - 43
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accreditation for deemed status purposes:
 Documentation of maintenance,
testing, and inspection activities for fire
alarm and water-based fire protection
systems includes the following:
Fire & Smoke Damper
Inspections
are by random sampling
 Confirm ILSM policy is implemented
for any horizontal exits or egress
enclosures that are compromised
by inaccessible dampers
 Evaluate adequacy of damper
accessibility plan
SIG Engineering 2011 - 44
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 Ensure inaccessible dampers truly
The master fire alarm control panel is
located in a protected environment
(an area enclosed with 1-hour firerated walls and ¾ hour fire rated
doors) that is continuously occupied
OR in an area with a smoke
detector.
 NFPA
72-1999 1-5.6 & 3-8.4.1.3.3.2
SIG Engineering 2011 - 45
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LS.02.01.34 EP 2
Master Alarm Panel
Month, day year and initials of inspector as per NFPA 10-1998
EC.02.03.05 EP 15
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all
fire extinguishers inspected, including those found to
require corrective action.
4-3.4.2 At least monthly, the date the inspection was
performed and the initials of the person performing the
inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the
fire extinguisher, on an inspection checklist maintained on
file, or in an electronic system (e.g., bar coding) that
provides a permanent record.
DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION
SIG Engineering 2011 - 46
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Fire Extinguisher: Dating
General Life Safety Interpretations
 Perimeter shelving and sprinkler provision:
 Are
perimeter wall shelving that
extends to the ceiling required to be
fastened to the wall?
 NO
Shelving is not required for storage
 There is no correlation between
• Shelving
• Clearance
• The need to secure any shelving
SIG Engineering 2011 - 47
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
Perimeter
Shelving
18” rule
Perimeter
Shelving
18”
18”
Wall
Wall
OK
Wrong
OK
OK
SIG Engineering 2011 - 48
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Ceiling
General Life Safety Interpretations
labels on the door and jambs
Jambs prior to 1966 may not
have a rating label
Are ILSM in place where noncompliant door assemblies
are found?
SIG Engineering 2011 - 49
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Rated doors must have legible
Firestop:
Existing application is acceptable when
It was installed in a manner
consistent with original design
specifications
It is in acceptable condition
currently
 If the firestop is cracking, etc,
then it is to be removed and
repaired using current
technologies
SIG Engineering 2011 - 50
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General Life Safety Interpretations
General Life Safety Interpretations
purposes is NOT an acceptable
firestop in any fire or smoke barrier
 This product does have a UL label:
for insulation properties
 Easily ignited
 Toxic gases may occur when
burned
NOTE: There are several acceptable
fire stop products that expand when
installed
SIG Engineering 2011 - 51
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 Expanding foam used for insulation
Non Flammable Medical Gas
Volume & Storage: Scoring
Score EC.02.03.01 EP 1 …fire risk
‘E’ cylinders (<300ft³) per smoke compartment
(22,500ft²) may be open to the egress corridor in a rack
or appropriate holders
Between 300 and 3000ft³ must be stored in a room that
is limited construction with doors that can be locked
 “In use” verses “in storage”
 Properly secured to a gurney is considered “in use”
 Properly racked is “in storage”
 Empty are NOT considered part of the 12 in storage
 Empty and full must be stored (racked) separately
SIG Engineering 2011 - 52
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12
NFPA 99-2005 edition has additional language
regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1
> 3000 cubic feet
9.4.2
300 – 3000 cubic feet
9.4.3
0 - 300 cubic feet
Other:
5.1.3.3.2
design and construction
5.1.3.3.3
ventilation of locations for manifolds
5.1.3.3.3.2 ventilation for motor driven equipment
5.1.3.3.3.3 ventilation for outdoors
NOTE: CMS also recognizes 9.4.3 reference
SIG Engineering 2011 - 53
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Non-Flammable Gas Storage:
NFPA 99-2005
Non-Flammable Medical Gas
Unsafe Conditions: Scoring
Score EC.02.06.01 …unsafe condition
cylinders
 Laying on top a gurney mattress; leaning against the wall
 Free standing
 Transfilling liquid oxygen
 Transfer of any gases from one cylinder to another in
patient care areas of health care facilities is prohibited.
 Transfilling of liquid oxygen shall be performed in an area
that is
• mechanically ventilated
• sprinklered
• ceramic or concrete flooring
• separated with at least 1 hour construction from any
patient care areas

SIG Engineering 2011 - 54
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 Unsecured
Tank Farm
maintains critical components of the piped medical gas
systems.
 Tank Farm is included in this EP
 The bulk storage tank(s) and associated systems are
critical components of the piped medical gas system
 Tanks above ground, not on roofs
 No electrical service above tanks
 10’ Clear from vehicles & sidewalks
 50’ from wood frame buildings
• At least 1’-0” from other buildings
• At least 10’ form any opening in wall of adjacent
structures
• Concrete pads at all spill points (3’ min)
 Permanent signage:
OXYGEN – NO SMOKING – NO OPEN FLAMES
 Access controlled (i.e. locked)
SIG Engineering 2011 - 55
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 EC.02.05.09 EP 1 states the hospital tests, inspects and
General Life Safety Interpretations
A. The UPS in this application is a
bridging device, and is not a SEPSS
SIG Engineering 2011 - 56
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Q. Is a UPS used to condition power
or supply power when normal
power is interrupted until
emergency power is established a
SEPSS?
NFPA 110: Emergency &
Standby Power Systems
devices that have normal electrical power entering
and leaving the ATS
 The power continues on to distribution panels
 When a ATS senses a disruption in power it sends a
signal to the alternative power source seeking power
 This start circuit initiates the emergency generator
starter
 The ATS is also equipped with a test switch to
simulate the power disruption
 Recommended practice is to rotate which ATS
initiates the start circuit to the emergency
generator
SIG Engineering 2011 - 57
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 Automatic Transfer Switches (ATS) are self-acting
Generator Loading
 The 30% requirement assures the diesel engine achieves
correct operating temperature
 The output of the EPSS is not as critical as the operating
temperature during the generator tests
 Two common ratings on the nameplate: KW & Amps
 The diesel engine drives the alternator, creating electrical charge
 Power factor and the nameplate ratings
 With a static load the power factor is 1.0
 With a dynamic load the power factor is .8
 The nameplate rating measures the capacity of the system with a
diesel engine driving the alternator
 The 30% is taken from the nameplate without calculating the
power factor
 EPs 5 & 8: …uses a dynamic or static load that is at least
30% of the nameplate rating…
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© Copyright, The Joint Commission
General Life Safety Interpretations
 Electrical
 Unlocked distribution panels in patient
care areas
 Based on policy
 Consider risk assessment
 Score EC.02.01.06 EP 1
 Open junction boxes
 Score at EC.02.03.01 EP 1
• Risk: arcing resulting in fire or loss
of service
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© Copyright, The Joint Commission
General Life Safety Interpretations
Supervisory Signals: EC.02.03.05 EP 1
 At least quarterly, the hospital tests
supervisory signal devices (except valve
tamper switches). The completion date of
the tests is documented. Note: For
additional guidance on performing tests,
see NFPA 72, 1999 edition (Table 7-3.2).
 Table 7-3.2 actually only states that
Supervisory Signal Devices must be
tested quarterly
• The Table does not actually define the
specific devices
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© Copyright, The Joint Commission
General Life Safety Interpretations
General Life Safety Interpretations
EC.02.03.05 EP 1:
Devices:
 2-9.1 Control Valve Supervisory Signal Initiating
Devices
 2-9.2 Pressure Supervisory Signal Initiating
Devices
 2-9.3 Water Level Supervisory Signal Initiating
Devices
 2-9.4 Room Temperature Supervisory Signal
Initiating Devices
This is further reinforced by the listing in NFPA 72-1999,
Table 7-2.1, 13.h as devices addressed in NFPA 721999
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 NFPA 72-1999, 2-9 lists Supervisory Signal Initiating
 Staff Safety
 EC.02.02.01
 EP 3: Precautions & PPE
 EP 4: Spill procedures
 EPs 5 – 10: minimizes risk
 EC.04.01.01
 EP 1: Monitoring & Reporting
 EPs 2 – 11: Specifics
 Manifests: EP 11
 DOT training for those signing
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General Life Safety Interpretations
General Life Safety Interpretations
 Unsafe Conditions & Suicide Risk
EP 1:
 Interior Spaces meet the need of the
patient population and are safe and
suitable to the care, treatment and
services provided.
 Any unsafe condition can be scored here,
provided it is in the patient care interior
spaces
 Suicide risk may be addressed by clinical
interventions or policies
 Work with other survey team members
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 EC.02.06.01
Outdoor Safety
 EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
 Grounds includes
 Sidewalks
 Parking lots
 Park ways
 Picnic and patio areas
 Play structures
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 The
Outdoor Safety
 EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
 Equipment includes
 Lawn maintenance equipment
 Snow removal equipment
 Maintenance equipment
 Paving
 Road repair
 Lighting
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 The
CE: Lessons Learned from 2010
 Scope issues
Contamination
issues
 Alarm Hazards
or otherwise
compromised
 Telemetry
 Infusion pumps
 Surgical Site Fires
Sentinel Event Alert
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Disabled
Q. Are defibrillators considered life support
equipment?
A. YES.
 Maintenance activities then must be identified
for equipment on the inventory
 A maintenance strategy for defibrillators could
include a range of activities from a visual
inspection of the single-use AED (automatic
external defibrillator) to the scheduled PM
maintenance of a defibrillator
Note: the daily and weekly observations are
assessed as per policy (see PC.02.01.11 EP2)
© Copyright, The Joint Commission
Defibrillators: FAQ
Emergency Management:
Key Concepts
All hazards approach
partners
Situational awareness
Active mitigation and
preparation, not just a written
plan
Monitor and evaluate
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Collaboration with community
Pre-Session documents
 Emergency Operations Plan
hazards approach
 Addresses the six critical areas
 Inventory of resources and assets
 Hazard Vulnerability Analysis (HVA)
 Mitigation and preparedness activities
for the top 2 or 3 events
 Disaster drill and real event evaluations
 Monitors and evaluates the six critical
areas
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 All
Hazard Vulnerability Analysis
defines
 Mitigation,
Recovery
Preparation, Response,
 Directs the survey process related to EM
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 Conducted by EM Committee/Team
 Use Multi-disciplinary Approach
 Experts within your facility
 Community
 Share information with:
 Community-prioritizes events
 Hospital Leadership
 For each emergency, the organization
Six Critical Areas
1. Communication
2. Resources & Assets
3. Safety & Security
5. Utilities Management
6. Patient Clinical & Support
Activities
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4. Staff Responsibilities
Overview of the 2011 EM Changes
disaster critiques
 Data collection tool and EM Tips
document
 Focused discussion on six critical areas
 Look at resources and assets inventory;
appropriate storage, expirations, training
SIG Engineering 2011 - 72
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 Stand alone EM session
 Up to 90 minutes
 Focus on mitigation and preparedness
 No disaster scenarios; use hospital
© Copyright, The Joint Commission
Questions?
SIG Engineers: 630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer
SIG
Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
SIG
SIG Engineering 2011 - 74
© Copyright, The Joint Commission
Michael Chisholm, CPE, CHFM
Engineer
SIG
The Joint Commission
Disclaimer
 These slides are current as of 4/22/2011. The Joint
Commission reserves the right to change the content of
the information, as appropriate.
 These slides are only meant to be cue points, which
 These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
SIG Engineering 2011 - 75
© Copyright, The Joint Commission
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.
Surveying
Maintenance Strategies
© Copyright, The Joint Commission
Medical Equipment
Utilities Systems
Changes to EC.02.03.05 EP 2
 Existing:
six months the hospital
tests valve tamper switches and
water-flow devices. The
completion date of the tests is
documented.
NOTE: for additional guidance on
performing tests see NFPA 721999 (Table 7-3.2)
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Every
 Revised:
 EP2 For hospitals that use Joint Commission
accreditation for deemed status purposes: At
least quarterly the hospital tests water-flow
devices. Every 6 months the hospital tests
valve tamper switches. The completion date is
documented.
NOTE: For additional guidance on performing
tests see NFPA 25-1998 (Section 2-1.3 &
2.3.3) and NPFA 72-1999 (Table 7-3.2 and
Section 7-5.2).
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Changes to EC.02.03.05 EP 2
EP 2 (continued) For hospitals that do not
use accreditation for deemed status
purposes: Every 6 months, the hospital
tests valve tamper switches and waterflow devices. The completion date of the
tests is documented. Note: For
additional guidance on performing tests,
see NFPA 72, 1999 edition (Table 7-3.2).
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Changes to EC.02.03.05 EP 2
NEW: EC.02.03.05 EP 25
 For hospitals that use Joint Commission
accreditation for deemed status purposes:
of maintenance, testing,
and inspection activities for fire alarm
and water-based fire protection systems
includes the following:
Next Slide for Contents
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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 Documentation
Continued Text:
 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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NEW: EC.02.03.05 EP 25
NEW: EC.02.03.05 EP 25
 For hospitals that use Joint Commission
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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accreditation for deemed status purposes:
 Documentation of maintenance,
testing, and inspection activities for fire
alarm and water-based fire protection
systems includes the following:
Fire & Smoke Damper
Inspections
are by random sampling
 Confirm ILSM policy is implemented
for any horizontal exits or egress
enclosures that are compromised
by inaccessible dampers
 Evaluate adequacy of damper
accessibility plan
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 Ensure inaccessible dampers truly
The master fire alarm control panel is
located in a protected environment
(an area enclosed with 1-hour firerated walls and ¾ hour fire rated
doors) that is continuously occupied
OR in an area with a smoke
detector.
 NFPA
72-1999 1-5.6 & 3-8.4.1.3.3.2
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LS.02.01.34 EP 2
Master Alarm Panel
Month, day year and initials of inspector as per NFPA 10-1998
EC.02.03.05 EP 15
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all
fire extinguishers inspected, including those found to
require corrective action.
4-3.4.2 At least monthly, the date the inspection was
performed and the initials of the person performing the
inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the
fire extinguisher, on an inspection checklist maintained on
file, or in an electronic system (e.g., bar coding) that
provides a permanent record.
DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION
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Fire Extinguisher: Dating
CMS Conditions of Participation
 42 CFR 482.41
Hospital must maintain adequate facilities for its
services
 42 CFR 482.41(c)(2)
 Facilities, supplies and equipment must be
maintained to ensure an acceptable level of
safety and quality.
 The CMS Interpretive Guideline states “the
hospital must monitor, test, calibrate and
maintain equipment periodically in accordance
with the manufacturer’s recommendation
and Fed and State law.”
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
CMS Conditions of Participation
 The Interpretive Guideline states the hospital must
monitor, test, calibrate and maintain equipment
periodically in accordance with the manufacturer’s
recommendation and Federal and State law.
 Medical Equipment includes
Biomedical equipment
 Radiological equipment
 Patient beds, stretchers
 IV infusion equipment
 Ventilators
 Laboratory equipment
 Etc.
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
CMS Conditions of Participation
 The Interpretive Guideline states the hospital must
monitor, test, calibrate and maintain equipment
periodically in accordance with the manufacturer’s
recommendation and Federal and State law.
 Utility Systems and Equipment includes
Elevators
 Generators
 Air handlers
 Medical gas systems
 Air compressors
 Vacuum systems
 Etc.
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
Manufacturer’s Recommendations
made to CMS regarding this issue
 The Joint Commission advocated to CMS the
importance of allowing the organizations to
continue using the Joint Commission process
 Based on these discussions, CMS noted that
they “understand the principles behind
applying risk assessment and hospital
experience to the frequency of hospital
preventive maintenance”
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 In January 2010 a formal complaint was
CMS technical review team has completed
its review if the Joint Commission’s
submission of surveyor instructions and
survey protocol for evaluating an
organizations preventive maintenance
schedule. The purpose of this review
was to ensure that Joint Commission’s
surveyors were properly trained to
evaluate the adequacey of an
organization’s recommended frequency
of preventive maintenance.
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© Copyright, The Joint Commission
CMS Response
CMS Response
CMS Deputy Director
July 26, 2010
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© Copyright, The Joint Commission
I am happy to inform you that the
Joint Commission’s approach of
utilizing a preventive maintenance
schedule has been approved.
Thank you for your cooperation
and collaboration.
The hospital maintains either a written
inventory of all medical equipment or a
written inventory of selected equipment
categorized by physical risk associated with
use (including all life-support equipment)
and equipment incident history.
The hospital evaluates new types of
equipment before initial use to determine
whether they should be included in the
inventory.
(See also EC.02.04.03, EPs 1 and 3)
SIG Engineering 2011 - 92
© Copyright, The Joint Commission
EC.02.04.01 EP 2
The hospital maintains a written inventory of
all operating components of utility systems
or maintains a written inventory of selected
operating components of utility systems
based on risks for infection, occupant needs,
and systems critical to patient care
(including all life-support systems).
The hospital evaluates new types of utility
components before initial use to determine
whether they should be included in the
inventory.
(See also EC.02.05.05, EPs 1, 3-5)
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EC.02.05.01 EP 2
Maintaining Medical Equipment
strategies:
 All equipment inclusion
 Physical risk based process
 For example, evaluating:
• Function
• Risk Levels
• Maintenance Requirement
 Utilize resources, i.e. the FDA MAUDE report
 All life support equipment is included
 All new types of equipment evaluated for inclusion
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 Inventory is populated based on one of two
Maintaining Utilities Equipment
strategies:
 All equipment inclusion
 Based on physical risks for
 Infection
 Occupant needs
 Systems critical to patient care
 All life support equipment is included
 All new types of equipment is evaluated for
inclusion
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 Inventory is populated based on one of two
Joint Commission Medical Equipment
used in
 Life support, such as
 anesthesia machines
 ventilators
 defibrillators
 heart-lung machines
 Monitoring, such as
 Bedside monitors
 Telemetry monitors
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 Medical equipment includes equipment
 Treatment, such as
 Electrosurgery
 Lasers
 Diathermy
 Diagnostic, such as
 Laboratory analyzers
 Radiology equipment
 Endoscopes
 Patient support, such as
 Patient beds
 Specialty beds
 Lifts
Taken from the Environment
of Care Handbook
Chapter 5 (page 73) 3rd edition
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© Copyright, The Joint Commission
Joint Commission Medical Equipment
Joint Commission Utilities Equipment
Utility System as defined in the Accreditation
Manuals Glossary and EC.02.05.03 include:
 Electrical distribution
 Emergency Power Supply System (EPSS)
 Vertical & Horizontal Transport
 Heating, Ventilation & Air Conditioning
 Boiler and Steam
 Piped Gases
 Vacuum Systems
 Communication Systems & Data Exchange
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 Plumbing
Joint Commission Utilities Equipment
 Specific Utility Systems include
Features of Fire Safety (EC.02.03.01)
 Alarm and Notification (LS.02.01.34)
 Suppression Systems (LS.02.01.35)
 Design criteria (EC.02.05.01)
 Power Distribution System (EC.02.05.03)
 Emergency Power Supply Systems (EC.02.05.07)
 Medical Gases (EC.02.05.09)
 Specific populations of equipment
Life support systems (EC.02.05.05)
 Infection Control utility systems (EC.02.05.05)

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
EC.02.04.01 EP 3
Note: Hospitals may use different strategies for
different items as appropriate. For example,
strategies such as predictive maintenance,
reliability-centered maintenance, interval-based
inspections, corrective maintenance, or metered
maintenance may be selected to ensure reliable
performance.
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The hospital identifies the activities, in writing, for
maintaining, inspecting, and testing for all
medical equipment on the inventory.
(See also EC.02.04.03, EPs 2 and 3)
EC.02.05.01 EP 3
The hospital identifies, in writing, inspection and
maintenance activities for all operating
components of utility systems on the inventory.
Note: Hospitals may use different approaches to
maintenance. For example, activities such as
predictive maintenance, reliability- centered
maintenance, interval-based maintenance,
corrective maintenance, or metered maintenance
may be selected to ensure dependable
performance.
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(See also EC.02.05.05, EPs 3 - 5; EC.02.05.09, EP 1)
Maintaining Equipment: Strategies
 Written strategies identify the activities for
Maintaining
 Inspection
 Testing

 Strategies may include
Predictive maintenance
 Reliability-centered maintenance
 Interval based maintenance
 Corrective maintenance
 Metered maintenance
 Other recognized strategy
 Manufacture’s recommendations
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© Copyright, The Joint Commission

Maintenance Strategies
 Preventive Maintenance
The scheduled activities designed to extend
equipment reliability based on performing
activities prior to equipment failure based on
risk levels and organization experience
 Interval Based Maintenance
 The scheduled activities are based on a preset
schedule that is established regardless of need
 Determine Interval Time:
 Manufacturer’s guidelines
 Accepted industry practices
 Regulatory code requirements
 Organization’s past experiences
 Most preventive maintenance software
programs are “Interval-Based”
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© Copyright, The Joint Commission

Maintenance Strategies
 Reliability-Centered Maintenance
on historical analysis of the
reliability of equipment
 Anticipated maintenance activities to
extend the reliability based on
intersecting historical failure
 Metered Maintenance
 Based on established amount of time
the equipment has operated rather
than a calendar schedule
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© Copyright, The Joint Commission
 Based
Maintenance Strategies
 Corrective Maintenance
is not serviced based on
preventive models, but allowed to
run until repairs are needed
 Also includes response to any
corrective measures related to the
physical environment
 Other, such as manufacturer’s
recommendations
 Always
during warranty period
 Evaluate against other strategies
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 Equipment
EC.02.04.01 EP 4
 The hospital identifies, in writing,
(See also EC.02.04.03, EPs 2 and 3)
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© Copyright, The Joint Commission
frequencies for inspecting, testing, and
maintaining medical equipment on the
inventory based on criteria such as
 manufacturer’s recommendations
 risk levels
 current hospital experience
EC.02.05.01 EP 4
intervals for inspecting, testing, and
maintaining all operating components of
the utility systems on the inventory,
based on criteria such as
 Manufacturer‘s recommendations
 Risk levels
 hospital experience
(See also EC.02.05.05, EPs 3-5)
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 The hospital identifies, in writing, the
Maintenance Frequencies
 Manufacturer’s Recommendations
equipment that has no operating
history should follow manufacturer’s
recommendations until enough history
and level of risk has been established
 Industry experience has established that
often manufacturer’s recommendations
are based on worse-case situations and
may exceed the normal operating
condition level maintenance activity
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© Copyright, The Joint Commission
 New
 Risk levels
 Evaluating the potential risk of equipment
failure is a significant part of evaluating
maintaining, inspecting and testing
requirements
 Based on physical risks impact for
 Infection
 Occupant needs
 Systems critical to patient care
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© Copyright, The Joint Commission
Maintenance Frequencies
Maintenance Frequencies
 Hospital experience
the benefits of maintaining,
inspecting and testing activities based
on history may contribute to increasing
or extending those activity periods
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 Evaluating
A manufacturer’s recommendation for telemetry
monitors required the Clinical Engineer open the
monitor case and inspect for dust
 Hospital experience identified that those
monitors that were opened tended to fail before
those monitors that were not opened
• the factory assembly was essentially air and
dust free, once opened the seal was
compromised
 Should the organization continue to open the
monitor cases?
 Would it be acceptable to conduct a visual
inspection of the case and service on an “as
needed” basis?
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Case Study #1
A manufacturer’s recommendation for an air
handler required the Building Engineer to change
the filters on a quarterly frequency based on the
manufacturer’s industrial application
 Hospital experience identified that those filters
were not soiled to the point where they needed to
be changed at the end of the quarter
• Slightly soiled filters actually increase the
efficiencies
 The organization determined that by measuring
the pressure differential across the filter bank the
filters could be replaced semi-annually
 Should the organization continue to change the
filters quarterly?
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Case Study #2
A manufacture of a device that may be used in
either an ambulance or in an ICU created its
manufacturer’s recommendations
• The manufacturer’s recommendations were
based on the unit being used in the field,
which would be the more extreme
environment
 Would the manufacturer’s recommendations be
appropriate for the device in the ambulance?
 Would the manufacturer’s recommendations be
appropriate for the device on the ICU?
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Case Study #3
Manufacturer’s recommendations for greasing a
165# washer is 2 strokes of the grease gun per
week to the main bearing
• This was based on industrial laundry
applications running two shifts per day, 6 days
per week
 The Facility Director determined that the
frequency was excessive as the hospital laundry
is operated one shift per day for 5 days per week
 Should the organization change to every other
week grease application although the
manufacturer’s recommendations is weekly?
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Case Study #4
EP 2. The hospital inspects, tests, and
maintains all life support equipment. These
activities are documented. (See also
EC.02.04.01, EPs 3 and 4; PC.02.01.11, EP
2)
EP 3. The hospital inspects, tests, and
maintains non-life support equipment
identified on the medical equipment
inventory. These activities are documented.
(See also EC.02.04.01, EPs 2-4 and
PC.02.01.11, EP 2)
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EC.02.04.03 The hospital inspects,
tests, and maintains medical equipment
EP 2. The hospital inspects, tests, and maintains the
following: Life support utility system components
on the inventory. These activities are
documented. (See also EC.02.05.01, EPs 2-4)
EP 3. The hospital inspects, tests, and maintains
non-life support equipment identified on the
medical equipment inventory. These activities are
documented. (See also EC.02.04.01, EPs 2-4 and
PC.02.01.11, EP 2)
EP 4. The hospital inspects, tests, and maintains the
following: Infection control utility system
components on the inventory. These activities are
documented. (See also EC.02.05.01, EPs 2-4)
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EC.02.05.05: The hospital inspects,
tests, and maintains utility systems
Survey Process
 Document Review
Evaluate the Management Plan
 Determine the Maintenance Strategies applied
to the inspection, testing and maintenance of the
equipment
 Evaluate the work completion rates (% complete)
 To compute the percent complete divide the
number of devices completed by the number of
scheduled work orders
Example:
795 devices completed out of 825 scheduled = 96.4%
795 ÷ 825 = 96.36
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
Survey Process: Medical Equipment
Evaluate the program documentation
Logs are completed and reflect both Life Support
devices and non-life support devices
 Accuracy of Inventory
 All Life Support equipment must be represented
on the inventory
 Preventive maintenance frequencies must be
clearly defined in writing
 Confirm work done as per scheduled activities
 Ensure appropriate work is scheduled based on
maintenance strategies
 Evaluate device failure against scheduled actions
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
Survey Process: Utility Systems
Evaluate the program documentation
Logs are completed and reflect both Life Support
Systems, Infection Control equipment, and Non-life
support equipment on the inventory
 Accuracy of Inventory
 All Life Support equipment must be represented
on the inventory
 Preventive maintenance frequencies must be
clearly defined in writing
 Confirm work done as per scheduled activities
 Ensure appropriate work is scheduled based on
maintenance strategies
 Evaluate equipment failure and scheduled actions
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
Survey Process: Staff Interviews
 Department Leader
Establish how the inventory was created
 Establish the Maintenance Strategies used
 Evaluate the Monitoring processes
 Evaluate the effectiveness of the program

 Equipment Maintainers
Evaluate their understanding of the maintenance
process/strategies
 Evaluate competencies based on repeat work
orders
 Evaluate work scheduled against completed
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
Survey Process: Staff Interview
 Users of the Equipment
Evaluate equipment reliability
 Evaluate response time when equipment fails
 Evaluate emergency response process
 Evaluate “Culture of Safety”
 Appropriate training of staff related to
equipment use
 Customer satisfaction with department
 Contract Services
Evaluate reliability of equipment serviced
 Evaluate integration of the process

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
Survey Process
 Evaluate the effectiveness of the program
to maintain the equipment
Repeat work orders
 Equipment turn-around time
 Completion rates

 Evaluate confidence of the users while
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using equipment
© Copyright, The Joint Commission
Questions?
SIG Engineers: 630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer
SIG
Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
SIG
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© Copyright, The Joint Commission
Michael Chisholm, CPE, CHFM
Engineer
SIG
The Joint Commission
Disclaimer
 These slides are current as of 4/22/2011. The Joint
Commission reserves the right to change the content of
the information, as appropriate.
 These slides are only meant to be cue points, which
 These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
SIG Engineering 2011 - 125
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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.