Since the Joint Commission's Implementation of the Life Safety Specialist As a Member Of

Environment of Care

Life Safety Deficiencies That Threaten Accreditation Status

Back in 2004, the Government Accountability Office, in a report to Congress indicated that “for three consecutive years, JCAHO’s accreditation program … exceeded CMS’s threshold for unacceptable performance.” Chief among the negative conditions identified were the number of Life Safety Code deficiencies found during validation surveys conducted for CMS by various agencies. When you look at it purely from an operational standpoint, how much was an Administrator surveyor going to find during the course of a fairly collegial 2 to 3 hour walking tour of a hospital. Clearly, The Joint Commission arrived at the same conclusion when they introduced the life safety specialist surveyor to the teams surveying hospitals of 200 beds or greater back in 2005.

Since the implementation of the life safety specialist as a member of the survey team, a number of organizations have become familiar with those most dire of terms “conditional accreditation” and "preliminary denial of accreditation". Certainly, these are not words you would want to hear during your survey.

But did you know that there are two standards in the Environment of Care chapter, which are specific targets for the life safety specialists,that can result in an automatic finding of conditional accreditation or even preliminary denial? Were you aware beginning January 2008,every hospital in the accreditation cycle will have a life safety surveyor on their team? And if your organization has greater than 750,000 square feet, you’ll have the (dubious) pleasure of two days’ worth of life safety survey. Will your organization's program stand up to this increased attention?

EC.5.20 and EC.5.50 are among the most intensely surveyed aspects of the Environment of Care, both of which have Elements of Performance (EC.5.20 EP #5; EC.5.50 EP #3) that can be used to invoke CON04, which is the conditional rule that states “the organization has failed to implement or make sufficient progress toward corrective actions described in as Statement of ConditionsTM, Part 4, Plan For Improvement, which was previously accepted by the Joint Commission, or has failed to implement or enforce applicable interim life safety measures.” The life safety specialist surveyors have received specific direction on the invocation of CON04, and have been very diligent in its application during surveys this year.

Are you at risk? Or perhaps more importantly – do you know with certainty that you aren’t?

We encourage our center clients to assess their vulnerabilities discussed above and contact your center advisor if you’d like some special focus in these areas. January 2008 will be here before you know it and we want you to feel confident in your Environment of Care Program.

Author: Steve MacArthur, Senior Consultant, Environment of Care Specialist