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Breaking Life Safety Code news: Start preparing for 2009

Accreditation Monthly, January 8, 2008

As you've probably heard, the Joint Commission's (formerly JCAHO) Standards Improvement Initiative has many changes on tap for 2009-including a completely re-vamped Environment of Care chapter that partitions two EC components into their own chapters-Life Safety Code (LSC)Compliance and Emergency Management.

I'm sure you've noticed that the changes to the 2008 Emergency Management standards already in effect have resulted in an increase in the number of possible RFIs during survey from two (EC.4.10 and EC.4.20) to nine (EC.4.11-EC.4.18 and EC.4.20). The good news is that a majority of hospitals have embraced the importance of emergency response planning and, so far, have faired well on this topic in recent Joint Commission surveys. We'll be closely monitoring survey results as the new year unfolds and will keep you apprised of any trends.

Survey changes in 2008, along with the adoption of a new dedicated LSC chapter in 2009, will combine to bring a new level of survey exposure as findings (mostly in the form of RFIs, but don't forget those elements that can result in conditional or preliminary denial of accreditation) under EC.5.20 will likely increase further as all hospitals must now undergo a full LSC specialist survey. In the most recent data available, 55% of hospitals surveyed by a LSC surveyor in 2006 received an RFI at EC.5.20, and  91% of these hospitals also picked up at least one other RFI from the EC chapter. Now, all hospitals will be facing this level of exposure. Given what we know about the currently proposed 2009 standards, RFI counts under EC.5.20 could increase dramatically a year from now. As it stands today, LSC violations roll up into only one RFI at EC.5.20.  But under the proposed revision to the standards and scoring, each finding under EC.5.20 will be unrolled and stand alone, thus leading to a potential of nine RFIs. 

So, what to do? I strongly suggest having one of The Greeley Company's EC/LSC experts assist you by providing a comprehensive assessment of your EC programs and LSC compliance well in advance of your next unannounced survey. Our accreditation practice recently added Brad Keyes, a former Joint Commission life safety specialist surveyor, to our full-time consulting staff. He joins our longtime EC stalwart consultant, Steve MacArthur, in heading up our EC  section. Brad and Steve stand ready to run your EC programs and LSC compliance through a dry run assessment survey. Remember, 12 months of performance data is critical to success in this portion of the survey process-don't wait until it's too late to ensure that things are moving on the right track. For more information, please call Robin Flynn, client relations manager, at 888/749-3054, ext. 3249.

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