Accreditation

Q&A: Managing LS, EC, and EM documentation

Briefings on Accreditation and Quality, December 20, 2016

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Editor’s note: The topic of maintaining proper Life Safety (LS), Environment of Care (EC), and Emergency Management (EM) documentation was brought up at the 2016 Hospital Executive Briefing in New York City. In the following edited Q&A, Steve MacArthur, a safety consultant at The Greeley Company in Danvers, Massachusetts, discusses how to keep your documents in order.

BOAQ: What are the most common problems and mistakes facilities have in maintaining documents?
MacArthur: The list is endless. Failing to thoroughly review the documentation provided by testing vendors. Failing to fully understand the scope of whatever is being tested. For example, if you tested 25 pull stations this year, you need to make sure that you test 25 next year (and within one year, plus or minus 30 days). And if there are more or fewer pull stations [than last year], then you need to know why that is the case.

[Also,] vendors not testing things in accordance with the code requirements and documentation not being readily available. And The Joint Commission is cracking down on the availability of documentation; it seems that a “reasonable” amount of time will be identified by the surveyor, and if the documents are not made available within that identified time frame, it will be a deficiency. Let’s see, what else: elements missing from the documentation—could be specific results that are considered part of the testing documentation, etc.

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