Survey Coordinators Beware--Life safety surveyors coming to a hospital near you!

Accreditation Monthly, January 22, 2007

Among the most significant developments of the unannounced survey process during 2006 has been the impact of the life safety specialist surveyor as part of the teams surveying hospitals of 200 and greater licensed beds. Deficient findings relative to NFPA 101 - The Life Safety Code (EC.5.10; EC.5.20; EC.5.30; EC.5.40; and EC.5.50) have gone from virtually nowhere on the survey radar to the second most-cited elements during 2006 surveys, with no relief in sight. To add even greater peril from an accreditation standpoint, two of the standards (EC.5.20--compliance with the Life Safety Code; EC.5.50--implementation of Interim Life Safety Measures) have Elements of Performance that can lead directly (and immediately) to a finding of Conditional Accreditation under Conditional Accreditation Rule CON04 in the Comprehensive Accreditation Manual for Hospitals (CAMH). And now, to increase the angst of survey coordinators everywhere, The Joint Commission has announced that, commencing in 2008, the life safety specialist surveyors will be participating in all triennial hospital survey visits, not just for hospitals of greater than 200 beds.

What this represents for the survey coordinator is a significant increase in exposure for the organization, minimally as the addition of another "pair of eyes" during survey. While the life safety surveyors are focusing on a very specific group of standards; as noted above, some of these elements are among the most potentially "injurious" standards in the CAMH. Failure to make sufficient progress toward the corrective actions described in a previously approved Statement of Conditions (EC.5.40.5) and not officially requesting an extension from the SIG for the deficient items "would result in a recommendation of Conditional Accreditation." The life safety specialist will be assessing compliance with this EP early on in the survey--would you want to be faced with a Conditional Accreditation finding, virtually before a tracer is conducted? A deficient finding relative to any of the EPs under EC.5.50 (the hospital develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code), can also lead directly to a Conditional Accreditation finding, and, potentially, the suspension of a survey if the identified risk is adjudged to be sufficiently critical.

As a further risk associated with the ever-changing nature of the Accreditation process, the implementation of the on-line electronic Statement of Conditions (e-SOC) process presents risks associated with the timely reporting of data and information to The Joint Commission, under the Accreditation Participation Requirements (APR). APR 19 (the hospital meets requirements for timely submission of data and information to The Joint Commission) has traditionally been within the "span of control" of the survey coordinator, but now the on-line management of the e-SOC will require much more coordination with those in your organization responsible for managing the Environment of Care. It is likely that the EOC leaders in your organization are somewhat familiar with the deadlines imposed for submission, but they may not be aware of how the process for managing the e-SOC can negatively impact the organization's accreditation status in very quick fashion if something gets "missed.

Speaking on behalf of my colleagues at The Greeley Company, any of us would be happy to assist you in fine-tuning your response to these changes including helping to craft policies and effective processes designed specifically to fit your organization. 

It may also be time to schedule an Unannounced Compliance Test-Run visit by one of our Greeley Company mock survey teams.  For more information please call Stacey Koch, Director of Client Relations at 888-749-3054, ext. 3193 or


John Rosing, MHA, FACHE
Practice Director, Accreditation and Regulatory Compliance
The Greeley Company

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