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Set schedule, adequate documentation vital to compliance with fire safety standard

Accreditation Connection, October 12, 2007

Staying up to date with EC.5.40, which requires hospitals to maintain "fire-safety equipment and building features," is really about paying attention to every facet of the standard. Complying with EC.5.40 "is all in the details," says Jodi Eisenberg, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago.

Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA, points out that written in this standard's 16 EPs are 15 instances of the word "all." The key to being in compliance, then, is being sure that all of what needs to be done is done, and according to policy. "You have to know how many 'all' encompasses," Di Giacomo-Geffers says. She specifically notes EP 4's "testing of fire pumps weekly for water-based automatic fire extinguishing systems."

"Are there 25 items? And how many were tested? Then were all 25 items documented as being tested? You have to keep a total count [inventory] of how many you have in the hospital," says Di Giacomo-Geffers. The number of fire pumps, or of any fire protection equipment, often changes with new additions or new life safety plans. If that happens, be sure that all of the new equipment is actually being tested and the testing is documented correctly, she says.

Access the full story in the October issue of Briefings on The Joint Commission; access is free for subscribers, nonsubscribers can sign up for a 30-day free trial of BOJExtra! or purchase a copy of the story for $10 by clicking here.

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