How to improve life safety compliance now

Hospital Safety Insider, March 17, 2016

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You already know that you need to be in compliance with the Life Safety Code(R). As if you need any kind of reminder that you'll have a Joint Commission surveyor letting you know every 18 to 39 months whether you're following the letter of the law. We asked some of the industry experts who know the dynamics of the LSC to share some of their knowledge and let us know some of the little things you can do today, at little cost and effort, to improve compliance in your facility.

Read the standards.
It is surprising to find how many facility managers do not take the time to actually read the accreditation organization standards, says Brad Keyes, CHSP, owner and senior consultant for Keyes' Life Safety Compliance. Do not rely on past survey results to determine your preparation efforts for the next survey. Surveyors are smarter and better prepared to find as many deficiencies as they can. You need to be aware of what is expected of you to meet that challenge.

Understand the standards
. After you read the standards, ask questions if you do not understand what you've read, says Keyes. Call your accreditation organization and ask them to explain any standards that you do not understand. Call your consultant and ask him or her what the standards mean. You can even call your counterpart at a neighboring healthcare facility and develop a professional relationship through which you can rely on each other for advice.

Know the different regulators, and what they will look for.
One of the things that keeps some safety officers awake at night is knowing the difference between The Joint Commission and CMS, and all the other regulators in between that are likely to inspect their facility and what they will let you get away with. In the past, The Joint Commission allowed facilities to file a "Statement of Conditions" document, essentially a waiver for the condition admitting to the violation, but mapping out an alternative plan in the meantime to fix the problem.

Constantly tour and prepare.
The most proactive and effective safety professionals are the ones that the rest of the hospital staff know well-because they constantly make it a point to walk around and be seen. At the same time, they are looking for violations from the perspective of an inspector. That's how you're going to find your life safety deficiencies before the regulators do. Look for evidence of smoking or a paint can improperly stored in a cabinet in the elevator room. Walk the stairwells and the different patient care areas, check fire extinguishers, open and close fire doors to make sure they latch (some won't), and take a look at fire alarm control panels to make sure there are no obstructions. Note when a physical therapist working with a patient has a chair in the corner of the stairwell, and make a note to make sure it's been removed.

Remove clutter from your hallways, period.
This is something that seems like it should be self-explanatory, but hospitals are constantly trying to push the envelope on this one, and they get nailed with life safety violations. Understandably, it is convenient to have crash carts and supply carts at the ready in patient treatment areas. Some facilities are building recessed areas and closets into the walls of corridors to allow the parking of such carts within easy reach but out of the path of egress. Consider doing this with your own facility as a way to comply. While you're at it, check the doors. Obstructed exits and egress paths will get you dinged by an inspector right away.

Join the local chapter of ASHE.
According to Keyes, ASHE is the very best professional organization you can join to assist you in accomplishing your goals and assignments in the healthcare industry. Join your local chapter of ASHE; it holds frequent meetings on topics of interest to healthcare facility managers. Develop relationships with other facility managers in your regions. Use them as mentors to assist you with your problems. Attend the ASHE annual conference (usually held in July in a different city each year). This is a great resource of education and technical exposition where you can learn from others who have experienced the same or similar problems.

Consider the certification of CHFM or CHSP. Certified Healthcare Facility Manager (CHFM) and the Certified Healthcare Safety Professional (CHSP) are two of the more appropriate certifications for facility management and safety compliance in healthcare organizations, Keyes says. ASHE administers the CHFM tests and offers preparation courses to assist you in being ready to take the test, and the Board of Certified Healthcare Safety Management administers the CHSP tests, and they also provide preparation courses before you take the test.

This is an excerpt from the monthly healthcare safety resource Healthcare Life Safety Compliance. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

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