Life safety surveyors will scrutinize your ILSM policies
Hospital Safety Connection, May 30, 2007
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Anecdotes from several hospitals we've talked to recently indicate that medical facilities need to ensure that their interim life safety measure (ILSM) policies match what actually takes place.
If Joint Commission life safety specialists believe ILSM policies are ineffective, they can invoke a rule known as "CON 04," which can send a facility into conditional accreditation. The same holds true if your facility misses a plan for improvement by more six months under the Statement of Conditions without a formal extension (a situation generally referred to as a "busted plan").
HCPro's video, A Guide to The Joint Commission Life Safety Building Tour, offers facilities a visual training tool about what life safety specialists review during their visits. To see a clip from the video, go to this YouTube link.
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