Greeley Reflections

Accreditation Connection, November 30, 2009

Gray matters: Red alert

Part 3 of 5

Question #3: “Why not?”

Please forgive me a moment while I default to standards numerology… LS.01.01.01 EP #3 (the management of PFIs) includes a cross reference to LS.01.02.01, which is the Interim Life Safety Measures standard. Now there may be claims of coincidence (which I’ve not had the pleasure of experiencing with Joint Commission standards, questionable clarity maybe, but nothing I’d call coincidental) when you try to imply that there is a direct correlation between the management of the Statement of Conditions and Interim Life Safety Measures, but on my honor, I swear to you that it is true.

At any rate, in general, there are not a great many “have to” requirements in the EC standards. Lots of gray, not so much the black and white. But this one is so gray in language of the standards that it becomes a frightening shade of black when you don’t have a clearly documented process.

Ultimately, it all comes down to assessing the risk that the condition, practice, whatever represents to the organization and identifying strategies to ensure that the level of risk is not excessive (See how gray that word is? “Excessive” is anything you want it to be until someone of the surveyor persuasion begs to differ – you can’t defend your position very well without being able to provide data, and analysis of that data, to support the decision you’ve made).

At any rate, with any luck, this level of conversation will prompt the facilities folks to document the assessment, and so we can continue on to the next question.

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