Accreditation

Q&A with Kurt Patton

Briefings on Accreditation and Quality, March 1, 2007

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What time frame should we use for testing inaccessible fire and smoke dampers?

Q: EC.5.40 EP 14 requires that hospitals test their fire and smoke dampers every four years to verify correct operation. We have identified both fire and smoke damp-ers that are not accessible to test. We have recently heard that The Joint Commission wants these to be noted on the Part IV, Plan for Improvement, but what time frames would we establish, as we cannot access these dampers until renovation takes place? What should we do to remain compliant with the standard?

A: A quick literature search identifies conflicting guidance from different sources relative to this subject. The Healthcare Interpretations Task Force has suggested that you keep a record of inaccessible fire and smoke dampers to keep track of them, inspect them to the extent possible, and share that listing with the fire marshal or authority having jurisdiction.

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