Accreditation

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

Briefings on Accreditation and Quality, October 1, 2007

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Editor's note: This feature explores problematic Joint Commission (formerly JCAHO) standards with expert advice from BOJ advisors Jodi Eisenberg, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, and Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA. 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 Eisenberg. Di Giacomo-Geffers 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."

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