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SDS Accreditation Update
Document your inspections, and evaluate LSC compliance with building maintenance program
Program evaluates effectiveness of inspections, performance of facility
Knowing your outpatient surgery program well enough to answer surveyors' questions and provide necessary documentation is a responsibility that all managers accept and understand, but when the surveyor focuses on Life Safety Code issues, some managers scramble for information.
"We did well in our Joint Commission survey, and we were ready for everything we thought the surveyor could ask, but I was asked a question about our electrical safety program that I had never been asked before," says Anne Cole, RN, BSN, administrator of Ingalls Same Day Surgery Center in Tinley Park, IL. "The surveyor wanted to know if the refrigerator where we store drugs is plugged into an outlet that is connected to our backup generator," she says. Although she assumed that the outlet was powered by the backup generator in case of electrical failure, Cole had to find the electrical blueprints for the facility to prove that the outlet was tied into the system run by the generator. "I suggest that all outpatient surgery managers know where the blueprints are located and check to see that essential outlets are powered by the generator," she says.
Other life safety features such as fire doors, exit signs, and corridor doors are issues checked by accreditation surveyors, so it makes sense to have a plan in place to prove that these items are working properly and in compliance with accreditation standards, says Gary D. Slack, PE, CCE, president of Healthcare Engineering Consultants in Dayton, OH. One step a surgery manager can take to ensure continued compliance with Life Safety Code requirements is the development of a building maintenance program (BMP) to proactively address facility issues, he suggests.
"A BMP is an optional process to periodically inspect and evaluate specific life safety features of a building, such as fire and smoke doors, above-the-ceiling unsealed penetrations, corridor doors, and exit signs to determine how many of these items are functioning properly or meet life safety requirements," he explains.
While a BMP requires the commitment of a staff member to document the items periodically, there are several benefits for the facility, Slack explains. Hospital-based programs with BMPs for which the effectiveness is measured and documented will have certain scores under related Life Safety Code compliance "capped," which will minimize the chance of receiving a recommendation for improvement (RFI) for those items, he says.
Few ASCs have BMPs
While it is not typical for freestanding ambulatory surgery centers to have a comprehensive BMP at this time because it is not currently addressed in The Joint Commission's ambulatory standards, it still is a good idea to create one, suggests Slack.
"Some ASCs may have periodic life safety inspections of fire and smoke doors as well as exit signs, but they do not measure the effectiveness of their program, which is required for a BMP," he says. [A copy of a sample BMP policy, a data collection form, and a BMP effectiveness summary form are available, click here.]
Consider these benefits
In addition to avoiding RFIs, there are other benefits to a proactive program to review conformance with the Life Safety Code and to avoid interruptions due to facility-related issues, says William E. Lindeman, AIA, NCARB, president at WEL Designs, a health care facility consulting and design firm in Tucson, AZ.
"Operational down time, or periods where regulatory violations or building system failures interrupt a facility's income-generating activities, is far more expensive than simple lost revenue," he says.
The loss of a single day's productivity due to a water leak in a critical sterilizer or newly discovered Life Safety Code violation, easily could result in financial losses in the tens of thousands of dollars when you take salaries, insurance expenses, lost revenue, and disruption to surgeon's schedules into account, he explains.
"My experience suggests few freestanding ASCs have a formalized BMP, and I have never seen one fully implemented in any setting," says Lindeman. "I also believe all successful ASCs have many if not most of the elements in place; they just haven't pulled them together into a coordinated entity and have not established a chain of command or accountability to make full use of it," he adds.
Life Safety Code issues that are typically overlooked by outpatient surgery programs may seem insignificant but can have serious consequences, says Lindeman. "For instance, removing the closer from a door that you would rather have stayed open could be defeating fire safety design requirements," he points out. "There are also specific requirements for weekly, monthly, and sometimes annual testing of emergency power systems, yet few facilities are aware of the weekly test and even fewer have required on-site documentation of the tests and maintenance."
Remember, too, that many states' licensure standards include air quality standards for a variety of areas, says Lindeman. "Any door held open between incompatible spaces at the very least violates those standards, and in a worst case threatens infection control," he adds.
The best way to start evaluating your compliance with Life Safety Code issues is to review the standards of your accrediting organization, says Lindeman. "The Accreditation Association for Ambulatory Health Care's standards publications can also be very helpful since their standards are specific to ASCs and identify the conditions they feel are most significant in an ASC," he adds.
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