The federal Life Safety Code standards for ambulatory surgery centers (ASCs) will continue to evolve over the next few years. They are moving toward patient safety-centric policies and procedures, and it might not be long before the next big changes arrive.

“We’ll be riding a wave for the next three to four years of continuous flux in life safety codes, as they settle on something that is acceptable that industry can handle and that also maintains patient safety,” says James Peck, operations manager and life safety healthcare specialist at Riteway Building Services in Winter Park, FL. Peck speaks about life safety compliance at national conferences.

A healthcare facility’s physical plant is important, and ASCs are starting to recognize this, Peck notes.

“In my personal opinion, this may have to do with the insurance industry and risk,” he explains. “Insurers are seeing the need to ensure that the people they underwrite the risk for are adhering to [all] regulations to ensure their risk is as low as possible.”

When the Centers for Medicare & Medicaid Services (CMS) adopted the 2012 codes of the National Fire Protection Association (NFPA), ASCs suddenly needed to rely on experts for life safety inspections, Peck says. The environment of care pertains to everything mechanical within a surgery center, including backup generators, medical gas systems, vacuum systems, fire alarms, and sprinklers. Each device must be inspected at least annually.

The Accreditation Association for Ambulatory Health Care (AAAHC) updated its standards in the recently released 2018 Accreditation Handbook for Ambulatory Health Care. The update includes the 2012 Life Safety Codes, says Mary Wei, MBA, assistant director of accreditation services at AAAHC.

“From my perspective, the most significant change in the 2012 codes isn’t really the codes,” Wei says. “Yes, there are some new requirements, but the most significant change was in how CMS defined [facilities] — what is now new and what was existing.”

Before the 2012 codes, new facilities were dependent on whether the organization was a participating provider with Medicare. If an ASC wanted to enroll with Medicare, then it was considered new at its enrollment, regardless of the age of its building, Wei explains.

“Now, with the adoption of the 2012 safety codes, Medicare took a more thoughtful approach and can go back to whenever the facility’s physical plant was built, regardless of whether the provider is a Medicare participating provider,” Wei explains.

CMS drew a line under the date of July 5, 2016. Any facility with permits approved prior to that date would be considered an existing facility. Any ASC with permits after that date is considered new.

AAAHC’s new handbook contains a physical environment checklist, including the 2012 changes.

“It’s not meant to be an all-inclusive list of absolutely everything, but it is meant to represent everything that we would possibly look at in a survey,” Wei says.

Surgery center administrators, who are just getting up to speed on the 2012 Life Safety Code changes, should brace themselves for another change, possibly in 2018. NFPA updates its own standards every year or two, and it typically takes CMS several years to adopt these.

“In 2016, CMS adopted NFPA guidelines for 2012, four years after the guidelines were written,” Peck says. “CMS read through everything, made some amendments to it, and then adopted the actual guidelines and put them out to the medical industry. These are the current standards CMS is effectively going to enforce, and CMS is the enforcer of all of these guidelines put forth by the [NFPA].”

The 2015 NFPA 99 guidelines also are out and in front of CMS for consideration.

“CMS is going through them and, more than likely, we suspect they’ll start enforcing those in the spring of 2018,” Peck says. “We’ve looked through them, and there are a ton of changes. They tend to side on the side of safety for the patient.”

Inspectors Must Be Certified/Credentialed

One of the biggest changes on the horizon is a requirement that only certified/credentialed experts be allowed to inspect and certify the functionality of medical equipment, Peck says.

Currently, ASCs can hire an outside contractor to conduct the inspections. Or, they can hire a vendor’s certified technician for each piece of equipment, or they can hire someone who performs this work on a regular basis. In the future, only those who have received special training and certification/credentialing will be permitted, he says.

“ASC administrators need to ensure the contractor they’re hiring and the technician, who is actually doing the inspections, have certification and credentialing,” Peck notes.

Another big change involves risk assessments.

“Risk management is massive in the healthcare environment because everything in healthcare is risk-based,” Peck says. “These assessments have to be formatted in a matrix so it’s clearly explained that there is so much risk involved in utilizing that piece of equipment.”

Because of this growing emphasis on risk assessment, the next changes to the Life Safety Code likely will not allow ASCs to hand someone a life safety compliance checklist and be finished with the inspection.

“You need to understand why it is that you’re doing it, and that’s where the thrust of the new compliance is going forward,” Peck says.

Measure Equipment Risks

The next change will add layers of analysis to risk assessment. For example, ASCs will need to discern how much risk is involved in pieces of equipment and whether the risk directly or indirectly affects patient care. Then, they’ll present findings to their governing body.

“Say there is a backup generator, and it has a huge level of risk because the ASC is located in Florida, and we lose power on a regular basis,” Peck says. “So, we assign that a level 1 risk, and because of that risk, we now need to ensure that piece of equipment is inspected on a periodic basis.”

The ASC decides whether the inspection will take place weekly, monthly, quarterly, or annually. Then, this assessment and decision are placed in the organization’s policies and procedures. Risk assessments like this are conducted for each piece of life safety equipment.

Another example involves fire alarm systems, which also carry a high level of risk. It will no longer be acceptable to simply direct some people to meet to discuss how to act in the event of a fire. ASCs must hold fire drills with all staff on a quarterly basis, at a minimum, Peck says. The practice fire drill includes staff walking through the steps, complete with mock patients.

“It’s nice to sit down and discuss it, but we need to see you do it,” he says. “The regulations give you the guidelines, saying this needs to be done and completed, but how you do it is up to you,” Peck says. “We suspect that in the first quarter of 2018, we’ll hear about the acceptance of NFPA 99 2015, and our suspicions have been right thus far.”