Surveyors zero in on life safety code compliance

Life safety code is key focus during patient tracers

Are you worried about the certified health care engineer surveyor who will be scrutinizing your organization’s life safety code compliance during your next JCAHO survey? If so, be aware that the attention paid to life safety and Environment of Care (EC) may be even more intense than you expect.

"Throughout the survey, the team looked at EC issues wherever they went," reports Kerri Anne Scanlon, RN, MSN, ANP, associate executive director of quality management at North Shore-Long Island Jewish Medical Center in New Hyde Park, NY. The organization had an unannounced JCAHO survey in April 2005.

"A lot of hospitals are nervous about the engineer, but it wasn’t just the engineer," she says.

"The administrator actually took a lead in doing the EC. He did the formal three-hour EC interview and was very educated in his approach. Your building safety program is just as important as any other safety program," notes Scanlon.

A 2004 report from the Government Accountability Office (GAO) was critical of JCAHO’s ability to ensure quality care. The report found that JCAHO surveyors did not find deficiencies in 123 out of 500 hospitals, including failure to adequately protect patients and staff from fire-related disasters.

The report found that of 167 serious deficiencies that were not detected by JCAHO, 87 were related to a hospital’s physical environment, which includes life safety code standards for fire prevention and safety.

At that time, JCAHO acknowledged that it needed to improve its assessment of life safety code compliance. As of Jan. 1, 2005, a certified health care engineer was added to the survey team for hospitals with 200 or more beds, and additional training in life safety code compliance was given to surveyors of smaller organizations.

"In my experience, smaller organizations are often in need of qualified engineers for consultative and educational purposes, as they are unable to afford to hire those folks or attract them to small and rural areas," says Ann Kobs, senior vice president for accreditation and standards at TUV Healthcare Specialists in Cincinnati.

Those surveyors will look closely at the standards in the EC chapter, she adds.

"It would be most beneficial for staff in quality to become conversant with the National Fire Protection Association code, the Statement of Conditions, and the standards, which have been left up to the in-house engineers in the past," Kobs says.

As of Jan. 1, 2005, several of the EC standards no longer require a Measure of Success (MOS) if the facility is not meeting the intent of the standards. "This does not mean that they are any less important," says Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO of Houston-based Mellott & Associates.

When developing an MOS, there must be a numerator and a denominator in the measure, and both need to be easily measurable and reportable.

"One common mistake is that the indicators selected really cannot be measured or do not really pertain to the area of noncompliance," she says.

As a quality manager, you need to work with the EC staff to establish MOS that meet the criteria, Mellott explains.

"You must then assure that the MOS are being monitored and improvements are being made and reported as appropriate," she says. "Quarterly reporting of the MOS to the quality manager should be required."

Ensure EC compliance

To ensure compliance, do the following:

  • Do an EC tracer on stained ceiling tiles.

"This is a perpetual problem," Kobs says. "What usually happens is that organizations order crates of ceiling tile and keep replacing the stained ones. Instead, they need to see if there is a leaky pipe above and fix the leak."

She advises removing a stained tile, tracing the leak to its source, and having the appropriate person fix it. "It could be their entire system may need repair or replacement instead of fixing one pipe," Kobs says. "In the meantime, if it’s growing mold, or Legionnaire’s, it’s unhealthy for workers or for patients."

She recommends answering these questions: What is staining the tiles? Where is the leak coming from? Why isn’t the leak fixed? Is there mold? Who is responsible for plumbing? Are they qualified? Were they oriented? How were they deemed competent?

Mock EC tracers should consist of two separate tracers: one focusing on the life safety aspects of the EC standards that the life safety specialist will look at, and a second focusing on the remaining EC standards, Mellott says.

During this second tracer, the EC records that correspond with the standards should be reviewed, she adds.

"There should also be interaction with staff, to assess staff knowledge about the high-risk areas for each of the seven plans," Mellott continues. "For example, does the staff know what to do if a bomb is possibly in the area? What does the staff do with medical equipment that is not working properly?"

Are your documents accessible?

The tracer also should include evaluations of the fire and disaster drills and assess whether necessary changes were made, she says.

  • Have documents accessible.

On the first day of a JCAHO survey at a hospital Mellott consulted for, the administrative surveyor was looking at EC documents while the life safety specialist was touring the building with the plant operations director.

"This had a great impact on this survey because the plant ops director had only been at the facility a little over a month, and the position had been vacant for four months prior to his arrival," Mellott points out.

The new plant operations director wound up fielding questions from both surveyors and was asked to provide some documentation that the secretary did not have, she notes.

"This created an issue when the administrator could not find the information he was looking for," Mellott says. "It is imperative that the plant ops director has the documents in an accessible place for the administrative surveyor that first day."

That includes risk assessments and annual evaluations for each of the seven EC plans, the EC/safety committee minutes, and evidence of reports regarding the EC being shared with the governing board for the past four quarters.

  • Review the seven EC plans annually.

"The surveyors are looking for demonstration of the effectiveness of each of the seven EC areas," Mellott explains. "This is the area where the quality managers can have the biggest impact during the survey, in regards to the EC standards."

The administrative surveyor was impressed with North Shore-Long Island Jewish’s annual evaluation process, says Scanlon. "He said all levels of staff were very knowledgeable about life safety and could speak to this. They could see it’s part of everyday practice here, not just for the survey."

The objectives, scope, performance, and effectiveness of each of the EC management plans need to be reviewed, so develop your plans for each of those areas and then list the evaluation of each area in the annual evaluation, Mellott says.

"This lets the surveyor know that you are aware of the requirement to have and evaluate these areas," she explains. "Of these, however, the effectiveness is the most important."

The indicators used throughout the year, as well as any MOS that have been monitored, should be discussed in the effectiveness section, Mellott notes.

If a request to the administration and/or board for implementation of an improvement has been requested, this should be discussed in the context of the appropriate plan evaluation, says Mellott. "The annual evaluation should then set the stage for what will be the priorities and monitored during the upcoming year," she adds.

  • Do unit-based EC rounds.

The surveyors at North Shore-Long Island Jewish did not find any EC deficiencies, which Scanlon credits to the organization’s ongoing EC and building maintenance program.

"The program is under the direction of the director of safety and reports up to our quality program," she explains. "They do unit-based rounds using a designated tool for EC, which covers the seven plans and also has a staff knowledge component.

"The rounds were key, because we had to assess whether we were in compliance or not, and this facilitates the momentum of the ongoing program," says Scanlon. "However, you need some type of scoring grid to report that information back. Otherwise, it becomes very subjective."

Staff are interviewed on EC compliance, with scores reported to unit managers on a monthly basis.

"All of that information gets aggregated and gets reported to the quality committee, up to the board of trustee committee on safety," says Scanlon.

"That information allows us to objectively measure our improvement over time," she says.

The organization’s administrative team for EC consists of Scanlon, the vice president of nursing, associate executive director for facilities and clinical services, director of engineering, director of housekeeping, and director of safety.

"We do rounds on all the units and all the services, identify any real-time opportunities to fix things then and there, and also reinforce staff knowledge," she says.

The team also assesses which units are failing to correct problems or submit corrective action plans.

  • Educate frontline staff.

At North Shore-Long Island Jewish, the surveyor spent a lot of time talking to unit staff, including housekeepers and receptionists, about fire drills, disaster codes, infant and pediatric abduction, and security, notes Scanlon.

"It was really frontline staff that they wanted to speak to. We were able to demonstrate our emergency management program, which was linked to many patient tracers," she says. "They observed practitioners doing actual clinical procedures in the patient rooms. It was a very different EC review."

Fire and life safety code was their biggest focus, says Scanlon. "They asked staff about the evacuation plan for exiting in a fire and then tested it, and also asked about oxygen and how it relates to this," she says. "They were very interested in the actual fire life safety program, including what disaster drills we run and if staff were aware of them."

  • Have a thorough building maintenance plan.

At North Shore-Long Island Jewish, the organization’s building maintenance plan covers the seven EC plans, including fire life safety codes and utilities management.

The administrator opened every fire door in all three hospital buildings, says Scanlon. "He was extremely thorough, even more so than the engineer," she says. "They opened up ceiling tiles and went into every nook and cranny. It was a five-day survey, so they were able to cover that much more ground, and there were several more surveyors this time."

The engineer surveyor validated and verified the plan, looked through emergency department records, and did the building tour, Scanlon explains. "From the first day, surveyors had a good understanding whether our building was in good shape or not," she notes. "That set the stage for how the rest of the survey would go."

The director of engineering accompanied the JCAHO engineer during the survey, which was helpful because they could "speak the same language," Scanlon says.

  • Work closely with engineering.

You may need to begin by finding out exactly who is responsible for EC, says Kobs. "I don’t say that to be facetious, but somehow in some organizations, they just haven’t crossed paths," she says. "Getting to know these persons is a good start."

Ask these individuals to walk you through the building to demonstrate how the Statement of Conditions are addressed and kept current, she recommends.

"Have them explain about the composition of the roof, future plans to upgrade old facilities, and what makes some areas not suitable for patient occupancy any longer," Kobs says.

At Baptist Hospital of Miami, the safety officer and director of engineering are co-leaders of the organization’s EC team, which is part of the JCAHO readiness team.

"Quality leaders really don’t have the level of expertise for this — engineering does. I think with the addition of the life safety engineer, we need to rely on their expertise even more," says Faith D. Solkoff, RN, BSN, MPA, director of performance improvement.

"As a quality leader, we can ask the right questions and ensure that the EOC standards are being met; but at the end of the day, you need your engineering folks to ensure that the building is safe," she adds.

A good way to prepare is to review your organization’s life safety findings from your state audits, Solkoff says.

"If you see that there are many issues, then you should recommend to your CEO that a consultant life safety specialist or engineer be brought in," she adds. "Thanks to the life safety leaders in our organization, we impressed JCAHO with our staff’s knowledge of the EC, as well as the safety of our structures."

Here are key areas of focus for life safety code compliance during the hospital’s recent JCAHO survey:

  • Document review was thorough.

"The surveyor had a list that he ran down and checked off as it was reviewed," says Jeff Zohn, director of engineering services at Baptist.

"He looked at our documentation especially hard to make sure we were testing at all of the appropriate intervals — monthly, quarterly, semi-annually, and annually."

Fire protection components were looked at especially closely, such as fire sprinkler testing and inspections, fire alarm testing, fire drills, and smoke damper inspections and maintenance.

  • Documentation on generator and transfer-switch testing was checked.

"Make sure you have documentation that all automatic transfer switches are tested in the designated time frame," Zohn advises.

  • Surveyor looked for penetrations.

"The surveyor spent a lot of time above the ceiling," he says. "He asked for every electric room door to be opened and looked for penetrations in them. He also checked numerous fire doors for latching as we toured the building and looked for clutter in the corridors."

  • Fire protection in the kitchen was reviewed.

The surveyor made sure the fire suppression system was inspected and up-to-date, that staff knew how to activate it and what type of fire extinguisher to use, that nozzles were positioned over the cooking areas, and asked staff what they would do if there was a grease fire.

  • Surveyor checked whether flammable material was contained, stored, and labeled properly.

"During the building tour, he asked employees about their role in the event of a fire, and asked several nurses about who can shut off oxygen," Zohn adds.

[For more information, contact:

  • Ann Kobs, Senior Vice President, Accreditation and Standards, TUV Healthcare Specialists, 463 Ohio Pike, Suite 203, Cincinnati, OH 45255. Phone: (513) 947-8343. Fax: (513) 947-1250. E-mail:
  • Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO, Mellott & Associates, 5322 W. Bellfort, Suite 208, Houston, TX 77035. Phone: (713) 726-9919. Fax: (713) 726-9964. E-mail:
  • Kerri Anne Scanlon, RN, MSN, ANP, Associate Executive Director, Quality Management, North Shore-Long Island Jewish Medical Center, 270-05 76th Ave., New Hyde Park, NY 11040. Phone: (718) 470-7825. Fax: (718) 962-6759. E-mail:
  • Faith D. Solkoff, RN, BSN, MPA, Director, Performance Improvement, Baptist Hospital of Miami, Quality Management Department, 8900 N. Kendall Drive, Miami, FL 33176. Phone: (786) 596-2685. Fax: (786) 596-5983. E-mail:]