Far below, where shadows fester as they grow…
Isn’t that a jolly holiday message?
So, just when you thought it couldn’t get any more stressful, our munificent friends in Chicago are bestowing yet another bounty upon the teeming masses–updated EOC standards—https://www.jointcommission.org/-/media/tjc/documents/standards/prepublications/hap_ec_edits_july_2022.pdf !!!!!!
In the interest of time, I’m just going to run through these quickly; for some strange reason, I have this feeling that some of this stuff is going to take a while to manifest itself in the field (though I also sense that things have already started to shift a bit). I guess it’s good that these don’t “count” until July (oh boy, another holiday impacted by impending doom…)
Conduction/scheduling of fire drills –The use of “alternative methods” for notifying staff for fire drills conducted between 9 p.m. and 6 a.m. has been “clarified” to mean “a coded announcement.” If I’m honest, I’m not sure how else you would meet the notification requirement for drills without using a coded announcement, but apparently there were enough funky findings in the field for them to draw a very specific line in the sand. So, coded announcements will be the strategy moving forward.
Also included in the fire drill requirements is the enjoinder to make sure that drills are separated by at least one hour for each shift from quarter to quarter, through four consecutive quarters. I don’t know that anyone truly has a hard time with this once it’s pointed out to them; it’s mostly a question of establishing the schedule ahead of time. I suppose it could put a damper on folks that use “false alarms” as they tend to be less predictable (unless you’ve got a construction project in the building—then it’s almost too predictable )
While it does not appear to figure in the language of the standard, I would also remind you to observe the whole sequencing of the fire drill quarters—1st shift drills every 3 months (+/- 10 days); 2nd shift drills every 3 months (+/- 10 days); 3rd shift drills every 3 months (+/- 10 days). You might also want to consider the odd weekend or holiday drill—it’s not required yet but somehow I suspect that before too long.
Locations for fire drills—A couple of new performance elements relative to fire drills in surgery and hyperbaric facilities—I’ll let you decide for yourselves whether you “rule in” on these, but I think your only “out” would be if you didn’t have surgery or hyperbaric facilities. These are clearly environments of greater risk for fire and so need to be managed accordingly. They don’t specifically mention MRI under the fire drill standard, but if you’ve got one of those, I’d be thinking about at least one fire drill per year. Because of the educational component of these drills, you might not want to try to include them as part of your quarterly program (it doesn’t make a lot of sense for these drills if you have minimal participation, which usually means some sort of notification), but again, that’s something to think about.
Life safety systems ITM—Some funky shifts that (at least for the moment) are leaving me scratching my head. For the quarterly testing of supervisory signal devices, it appears that TJC is expanding their definition of supervisory signal devices to include a collective “other supervisory initiating devices.” The reason I am scratching my head is that NFPA 72-2010 requires “other supervisory initiating devices” to be tested annually, so I’m not sure where this is coming from. Additionally (sticking with supervisory devices), the supervisory signal devices associated with the fire pump (fire pump running; fire pump power loss) only need to be tested annually; again, not sure where that’s going, but I guess we’ll wait and see. Continuing on, please note that there are gaseous fire extinguishing systems (most notably halon systems) that require testing every 6 months; carbon dioxide systems are still at an annual frequency and if you have gaseous systems that are neither halon or carbon dioxide, you need to consult the manufacturer specifications for appropriate testing.
Medical Equipment—A return of an oldy but goody—Safe Medical Device Act (SMDA) reporting. I’m not entirely certain when this was removed from the Medical Equipment Management section of the EC standards (I think shortly after the turn of that last decade), but it’s back as a specific performance element. At any rate, not sure what’s prompted the return for this mandatory requirement, but it might be a good opportunity to check out the process to ensure that everyone in the mix is solid on your internal process. This is one of things that I would have tended to take for granted, but it’s not necessarily a highlight of the safety year so it might be worth an annual touch (can you say “annual evaluation?” Sure you can!)
Utility Systems – Some Control Systems—This one is going to have some individuality when it comes down to how much angst is going to be generated; the overarching consideration for existing engineered smoke control systems is that it be in compliance with NFPA 101-2012 19.7.7.1 or be specifically approved by the authority having jurisdiction (AHJ). I can think of one or two instances in the past where compliance (or lack thereof) was primarily a function of not having an engineered smoke control system, so I’m not sure how big a deal this is going to be. I don’t think this is a “gonna make you cray-cray” change, but sometimes you have to wait for other shoes to drop before the enormity of it all is discernible.
Last week, I was a little behind the curve and neglected to include a seasonal listen; when I think of vocal Yule offerings, this is the one that comes to mind first—it’s, in turn, elegant, graceful, joyous, and a lot fun. Check it out: https://www.youtube.com/watch?v=nqlmZbyl9Zw&list=OLAK5uy_mmhHKZQFH-brbv39CTNGkAJ3xFCM-yaAQ
As this is the last missive before the holiday proper, I wish for each of you and your family a most joyous, safe and healthy turn of the season!
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.