What you need to know about ILSMs in 2017

he Joint Commission announced it was changing its interim life safety measure (ILSM) evaluation process back in November 2016. From now on, the accreditor stated, when a surveyor identifies a Requirement for Improvement (RFI) level deficiency they’ll confer with the facility to pick the most suitable ILSM to use.

ILSMs are meant to mitigate potential risks when life safety features are deficient, compromised, or removed from service due to construction, maintenance, or breakdown/repair. Such features include fire sprinklers, fire doors, and means of egress.

The Joint Commission also created a new element of performance (EP) for the LS.01.02.01 standard. EP 15 states that if the hospital’s policy allows for ILSMs not addressed in EPs 2–14 to be used, then they must be documented in the “other” section of the hospital’s Survey-Related Plan for Improvement (SPFI).

To learn more about ILSMs, we spoke with three experts to pick their brains on proper life safety compliance and policy.

Steve MacArthur

ILSMs in 2017
Steve MacArthur, safety consultant at The Greeley Company, Danvers, Massachusetts, says the important piece of picking the best ILSM is knowing that whatever measure you choose to implement must demonstrably compensate for the deficiency. He notes that The Joint Commission specifically identifies only a dozen or so specific ILSM actions, which should help narrow down which one to pick.

“That said, unless you have a list of ILSMs a mile long, it’s better to do a little more to compensate for an escalated risk than to do a little less,” he says. “But doing a lot more tends to result in operational challenges that are not easily managed. You want to protect the building and its occupants, but preventing them from doing their work within the confines of the building is somewhat less helpful.”

The most important thing facilities need to know, he says, is that there’s probably going to be a spike in Joint Commission findings in 2017. This is due in part to the adoption of the SAFER Matrix, and  the elimination of plans for improvement (PFI ). And an increase in life safety findings will mean that facilities will have to implement more ILSMs.

“To be fair, the SAFER Matrix in and of itself won’t increase the number of findings,” he says. “But past experience indicates that any time there are sweeping changes—and I feel pretty comfortable describing the current changes as sweeping—there’s a period of time in which there’s confusion on both sides [between surveyor and surveyed], which results in more findings.”

He says that it will probably take a full triennial cycle to sort out all the kinks with SAFER. In the meantime, the physical environment is going to remain a focus for surveyors.

“There are no perfect buildings and thus lots of stuff to find,” he says. “And CMS is hammering the living daylights out of The Joint Commission because they are not finding enough existing physical environment issues.”

Problem area
When chatting about ILSMs, MacArthur says that the most common mistake he sees are facilities putting different types of deficiencies. He says that most places have very robust processes for managing construction-related ILSM implementation. But the same can’t be said for processes dealing with “regular” Life Safety Code® (LSC) deficiencies that can’t be immediately corrected within 24 hours of identification.

Another issue arises when policies don’t allow one to simply make the determination that an ILSM doesn’t need to be implemented. Just because something may take a little while to correct doesn’t necessarily mean that will need an ILSM, he says.

 “For example, late on a Friday a door is identified as needing new latching hardware and you can’t get the new hardware until Monday,” MacArthur says. “You’re not going to implement any ILSM that is legitimately going to compensate for the risk—which in this example is pretty minimal—but you have to document the assessment; in this particular instance as with so many things related to compliance, you don’t get to do the math in your head. Once you’ve documented the assessment, considered the options, etc., then you have a process that is complete.”

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