By James Kendig, Field Director, The Joint Commission
Assessing and preparing for a successful Joint Commission Life Safety Code survey within a surgical setting does not have to be a laborious or anxiety-producing event. With proper planning and prior knowledge of processes, ambulatory surgical centers (ASCs) can easily prepare for a successful survey.
- Below is basic information, divided by process, to help ASC staff prepare for a successful survey:
- Keep a flashlight available to help view spaces above the drop ceiling.
- Provide surveyors with a ladder that expands to easily reach an ambulatory facility’s ceiling. Most ladders are sold with a rating, so review weight requirements prior to purchase. Routinely, a ladder with a rating of Type 1 (250 lb. capacity) or Type 1A (300 lb. capacity) is sufficient.
Select inspection vendor
Selecting a vendor for inspection, testing and maintenance activities is an important step prior to the survey process. The inspection vendor must be knowledgeable about systems they are inspecting, testing and maintaining and should be up to date on related National Fire Protection Association (NFPA) requirements and Joint Commission standards.
The inspection vendor is also responsible for thoroughly understanding Joint Commission requirements. So, providing them with a copy of the standards manual and becoming familiar with standards and requirements is an important step before document review during survey.
Additionally, identifying a staff member to serve as a standards manual expert to enforce its requirements within a health care facility helps to successfully complete the document review. Larger organizations may receive standards enforcement support from their corporate offices; however, stand-alone facilities require staff to personally become familiar with standards, elements of performance and how they are organized within the standards manuals.
Keep current with updated code requirements
Specific NFPA codes are found in the Life Safety Code 101 document (2012 edition) in Chapter 2 “Referenced Publications.” Chapter 2 is a valuable reference for scenarios that involve multiple versions of updated codes. For example, in the chapter “Evaluating a Sprinkler System,” it notes that the 2010 edition of NFPA 13 and the 2011 edition of NFPA 25 are used. Another example notes that NFPA uses the 2010 edition of NFPA 10 related to fire extinguishers.
It is imperative to keep up with current codes used, since NFPA codes get updated approximately every three years. Erroneously using an earlier or later edition of the code may result in edits that would impact the inspection testing and maintenance of the various systems. Additionally, various versions of NFPA codes may add, delete or even edit certain sections. So, make sure the vendor is using the appropriate code to complete inspection, testing, and maintenance activities (they are found in Chapter 2 of the Life Safety Code 101-2012).
Determine if the health care organization has CMS “deemed status”
Centers for Medicare and Medicaid Services (CMS) adopted the NFPA 101-2012 edition of the Life Safety Code on July 5, 2012, for deemed health care organizations. In simple terms, “deemed status” demonstrates that a health care organization not only meets but exceeds expectations for a particular area of expertise.
Deemed status is given by CMS or through an accredited agency. Health care organizations that achieve accreditation through a Joint Commission “deemed status” survey are determined to meet or exceed Medicare and Medicaid requirements. So, a health care organization with “deemed status” would not be subject to the Medicare survey and certification process because it has already been surveyed by an accrediting organization.
Pass document review, inspection, testing and equipment maintenance
On the day of survey, Joint Commission surveyors typically arrive early, so it is important to be ready to greet them as early as 7:30-7:45 a.m. After introductions, the Life Safety Code surveyor completes a document review to specifically focus on inspection, testing and maintenance of a facility’s fire sprinkler system, fire alarm system, generator and related medical gases. It is wise to reference The Joint Commission’s Survey Activity Guide (SAG) for additional details of document review.
Typically, the Life Safety Code surveyor asks three introductory questions to orient themselves to an ASC:
- What type of fire stop does the health care organization use? (This is followed up with review of training for use.)
- Are there any prohibitions or safeguards when accessing the interstitial spaces above the ceiling?
- What does the health care organization use for high-level disinfection? (This is asked to determine appropriate air exchanges for a specific product.)
Observe fire panels and pumps
Joint Commission surveyors observe an ASC’s fire panels to assure they are in working order. Additionally, they assess a facility’s generator to ensure it is in good condition and that it is equipped with an emergency light. Surveyors also ensure a remote emergency “power off” indicator is located a safe distance away from the generator.
A fire pump is less likely to be used unless the surveyed facility is an expansive or a multi-story building. In these cases, community water pressure is commonly used to support the approved automatic sprinkler system.
Complete building tour, emergency management session and report review
During a survey building tour, the Joint Commission surveyor focuses on NFPA code requirements as well as air pressure and relative humidity requirements within a building’s surgical areas. Remember, relative humidity is addressed in CMS memo S&C: 13-25-LSC & ASC. ASCs are not subject to all the same Life Safety Code (LSC) requirements as hospitals, but are required, consistent with 42 CFR 416.44(a)(1), to maintain relative humidity (RH) in operating rooms in accordance with nationally accepted guidelines.
After completing document review and a building tour, it is time to complete an emergency management session to assess a facility’s compliance with ambulatory requirements. This overview takes approximately one hour and covers emergency event drills, staff training and responses during an emergency drill or actual event.
Once the emergency management session is complete, the Life Safety Code surveyor and clinical surveyor, if present, exit the survey to conduct a preliminary report review. Remember, however, that the report is not considered final until it is reviewed and approved at The Joint Commission’s central office. For this reason, version control of documents is vital.
Conclusion
Joint Commission surveyors work onsite with ASC staff to ensure they are prepared for a successful survey. During survey, staff should feel free to ask the Life Safety Code surveyor questions to better understand the survey processes. Additionally, it is important to obtain answers to any questions regarding code requirements. Joint Commission surveyors are present during survey to guide staff so that health care organizations, including ambulatory facilities, earn the Joint Commission Gold Seal of Approval, indicating that their facility meets The Joint Commission’s rigorous performance standards in delivering care and is committed to the highest level of health care quality and safety.
– James Kendig is field director at The Joint Commission.
