TSIG Overview and Inspections - Hilti

Physical Environment 

Essentials 

George A. Rivas, CHSP-FSM 

2011 NYC Healthcare Symposium 

10/27/2011 

1

Scoring changes that took effect in 2009 

• No more supplemental recommendations 

• Introduction of direct & indirect impact scores 

• Added “documentation” expectations 


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2011-12 Changes? 

WHAT HAVE YOU HEARD? 


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So What’s New for 2011 - 12? 

• Fewer C Category Scores for Elements of Performance 

• Greater Emphasis on Life Safety 

• - Added Days for Life Safety Surveyor 

• - Additional LS Surveyors Hired & Trained 

• - LS Surveyors Auditing the EC EP’s 


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Life Safety Code Recommendations For 

Improvement’s (RFI’s) Remain Consistently within the 

Most Frequently Cited RFI’s (Top 10 in 2008, 2009 & 

2010) 


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• LS.02.01.20 (45%) The hospital maintains the 

integrity of the means of egress. 

• LS.02.01.10 (43%) Building and fire protection 

features are designed and maintained to minimize the 

effects of fire, smoke, and heat. 

• LS.02.01.30 (36%) The hospital provides and 

maintains building features to protect individuals from 

the hazards of fire and smoke. 


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• 2010 

• PRELIMINARY ACCREDITATION 

• ACCREDITED 

• PROVISIONAL ACCREDITATION 

• CONDITIONAL ACCREDITATION 

• PRELIMINARY DENIAL OF ACCREDITATION 

• DENIAL OF ACCREDITATION 

• 2011 

• PRELIMINARY ACCREDITATION 

• ACCREDITED 

• ACCREDITED WITH FOLLOW UP SURVEY 

• - Requires Follow Up Survey usually within 30 days to 6 

• months 

• CONTINGENT ACCREDITATION 

• - Requires Follow Up Survey in 30 days 

• PRELIMINARY DENIAL OF ACCREDITATION 

• DENIAL OF ACCREDITATION 


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Criticality 

• The levels of criticality fall into four categories: 

1. Immediate Threat to Life 

2. Situational Decision Rules 

3. Direct Impact Requirements 

4. Indirect Impact Requirements 


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Accreditation Based on Impact on Patient 

Care 

Immediacy of risk to patient 

care and the 

organization’s 

accreditation status 

Higher 

“Sharp End” 

Immediate 

Threat To Life 

(PDA until resolved) 

Situational 

Decision Rules 

(Conditional Accreditation and 

Preliminary Denial of Accreditation ) 

Timeline for resolution of noncompliant 

findings 

Shorter 

= Resolution/ 

Validation 

Direct Impact Requirements 

“Implementation” Based Requirements 

(Short Resolution Timeframe) 

= Resolve in 45 

Days 

(PFI Acceptable) 

Lower 

Indirect Impact Requirements 

“Planning” and “Evaluation” Based Requirements 

(Longer Resolution Timeframe) 

= Resolve in 60 Days 

(PFI Acceptable) 

Longer 


“Blunt End” 

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• A indicates scoring all or nothing 

• C indicates scoring based on >90% of sampling 

• 2 indicates situational rules apply 

• 3 indicates direct impact requirements apply 

• M indicates Measure of Success 

• D indicates documentation is required 


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Emphasis of Current EC Surveys 

• Focus on integration of Life Safety & Emergency Management 

*Independent Chapters began in 2009 

• Use of Tracer process to validate how EC processes work 

• Living up to your management plans 

• Documentation of risk assessment is critical 

• Staff behavior is under constant watch 


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Goal 2 Improve communication 

among caregivers. 

58% 

Goal 8 Accurately and completely 

reconcile medications 

46% 

MM.2.20 Medications are properly 

and safely stored. 

44% 

UP 1 Fulfill expectations set forth in 

the Universal Protocol. 

30% 

EC.5.20 Environment designed & 

maintained to comply with NFPA 101 

26% 

MM.3.20 Medication orders written 

clear & transcribed accurately. 

26% 

PC.8.10 Pain is assessed in all 

patients. 

19% 

IM.6.10 Complete & accurate 

medical record for patients 

18% 

EC.1.10 The hospital manages 

safety risks. 

17% 

Goal 3 Improve the safety of using 

medications. 

17% 

0% 10% 20% 30% 40% 50% 60% 70% 


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Life Safety Planning & Implementation 

• Compliance with NFPA Life Safety Code 101 2000 

edition 

• Comply with NFPA 101, 2000 edition or, 

• Obtain & equivalency or approved PFI 

• Maintain a current Statement of Conditions 


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Life Safety Planning & Implementation 

• Statement of Conditions 

• SOC requirements (required buildings) 

• Accurate assessment & correction plans 

• Necessity of keeping SOC current 

• BMP alternatives 

• Qualifications 


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Life Safety Code Recommendations For 

Improvement’s (RFI’s) Remain Consistently 

within the Most Frequently Cited RFI’s (Top 10 

in 2008, 2009 & 2010) 


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CMS Survey Results 

• Nearly x 5-10 times the Number of RFI’s 

uncovered, compared to TJC Surveys! 

• DNV: too early to tell 


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Life Safety Requires: 

• A diligent, ongoing process for monitoring, 

surveying and repair 

• Someone with a knowledge of the NFPA 101 Life 

Safety Code 

• A sound, rational and realistic approach for 

alternatives and interim measures 


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STEP ONE 

• Identify the deficiency! 

• Ignorance of the code is not an excuse 

• When in doubt, consider it a deficiency 

• And then seek the answer 

• Multiple resources include: 

• TJC Standards (LS Chapter) 

• NFPA Membership 

• Ask a Consultant 

• rivasg@tsigconsulting.com (847) 612-8424 


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STEP TWO 

• TJC Provides the Following Options 

• Option #1 - Resolve the deficiency immediately with 

documentation. 

• Option #2 - A documented management process identifying 

the deficiency, actions to resolve the deficiency, date 

observed and date corrected. This process is permitted for 

deficiencies that can be resolved in 45 days. *** (documented 

+/- 90 days & Code ref) 


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STEP TWO 

• Option #3- A Plan for Improvement (PFI) which is 

located in the Statement of Conditions (SOC). This 

process is used for deficiencies identified in the 

Life Safety Chapter that require more than 45 days 

to resolve. This process also includes the 

implementation of ILSM’s (Interim Life Safety 

Measures) as per the organizations policy. 


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STEP TWO 

• Option #4 – A Life Safety Equivalency approved by 

The Joint Commission. To protect occupants 

during submittal process, deficiencies and ILSM’s 

implemented per organization policy must be 

documented. 


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Option #3 

• What is the SOC? 

• A Documented (electronic) Record of Life Safety Code 

Deficiencies for each building, defining: 

• The specific deficiency & location *LSC related 

• The date identified 

• The corrective action 

• The approximate cost for repair 

• The allocation of funding 

• The projected completion date* 

• The above are the “Plan for Improvement” (PFI) 


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Option #3 

• What Buildings can we use the SOC for? 

• Healthcare occupancies (including LTC) 

• Ambulatory occupancies 

• NOT business occupancies! 

• Ensure you identify who is responsible for maintaining the SOC 

• Identify the qualifications for those who prepare the SOC 

• Must have current and updated Life Safety Drawings* 


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Option #3 

• Entering a plan for improvement is solely not 

enough. 

• You must assess Interim Life Safety Measures (ILSM) 

• Assess the risk of each PFI or group like issues 

• Determine the measures that are the most rational and 

practical, as related to each PFI 

• Failure to do so will result in serious adverse consequence! 


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Option #3 

• What is ILSM? LS.01.02.01 EP 1-14 

• Administrative controls to create a fire-safe 

balance for the current deficiencies defined 

• Must have written Policy & Procedure 

*The policy includes criteria for evaluating when and to what extent the hospital follows special 

measures to compensate for increased life safety risk 

• Must have completed assessment 

documentation, indicating measures deemed 

necessary. 

• ILSM is an ongoing assessment process (things 

change) 


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• Interim Life Safety Measures (ILSM) 

• Assess each deficiency 

• Select appropriate measures (if any) 

• Implement selected measures 

• Document implementation of measures 

• Monitor program effectiveness 


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Option #3 

• Be careful when defining your ILSM measures 

• Are you capable of living up to your own expectations? 

• Does the temporary balancing measure(s) truly fit the 

deficiency? 

• Are you monitoring and adjusting measures? 


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Option #4 

• There are Two Types of Equivalencies: 

• The Traditional Equivalency 

• The Fire Safety Evaluation System (FSES) – 

NFPA 101A (2001 Edition) 


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Option #4 

• Traditional Equivalency includes: 

• Defining the deficiency in detail 

• Providing a rational defense as to why the 

equivalency should be approved 

• This includes taking into account all other safe-guard 

measures in place including ILSM 

• Must be submitted electronically via your TJC eSOC 

web access site 

• Limited to acceptance only by TJC, NOT CMS! 


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Option #4 

• FSES 

• FSES may be used when prescriptive compliance 

cannot be achieved 

• The FSES is based on a point system 

• Not typically accepted for new construction 

• Accepted by all regulatory accreditation agencies 

(provided scores align in your favor and completed 

correctly) 

• Requires preparer to be very knowledgeable of 

NFPA and 101A 

• Must be resubmitted and approved annually for 

CMS 


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WHICH OPTION TO CHOOSE? 

• It’s up to the organization to determine what 

works best but ask this question: 

• Can we live up to the demand of our choice? 

• Timeliness 

• Effort 

• Cost 

• What if? 


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Questions 

Thank you for your time! 

George A. Rivas, CHSP-FSM 

TSIG Consulting rivasg@.tsigconsulting.com 

740 Broadway 847-612-8424 

10 th Floor 

New York, NY 10003 


10/27/2011 

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TSIG Overview and Inspections - Hilti

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