In my last entry, “Preparing Your Facility for a Joint Commission Review,” we discussed what the Joint Commission is, what it does, and laid the groundwork for a Joint Commission review.  This entry looks at the review process a little further, focusing on the role of the Life Safety Specialist.

The Life Safety Specialist:  dotting Is, crossing Ts

An important part of the Joint Commission hospital review team is the Life Safety Specialist (LSS).    The LSS will usually arrive with the review team on the first or second day.  Today, the average time that the LSS spends on each hospital review is increasing; in most cases, he or she may stay an extra day.

As defined on the ASHE website:

The life safety code specialist is present for two days at facilities of more than 750,000 square feet and one day for facilities under 750,000 square feet.  Typically, the specialist is at the facility while the survey team is there, but occasionally he or she may come at a different time, either before or after the rest of the team.

The life safety code specialist focuses on compliance with the Life Safety Code, the Statement of Condition (SOC), medical gas system requirements, and certain Environment of Care standards. The specialist will tour the building and may want to tour construction sites.


The review, tour, and checklist

I want to briefly discuss the sequence of a facility tour conducted by a visiting LSS.   A typical tour will start at the highest floor level of the facility.  Beginning at a penthouse, mechanical room, elevator control room, or the roof, the LSS will use the stairwells that are most traveled moving from top to bottom.    At the lower basement levels, the LSS will look at the kitchen/dietary departments, loading docks, fire pump rooms, emergency generators, fire annunciator panel, compressed gas and any infectious waste storage.   After reaching the bottom the LSS will then proceed back to the highest patient floor level.

What the LSS is doing is reviewing fire doors, smoke doors, rated walls between smoke compartments, multi-story chutes, storage areas utility chases and hazardous areas for safety and security.  He records his findings using a facility tour checklist,  which includes the following areas:


    • Stairwells


    • Smoke doors and compartments


    • Fire doors and compartments


    • Electric and communication closets


    • Linen and trash chutes


    • Mechanical rooms


    • Utility chases


    • Fire pumps and panels


    • Loading docks


    • Chemical and medical waste storage


    • Compressed gas storage


    • Emergency generators


    • Kitchen/dining facilities


    • Corridor storage


    • Penthouses


    • Construction and outside roof areas


    • Plans for Improvement verification


    • Interim Life Safety Measures verification

Knowing what the LSS is looking for gives you an idea of the extensive safety requirements mandated for hospitals and healthcare facilities.  Great measures are taken so that our healing centers are safe for us all.

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