It’s a normal day at your healthcare facility—doctors and nurses are buzzing about tending to patients, clerks are pulling files and directing visitors.  Then, an official looking group of people step onto the premises—a Joint Commission survey team.  Is your facility prepared?

While at the Kentucky Healthcare Coalition Conference last month, I had the opportunity to attend a seminar hosted by Gary D. Slack, PE, CCE, of Healthcare Engineering Consultants.  The seminar was called “Biggest Pitfalls & Best Practices:  Achieving Survey Success.”  It made me think about the services that Luckett & Farley offers that could help ready your facility for required Joint Commission surveys.

The Joint Commission: What it is, what it does, how we can help


The Joint Commission is a non-profit organization that ensures that all required safety measures of health care facilities are met. Joint Commission survey teams are required to survey facilities once every 39 months (once every 2 years for laboratories) to make sure that all standards and guidelines are being met and followed.  According to the new Joint Commission accreditation standards, the surveying life safety specialist will now be scheduled for an extra day on site, allowing more time on the facility tour portion of a joint commissioning visit. In the services we provide, we help our clients with updating life safety documents for the required joint commission checklist. These Life Safety drawings need to include occupancy separations, fire rated walls, suite designations, and accurate square footage totals for these facility areas. We also include exits, egress widths, fire alarm pull stations, and fire alarm strobe/horn locations on these same documents. Our healthcare team also assists with fire penetration review by looking at above-ceiling areas that will be reviewed by the Joint Commission survey team at some time during their visit.

Interim life safety measures


Another important task is documenting all interim life safety measures, especially in the case of ongoing construction. Nothing draws a Joint Commission survey team’s attention like new construction on a job site. If a JC team arrives for a survey and there is ongoing construction at your facility, whether new or renovation, they will want the facility to produce an interim life safety plan to ensure that the site remains safe and secure while construction is going on. The survey team wants to make sure that egress around the work site is maintained, and an interim life safety plan is what will display the safety measures taken. They will also review that all your utility systems are maintained during the construction duration and that you have a documented plan.

Check in for Part II of this entry, where I will follow-up with a hospital tour checklist, the document that guides the Life Safety Specialist during the inspection.

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