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Fire Life Safety Compliance for Hospitals

Posted on: February 3, 2021

Being accredited by TJC, DNV, HFAP or some other organization, shows your commitment to quality healthcare care and documents compliance with the performance standards set forth by that organization. Although the details vary between accreditation organizations, the basic underlying codes, standard and laws are quite consistent. Obtaining and maintaining your status is no small task, requiring a tremendous amount of time, effort and cost. It requires focus on the part of the hospital administration, staff and all the trusted contractors and vendors that provide services to the facility.

The importance of documentation cannot be overstated. The starting point for any evaluation of your operational compliance is a thorough document review. Since TJC is the largest and most commonly use organization, we will stick with their terminology to make our point.

Picking the right fire and life safety services partner that is familiar with the Elements of Performance (EP) within the Environment of Care (EC) can save a lot of time, effort and cost. Your Inspection Test and Maintenance (ITM) information should be pre-sorted into the various EPs so that it may be easily added to your overall TJC document package. Any discrepancies should be clearly documented with a suggested plan of action to repair/replace and remove the discrepancy from the report prior to submission to TJC. A label, like a barcode, should be affixed to every device to validate inventory accuracy. Close attention should be given to the timing of the periodic test requirements. Devices testing periods range from every month to every five years.

One might believe that choosing a large international firm as your partner for Life Safety ITM services would provide an advantage over smaller local firms. After all, they have dedicated resources that focus on the healthcare industry with a large checkbook to support this dedicated effort, right? However, the larger international providers find themselves tied up in procedural handcuffs that prevent any customization of services. Their dedicated, well trained resources find themselves spread so thin that they must rely on the local branch talent to take the lead. The local team often develop animosity toward the “HQ specialist” and are less than motivated to add to their workload with something they know little about.

As an Oregon and Washington regional fire life safety services provider, PSI is dedicated to understanding the local, state and regional requirements for system design, installation and ITM services. We currently provide more than 300 accredited and licensed healthcare facilities with ITM services. Each gets a custom reporting acceptable to their individual accrediting organization.

Contact us today to learn more about how we can help your accreditation team.

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