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Compliance News: ASHE Addresses Historically Problematic Compliance Issues

| David Stymiest

The November 2015 Compliance News issue discussed the joint work that both ASHE and TJC had performed to that point in providing assistance on major physical environment compliance problem areas.  Last month’s Compliance News issue discussed TJC’s contributions to that initiative through July 2016.  This article reviews ASHE’s ongoing contributions to their joint program through July 2016.

ASHE’s FOCUS on COMPLIANCE (ASHE FOC) web page is available at ASHE’s website ( under the main NEWS & RESOURCES heading.  Interested parties can sign up to receive email alerts from ASHE when new physical environment compliance resources are added, and do not need to be ASHE members to receive the alerts.  The majority of ASHE’s posted resources are available to all persons; however a few of the resources are available only to ASHE members.

Each web page links to the other organization’s web page for easy migration between them.  Both web pages have numerous helpful resources posted.

In addition to the resources mentioned in the November 2015 Compliance News issue, ASHE has also continued to post very useful new compliance discussions and advice at ASHE’s Focus on Compliance web page.  Among the new postings are topics covering:

Built Environment

  • Discussion on medical gas cylinder storage issues, follows the common approach that includes RISK (defining failure modes) and IMPACT (identifying patient outcomes). Then the MITIGATION assistance includes a document discussing medical gas cylinder storage requirements and a medical gas cylinder sample policy and procedure. ASHE also provides a link to a separate ASHE Management Monograph on Medical Gas Cylinder and Bulk Tank Storage, which is available free to ASHE members.
  • Resources relating to built environment safety hazards include an OSHA hospital worker safety publication along with an FGI best practice publication (Design Guide for the Built Environment of Behavioral Health Facilities.) Another resource is a detailed chart identifying the most commonly-cited types of safety findings under the built environment.  The MITIGATION assistance provided include links to publications from the AHRQ on detection of patient safety hazards and a survey on patient safety culture, a link to the very helpful OSHA Hospital eTool web page, and finally a link to the CDC’s NIOSH web page on workplace safety and health topics for healthcare workers.
  • Resources related to air flow and HVAC issues, a perennial problem area for many hospitals, include three detailed charts (charts discussed in this article were based upon TJC survey findings) identifying the types of spaces with the highest number of adverse survey findings regarding:
    • Pressure relationships
    • Inappropriate humidity / temperature
    • Non-monitored humidity / temperature

Fire Protection

  • Lack of inventory – Under this category is a detailed chart indicating the specific types of equipment with the most adverse survey findings about lack of inventory. ASHE also provides as a mitigation tool a paper on the topic of developing a complete inventory.
  • Insufficient documentation – ASHE provides a detailed chart indicating the specific reasons for the most common TJC findings related to inadequate documentation. ASHE also provides two short papers on documenting fire alarm and fire protection system inspection, testing & maintenance (ITM).
  • Standard not provided in documentation – Under this category is a detailed chart indicating the specific types of fire alarm and fire protection equipment with the most adverse survey findings where the standard was not included within the documentation.
  • Incorrect duration (between required activities) – ASHE has included under this category a detailed chart indicating the specific types of equipment with the highest quantities of adverse findings where activities were not performed within the required ITM intervals. ASHE also has made available documents from its Managing Life Safety® course, detailed tables of required tasks and frequencies with codes and standards references for both fire safety equipment and fire safety building system ITM.

Building and Fire Protection Features and Life Safety Protection

  • Fire door maintenance – ASHE has provided numerous detailed charts illustrating the most commons reasons that fire doors and smoke doors have adverse survey findings. Additional detailed charts indicate the types of door applications (rooms/locations) where each major type of failure was most commonly observed.  This information can assist some hospitals in focusing their extra door maintenance activities.  ASHE also made available a detailed checklist for fire door assembly inspections and a video of a webinar on inspecting swinging fire doors.
  • Barrier penetrations – This section includes two detailed charts with the most common locations where TJC surveyors have observed unacceptable barrier penetrations. There is also a video of the recorded FCIA webinar ion barrier penetrations.

Automated suppression systems

  • Items being supported from sprinkler systems – This section includes a detailed chart identifying the most common types of items observed that created adverse survey findings. There are also two MS Word files with a sample above ceiling permit policy and procedure along with a sample permit form.
  • Inadequate sprinkler maintenance – This section has a detailed chart identifying the most common reasons for adverse findings on sprinkler head maintenance.
  • Obstructions being stored with the 18-inch area beneath sprinkler heads – This section has a detailed chart identifying the most common reasons for adverse findings on sprinkler obstructions. It also includes a copy of the NFPA 13-2016 graphic illustrating obstructions to sprinkler distribution pattern development.  And finally this web page includes copy of the graphic often shown by TJC speakers clearly indicating where TJC allows and does not allow storage in sprinklered areas.

The information being provided is clearly useful and should be reviewed by hospital personnel responsible for the physical environment.   We recommend that the above-linked web locations be bookmarked for future reference.  We also recommend that those interested in obtaining future information when it is posted subscribe to the related (ASHE or TJC or both) email alerts.

Questions regarding this article may be addressed to the author at