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Compliance News: TJC Clarifies Life Safety Surveyors’ Survey Assessments

| David Stymiest

TJC Director of Engineering George Mills announced some July 2015 changes to the Life Safety Surveyor’s portion of hospital triennial surveys during his recent TJC Update session at the ASHE Annual Conference in Boston.

Mr. Mills covered many important subjects during this presentation.  This SSR Compliance News issue discusses only some changes that directly affect the TJC Life Safety Surveyor responsibilities and clarify the required documentation to be provided at the commencement of a triennial TJC survey.

The changes are officially documented within TJC’s July 1, 2015 publication entitled “Accreditation Survey Activity Guide for Health Care Organizations – July 2015.”  The PDF of this document is available here.  A referenced enclosure included with the new Survey Activity Guide is TJC’s new EC and LS chapters Document List and Review Tool.  TJC states that “This tool is provided to organizations for use in their continuous compliance and survey readiness efforts.”  The PDF of that handy tool is available from TJC here.

The new document list and review tool is not an all-encompassing list of the documents and questions that could be asked during TJC’s hospital EC and LS surveys.  Although the introduction to that tool states “These documents will be reviewed by the Life Safety surveyor upon their arrival for the on-site survey” an additional explanatory statement on its first page includes the following: “Other EC and LS documents may be requested by surveyors there, as needed, throughout the survey.”  Full compliance, of course, includes meeting all requirements within the 2000 NFPA 101 Life Safety Code® as well as other direct and indirect mandatory references from that document.

Since we recommend that all TJC-accredited hospitals obtain and review TJC’s new Document List and Review Tool as soon as possible, it is not necessary to provide its contents within this short article.

The Life Safety Chapter content addresses all 4 Elements of Performance (EPs) included within Standard LS.01.01.01 and all 14 EPs included within LS.01.02.01.

The Environment of Care (EC) Chapter content addresses the following:

  • 2 of the 5 EPs in Standard EC.0.03.01 on managing fire risks
  • All 5 EPs in Standard EC.02.03.03 on fire drills
  • 20 of the 21 EPs in Standard EC.02.03.05 on fire protection and suppression inspection & testing
  • All 10 EPs in Standard EC.02.05.07 on emergency power testing & maintenance
  • All 3 EPs in Standard EC.02.05.09 on medical gas and vacuum systems inspection & testing

Mr. Mills told his ASHE Annual Conference audience his intent that the Life Safety Surveyor will be testing pressure relationships within the operating rooms by 10:30 AM of the first morning of the triennial survey.  This focus, which has been mentioned by TJC speakers in some previous conferences, is now also stated under the SAG’s Life Safety Code® Building Assessment within the top-listed item of the Overview of Building Tour:

  • Assess Operating Room(s) for proper pressure relationships

Questions on this newsletter edition can be directed to the writer at