One of your sprinkler heads is loaded: Can you find it before they do?

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April 11, 2019

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).

  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!






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