Interim Life Safety Measures: How Can Something So Simple Cause So Much Trouble During Survey?

Over time, The Joint Commission (TJC) has intermittently circled back to the processes organizations use to manage Life Safety Code (LSC) issues during construction and renovation activities, as well as LSC deficiencies that cannot be immediately corrected. Collectively, these processes are known as Interim Life Safety Measures or ILSMs. (Note: If you conduct a web search for this term, make sure you use the correct acronym, “ILSM,” or the full term, “Interim Life Safety Measures,” as searching may prove difficult otherwise.)

The LSC (now, the 2012 edition) indicates:

  • The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with egress requirements
  • The hospital evacuates the hospital or notifies the department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or when a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building

You’ll want to be attentive to what the LSC describes as some fairly significant conditions—construction and renovation activities and fire alarm or sprinkler system impairments, noting that the LSC is indicating fire watches for those instances in which a “system” is out of service, pretty much leaving out limited numbers of devices being out of service.

Of note is TJC’s interpretation of the LSC when it comes to the practical application of this process. TJC is now including the management of any life safety deficiencies that are identified during your triennial survey that can’t be corrected before the end of the survey. Any uncorrected items will have to undergo an assessment, and the identified ILSMs will be included in the organization’s official accreditation report.

These seem like pretty straightforward concepts, but the response to pretty much every standards-based question revolves around the “gray” of interpretation. So ask: “What actions could—or indeed, should—be taken to ensure that the safety of the building occupants are appropriately maintained for the duration of time in which the identified deficiency exists?” TJC, under standard LS.01.02.01, indicates lots of potential strategies, many of which make good sense, and some of which your facilities and safety folks might already be doing; but a number of which are not necessarily reflected in the LSC requirements.

Bottom line—the actions taken should absolutely reflect the level of risk to the occupants of the space (and perhaps in adjacent spaces, depending on how significant the risk), but not to the extent that exceeds the level of risk. It’s all about saying what you do, doing what you say—and doing the right thing. If you use those as your guiding principles when setting up your ILSMs then you will be appropriately protecting folks—which, after all, is the purpose of this whole undertaking. Construction and renovation activities are among the most risky occurrences in the physical environment—and we typically do a good job of providing appropriate protections. Now we have to shape the algorithm for managing those “lesser” deficiencies (a penetration in a fire wall, a fire door that needs to be replaced) in a manner that does no more (and no less) than what is required to ensure folks’ safety.

So, how do you make ILSMs work?

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