Joint Commission Revisions Related to Life Safety Code Update

PUBLISHED: Oct 19, 2017
Relevant to: Critical Access Hospitals, Hospitals

After adopting the 2012 editions of the National Fire Protection Association’s NFPA 101: Life Safety Code and NFPA 99: Health Care Facilities Code, the Joint Commission revised standards in its Life Safety (LS), Environment of Care (EC), and Equipment Management (EQ) chapters. Joint Commission began assessing compliance for their new standards in November 2016.

As a part of updates to comply with the 2012 editions, TJC has made revisions to standard EC.02.03.01, which requires hospitals to manage fire risks. These revisions are effective January 1, 2018.

Element of Performance 9 has been revised to require the written fire plan to:

  • Describe the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin
  • Include when and how to sound and report fire alarms
  • How to contain smoke and fire
  • How to use a fire extinguisher
  • How to assist and relocate patients
  • How to evacuate to areas of refuge
  • Instruct (on a periodic basis) staff and licensed independent practitioners of their duties under the plan.
  • Maintain a copy of the plan with the telephone operator or security in a manner that makes it readily available.

Element of Performance 11 is new and requires hospitals to:

  • Conduct periodic evaluations of potential fire hazards that could be encountered during surgical procedures.
  • Establish written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics.

Element of Performance 12 is new and requires hospitals to:

  • Ensure the following conditions when flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers:
  • Packaging is nonflammable
  • Applicators are in unit doses
  • Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify the following:
    • Application site is dry prior to draping and use of surgical equipment
    • Pooling of solution has not occurred or has been corrected
    • Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices (For full text, refer to NFPA 99-2012: 15.13)

Element of Performance 13 is new and requires hospitals to:

  • Meet all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.

Included with today’s notice are example policies related to these new and revised requirements.

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