Life Safety Ranks in Top 10 Most Cited Standards: Five Strategies for Compliance

by Bryan Connors, M.S., C.I.H., H.E.M.

Life safety (LS) inspection, testing, and maintenance related deficiencies continue to plague hospitals. According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. The LS and EC requirements have not changed significantly in recent years and yet hospitals continue to fall short with meeting compliance in these areas.

EH&E is often asked to assist hospitals with life safety and environment of care compliance. Based on our experience, we’ve identified causes of non-compliance and strategies hospitals can take to help assure a compliant program.


1. Establish a Central Tracking Program

The responsibility for LS/EC programs lies with one or more individuals who often have limited time and insufficient tools for properly maintaining and organizing the program. Commonly LS inspection, testing and maintenance documentation is tracked in binders that are poorly organized and the information is not up-to-date. Virtually all hospitals utilize work order systems to monitor compliance-related tasks, however, they generally do not have the functionality to alert a manager that a critical compliance step is about to be missed – while there is still time to act before non-compliance occurs.  For example, during mock audits we often find that one or more weekly or monthly tests are missed for reasons that are avoidable, such as a staff member is on a leave of absence or vacation.

Software is an excellent tool for automating the tracking and maintenance of compliance and can help close gaps in existing processes that rely solely on a work order system. Applications such as EH&E’s Life Safety Utility Compliance Management tool and dashboard automatically integrate data from an existing work order system and alert managers when a critical test may be missed. The compliance dashboard (Figure 1) provides the program manager with a clear indication of their compliance status.


Figure 1 – Fire and life safety dashboard allows mangers to easily see compliance status.

In addition to automating the life safety program compliance tracking; a simple, effective solution is a brief checklist (Figure 2) of all the LS/EC inspection, testing, and maintenance requirements. The checklist should be the first page or cover of the compliance binders and the binders should be tabbed and organized by EC/LS standard (for example, EC 02.05.07 EP1, test of battery-powered lights required for egress).


Figure 2 – Include a checklist on the cover of the LS/EC testing, inspection, and maintenance binders.

2. Ensure Proper Documentation and Close the Loop on Addressing Deficiencies

One of the vulnerabilities within EC.02.03.05 is inspection of fire device and sprinkler systems that are routinely assigned to third party vendors.  Citations in this area are rooted in inadequate forms that do not meet TJC standards, missing devices (varying device inventory numbers from inspection to inspection), undocumented repairs, and missed inspection dates.

The requirements enforced by TJC and set by the National Fire Protection Association (and the Authority Having Jurisdiction) are quite prescriptive relating to the equipment that must be tested, inspected, and maintained, and the documentation for these items must be detailed. The third party vendor must provide complete documentation that clearly identifies each required component, what was tested, testing results, and   corrective actions related to any deficiency findings. For example, if the vendor conducts testing of automatic smoke-detection shutdown devices for air-handling equipment and the detector activation caused the heating, ventilation, and air conditioning unit to shut down; this deficiency and the corrective actions must be detailed in the documentation. Evidence of completion of the recommendations are often not provided or tracked to the report. This results in citations because of an overall inability to demonstrate “closing the loop” for deficiencies that were identified by the vendor.

To address these issues hospitals should consider the use of electronic inspection forms (Figure 3) modeled on the existing vendor forms and vet them to ensure compliance with regulatory requirements. This will ensure that all Life Safety Code requirements are performed and documented. Electronic forms also eliminate the need for interpretation of any handwritten notes made by the inspectors.


Figure 3 – Example of an electronic fire and life safety inspection form.

3. Conduct Commissioning and Fire Stopping Inspections of New Spaces

Newly designed healthcare occupancies must meet the minimum requirements of the current Life Safety Code. Incorporating a Life Safety Code review into the preconstruction risk assessment process (PCRA) will help ensure compliance by identifying potential issues such as dead end corridors, inadequate fire walls, and missing spaces that should be characterized as “hazardous areas”. Commissioning healthcare environments, a practice recommended by professional organizations such as the American Society for Healthcare Engineering (ASHE), will also ensure that the space is code compliant and that it is operating in accordance with the design and intended operations.

Fire wall penetrations are generally attributable to changing space use and normal maintenance activities over time, as well as the increasing need for data networks. However, EH&E has found that many hospitals are inheriting newly constructed or renovated spaces that are not properly fire stopped. When contracting with a commissioning agent, hospitals should make sure that fire stopping inspections are part of the commissioning process. In this situation the cost of repair, which can be significant, is transferred to the hospital from the contractor whose job was to construct the space with proper fire and smoke walls. EH&E conducts fire stopping inspections and on a recent project for a hospital we identified over 500 fire stopping issues within one newly constructed floor. A review of invoices revealed that the average cost to the hospital was approximately $700 per correction of a non-compliant issue.

Hospitals should document the repair of any penetrations that are made as part of construction and renovation projects to facilitate tracking for possible chargeback. Appropriate documentation should be provided to distinguish penetrations that currently exist, and those that are present due to activities associated with the construction or renovations.

4. Use Life Safety Mock Audits to Fix Deficiencies AND Their Root Causes

Most hospitals conduct life safety mock audits to identify deficiencies and potential vulnerabilities. It is common for a hospital to have the same or similar deficiencies occur repeatedly during mock audits. This indicates that the corrective actions addressed the deficiency for the short-term but the root of the problem was not identified.

To get the greatest benefit from life safety mock audits hospitals should both address the specific deficiency and assess the root cause(s). Root cause analysis is the process of defining what happened, exploring how it happened, and ultimately determining why it happened. Once these questions are answered, effective corrective measures can be implemented and monitored, to prevent similar problems in the future.

5. Apply ILSM to Construction Related Issues AND Existing Issues – It’s Required!

It is a common misconception that Interim Life Safety Measures (ILSM) need to be implemented only when the life safety deficiencies are associated with the pre-construction risk assessment and while construction is occurring. The Joint Commission’s intent is that ILSM must be implemented for both construction related life safety deficiencies and existing deficiencies. For example, if construction of a space is complete but it was designed incorrectly and does not provide compliant access to a means of egress, the hospital must implement ILSM (e.g., training, additional signage, increased fire drills) to protect staff and patients. The Joint Commission’s ILSM process allows hospitals to manage those life safety deficiencies that can’t be fixed immediately and maintain compliance.

Strive for Continuous Compliance

Virtually all facility managers feel the pressure to prioritize other operational and facility projects above life safety compliance. Unfortunately, this puts many of them in the position of having to “cram for the test” six months before the next expected Joint Commission survey. EH&E has assisted hundreds of hospitals with compliance and we’ve seen that it is far more costly (dollars and labor) to try and get into compliance right before a survey than it is to establish processes to maintain compliance over time. To aid in maintaining compliance, the use of software tools to track and administer compliance is especially cost effective. Additionally, investing time to get the most out of existing initiatives such as mock audits, design reviews and the commissioning process will be well worth the investment.

Bryan Connors, M.S., C.I.H., H.E.M., is Practice Director, Healthcare at EH&E.  He has extensive program management experience in environmental health and safety and facilities compliance programs in the healthcare and biotechnology sectors, including 10 years of direct program management responsibilities in several tertiary care hospitals.  For more information, contact Bryan at