sitefm interim life safety measures webinar

The Standard for Healthcare Facility Management Compliance

SiteFM's Education Webinar Series

Interim Life Safety Measures

Host: Martyn Buffler Vice President, Sales and Marketing Email: mbuffler@sitefm.com Phone: 512-480-0883 x125 SiteFM

Faculty: Tom Zahorsky CHFM, CHSP-FSM Vice President of Client Services Email: tomz@sitefm.com Phone: 281-362-1686 SiteFM

Copyright @ 2014, SiteFM. All rights reserved.

Thank you for joining us today!

Agenda • Introductions (5 minutes) • Presentation (40 minutes) • Next Steps (5 minutes) • Q&A

Housekeeping • We will be in webinar mode – all lines muted • Please enter questions in the control panel

About SiteFM

SiteFM is Exclusive to Healthcare • Based in Austin, TX for 22 years

• Over 400 facilities across the US using SiteFM • SiteFM Work Order / Compliance Manager • SiteFM Space and Life Safety Drawing Management • SiteFM Vision – RTLS and Critical Asset Monitoring and Equipment Location

Healthcare Facility Management Experience • Healthcare FM Experience on Staff • Partnerships with Industry Leaders • Compliance-Focused Solutions

“Technical knowledge of hospital operations, codes and regulatory standards, the IT design team, and customer support truly set SiteFM apart from other vendors. The management of a complex medical facility can be greatly enhanced by forming a partnership with the SiteFM team “

Northwest Hospital and Medical

Center / UW Medicine Jim Ellis

Compliance Manager and Fire Marshal

SiteFM Compliance Manager The latest mobile software technology is integrated in the NEW SiteFM program, providing unprecedented work order mobility and efficiency for all types and sizes of healthcare facilities.

SiteFM Vision Environmental Monitoring & Asset Locating SiteFM Vision improves healthcare facility workflow, operational visibility and profitability by creating a healthcare based, scalable system with comprehensive asset locating and environmental monitoring. This comprehensive system empowers hospitals to increase staff -facility efficiencies and improve documentation & reporting – while boosting customer service. “95% of healthcare facilities utilizing RTLS have realized operational efficiency gains.” -Recent KLAS report

Life Safety Drawing – Creation and Hosting SiteFM will review and assist you with updating your Life Safety Drawings

Deliverables • Review of existing Life Safety Drawings • Creation/Update to all specified Life Safety areas • Printed Life Safety and SOC floor plans, along with CAD files • Free Hosting – Online web access

We proudly serve many of the premier healthcare networks in the United States.

Value to Attendees

• Please submit questions during the presentation to be read during the Q&A session at the end of the presentation.

• To receive a copy of the slides, fill out the post-webinar survey and a SiteFM team member will follow up with you.

• SiteFM offers a free CMMS data analysis and/or an expert review of your Life Safety Drawings.

• Stay connected with SiteFM for future webinars.

•Sign up for a product introductions/demonstrations for:

- SiteFM Work Order Manager - SiteFM Space and Life Safety Drawing Services - SiteFM Vision – Asset Locating and Monitoring www.SiteFM.com

Faculty Background

Tom Zahorsky CHFM, CHSP-FSM

• VP of Client Services, SiteFM • 35+ Years in Healthcare Facilities Management • Former Joint Commission Life Safety Surveyor • Former OSHA Voluntary Protection Program

(VPP) STAR Worksite Coordinator

Objectives

To increase participant’s understanding of: • What ILSM is • The reasons for ILSM • When to Assess ILSM • The ILSM process • ILSM Implementation • Fire Watch, When and Hos • Documenting ILSM

Self Test

• Today’s program will start a bit differently. • The following self quiz will help you assess

your knowledge of ILSM Requirements. • There will be 10 questions. • We will review the answers at the end of the

program.

Self Test

1. Hospitals are different from most occupancies in that building occupants cannot get up and leave in the event of a fire. The strategy to address this is called -

a) Fire Drill b) Disaster Drill c) Evacuation Plan d) Defend in Place

Self Test

2. The Fire Safety Triangle includes the following - a) Detection, Suppression, Containment b) Detection, Extinguishing, Evacuation c) Detection, Compartments, Fire Walls d) Fire Alarm, Sprinkler, Fire Extinguishers

Self Test

3. Detection is accomplished by the - a) Sprinkler system b) Fire and smoke barriers, doors and dampers c) Fire Alarm system d) Code Red Plan

Self Test

4. Suppression is accomplished by - a) The Sprinkler system b) Fire and smoke barriers, doors and dampers c) Fire Alarm system d) Code Red Plan

5. Containment is provided by - a) Sprinkler system b) Fire and smoke barriers, doors and dampers c) Fire Alarm system d) Code Red Plan

Self Test

6. ILSM evaluates the impact of the impairment and provides an alternate means of maintaining Life Safety.

a) True b) False

Self Test

7. The reason for ILSM is - a) To recognize the impact of Life Safety

deficiencies or impairments b) To compensate for identified deficiencies or

impairments c) To maintain the level of Life Safety normally

required in a Healthcare or Ambulatory occupancy

d) All of the above

Self Test

8. ILSM must be assessed when (all that apply) - a) Considering construction b) A Life safety deficiency is found that cannot

be corrected in the same shift in which it is discovered

c) A Life Safety deficiency cannot be corrected within 45 days

d) A PFI will be in effect for more than 6 months

Self Test

Self Test

9. Acceptable alternatives for addressing Life Safety deficiencies include (all that apply) -

a) Repairing the problem during the same shift in which it was discovered

b) Making a 45 day work order c) Assessing for ILSM and making a 45 day

work order d) Assessing for ILSM and creating a Plan for

Improvement (PFI)

Self Test

10. All ILSM assessments must be documented - a) True b) False

Self Test

Good luck. Watch for answers throughout today’s program. We will begin with What are Interim Life Safety Measures (ILSM)?

INTERIM LIFE SAFETY MEASURES (ILSM)

What are ILSM? – A series of 14 administrative actions provided

by The Joint Commission in the CAMH manual – TJC Standard LS.01.02.01 EP 1-14 – One of two standards in Life Safety that can

jeopardize accreditation severely

INTERIM LIFE SAFETY MEASURES (ILSM)

What are ILSM? – Assessment and steps required to temporarily

compensate for Life Safety deficiencies per NFPA® 101 Life Safety Code® (LSC) deficiencies (2000 edition)

INTERIM LIFE SAFETY MEASURES (ILSM)

What are ILSM? – A means of maintaining a continuous level of

Life Safety in spite of impairments of Life Safety building features

The Reasons for ILSM

– First understand that Healthcare is a “Defend in Place” occupancy

– Provision of a safe patient care environment relies on the fire safety triangle

Containment

The Reasons for ILSM - Detection

• Smoke Detectors • Heat Detectors • Duct Detectors • Water Flow Switches • Pull Stations • The Fire Alarm System

– Detection – Notification – Control

The Reasons for ILSM - Suppression

• Fire Protection System • Water Based – “Sprinklers” • Kitchen Hood Suppression • Other Gaseous Systems • Portable Fire Extinguishers • Fire Hoses (if in place)

The Reasons for ILSM - Containment

Containment is the concept of using various building components (fire rated walls and doors, smoke barriers, fire rated floor assemblies) to prevent the spread of fire and the products of combustion.

These features help to protect occupants from smoke and fire as well as to provide a safe means of egress to an area of refuge or approved exit.

• Confining the fire/smoke to the: – Room – Smoke Compartment – Floor – Building

The Reasons for ILSM - Containment

• Walls properly installed and sealed at construction joints (especially top of wall)

• Walls maintained to be free of unsealed penetrations

• Walls with all openings properly protected – Doors

• Fire Doors • Smoke Doors • Corridor Doors • Horizontal/vertical fire doors

– Windows – Ductwork (dampers)

The Reasons for ILSM - Containment

– If any of these attributes are impaired, the risk to Life Safety is increased

– ILSM evaluates the impact of the impairment and provides an alternate means of maintaining Life Safety

Containment

The Reasons for ILSM

• To recognize the impact of Life Safety deficiencies or impairments

• To compensate for identified deficiencies or impairments

• To maintain the level of Life Safety normally required in a Healthcare or Ambulatory occupancy

The Reasons for ILSM

• One of only two standards under Life Safety that can place the organization’s accreditation in jeopardy

• Failure to comply may result in a situational decision process or non-accreditation

• When in doubt, assess

The Reasons for ILSM

INTERIM LIFE SAFETY MEASURES (ILSM)

The 14 Steps 1. Fire Watch 2. Signage to alternate exits 3. Written policy and assessment criteria 4. Exits inspected daily 5. Temporary fire alarm 6. Additional fire-fighting equipment 7. Temporary construction barriers

The 14 Steps (cont) 8. Surveillance 9. Storage practices 10. Training of those working in affected areas 11. Additional fire drills 12. Inspection/testing of temporary systems 13. Education 14. Training of all hospital staff

INTERIM LIFE SAFETY MEASURES (ILSM)

• 1. The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented.

• For full text and any exceptions, refer to:

NFPA 101-2000: 9.6.1.8 and 9.7.6.1 (See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

• 2. The hospital posts signage identifying the location of alternate exits to everyone affected. (See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

ILSM Signage

• Interim Life Safety Measures in Effect: – This exit is closed and leads to a

construction area. – Please use alternate exits as marked.

Temporary Fire Exit

• 3. The hospital has a written Interim Life Safety Measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

(See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

• 4. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Inspects exits in affected areas on a daily basis. • The need for these inspections is based upon

criteria in the hospital's Interim Life Safety Measure (ILSM) policy. (See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

• 5. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

• The need for equivalent systems is based upon criteria in the hospital's Interim Life Safety Measure (ILSM) policy. (See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

• 6. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Provides additional fire-fighting equipment. • The need for this equipment is based upon criteria

in the hospital's Interim Life Safety Measure (ILSM) policy. (See also LS.01.01.01, EP 3)

INTERIM LIFE SAFETY MEASURES (ILSM)

• 7. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Uses temporary construction partitions that are smoke-tight, or made of noncombustible material, or made of limited combustible material that will not contribute to the development or spread of fire.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 8. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 9. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Enforces storage, housekeeping, and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 10. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Provides additional training to those who work in the hospital on the use of fire-fighting equipment.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 11. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Conducts one additional fire drill per shift per quarter.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 12. When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following:

• Inspects and tests temporary systems monthly. • The completion date of the tests is documented.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 13. The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

INTERIM LIFE SAFETY MEASURES (ILSM)

• 14. The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.

INTERIM LIFE SAFETY MEASURES (ILSM)

When?

• Prior to construction activities – New Construction – Renovation – Equipment Replacement

• Prior to commencing any project that would negatively impact Life Safety in the facility

• As a result of Life Safety surveys and inspections or reported deficiencies: – When a Life Safety deficiency is discovered

that cannot be corrected during the same shift in which it was discovered (immediately corrected)

– Conduct the assessment during that shift – Document the assessment and the

conclusion of the assessment

When?

Managing LS Deficiencies (Brief)

• A deficiency is discovered – Fix it now – no ILSM Assessment Required – Create a Life Safety work order due within 45

days • ILSM Assessment Required

– Create a PFI • ILSM Assessment Required

– Multiple PFIs • Evaluate the cumulative affect of all PFIs combined

– ILSM Assessment Appropriate

The ILSM Policy

• Establishing an ILSM Policy – State who will assess ILSM – State their qualifications (training/experience) – State when ILSM will be assessed – Make assessment process clear (if/then) – Indicate how assessment is documented – Indicate how ILSM activities are documented

The ILSM Policy

THE ASSESSMENT TOOL

THE ILSM PROGRAM

• Staff Training – Determine target audience (affected staff) – Develop training content

• What the shortcoming is • What the impact of that shortcoming is • How the shortcoming will be compensated for • What their role is

– Conduct training programs – Document completion of training

Implementing ILSM

• Implementation – Complete evaluation sheets per project – Select appropriate ILSM – Select frequency for monitoring – Monitor sites – Document and Report findings – Document in ILSM records

Documenting ILSM

• Documentation – The Assessment itself – The conclusion of the assessment – Possible Work Orders – Training Records – Surveillance Records – Keep these all together in an ILSM binder – Safety Committee minutes

Test Answers

1. D – Defend in Place 2. A – Detection, Suppression, Containment 3. C – Fire Alarm System 4. A – Sprinkler System 5. B – Fire and Smoke Barriers, doors and

dampers 6. A – True 7. D - All of the Above

6. A – True 7. D - All of the Above 8. A & B – both when considering

construction and when an LS deficiency cannot be immediately corrected

9. All but B – if it is not corrected within the same shift as discovery, ILSM must be assessed

10.A – True – if it is not documented, it did not happen.

Test Answers

In Review

• All ILSM Assessments must be documented • Assess the impact of any Life Safety deficiency that

cannot be resolved (corrected) within the same work shift in which it was discovered

• Most Life Safety work orders will required assessment • All PFI’s require ILSM Assessment • Assess for cumulative effect of multiple issues as the

outcome will be different than for the individual issues

Thank you

• Thank you for your time today • We hope that you found it worthwhile • Check our website for future webinars:

– www.SiteFM.com • Encourage others to participate

Next Steps

• Please fill out the post-webinar survey!

• Sign up for a SiteFM product demonstration and/or request a competitive proposal for:

•SiteFM Work Order Manager

•SiteFM Life Safety Drawing Manager

•SiteFM Vision

• Please share this information with your peers.

Thank you!

The SiteFM team…..

is hereby granted to

for participation in the webinar

Interim Life Safety Measures March 20, 2014

Thomas A. Zahorsky, CHFM, CHSP-FSM

SiteFM – Compliance Management Software

____________________

Certificate of Training

Thomas A Zahorsky

The Standard for Healthcare Facility Management Compliance

Questions and Answers

Tom Zahorsky CHFM, CHSP-FSM Vice President of Client Services Email: tomz@sitefm.com Phone: 281-362-1686 SiteFM

Martyn Buffler Vice President, Sales and Marketing Email: mbuffler@sitefm.com Phone: 512-480-0883 x125 SiteFM

Copyright @ 2014, SiteFM. All rights reserved.