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A Three Step Approach to an Effective ILSM Program

By Randy Gieseking (email)
Safety Management Group

Zero Disruptions to Patient Care and Hospital Operations is the goal of an effective ILSM (Interim Life Safety Measures) program. Prior to defining the 3-step approach, let's take a quick look at some definitions and how they apply to the program we will discuss.

Life Safety Measures are health and safety measures that are put in place to protect the safety of patients, visitors, and staff who work in the hospital. In simple terms we are talking about things like exit signs and pathways to an egress point, fire protection systems including smoke detectors, fire suppression, fire extinguishers and fire alarm systems, smoke barriers, emergency evacuation plans, in addition to many other items that contribute to the well being and safety of occupants in the hospital or healthcare facility. The word Interim comes into play when construction or maintenance activities will have an impact on the life safety systems in the hospital, thus requiring an Interim plan to address the deficiencies created by the work activity. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed Interim Life Safety Measures (ILSM) to protect the safety and health of patients by compensating for hazards caused by Life Safety Code deficiencies or construction activity.

In the remainder of this article, we will discuss a 3-step program that will help you control the work that is taking place in your facility that may have an impact on the life safety of your patients, staff, and visitors.

Pre Construction/Project Assessment Tool

The first step you should consider is the implementation of a pre-project assessment tool. The intent of this tool is to help you identify any Life Safety System impairments that may occur during the construction or maintenance activity. Prior to beginning the project, representatives from the hospital safety staff along with the group performing the work (maintenance or contractor), and the hospital project manager, will walk through the planned work area and complete an assessment tool. The walk through will help the project team to identify and plan for safety issues that may impact hospital operations and life safety before beginning actual construction or maintenance work activities. The assessment tool helps the team by asking the following questions:

  • Will any egress pathways or exits be altered or obstructed'

  • Will access to emergency services be restricted or rerouted, or will access for emergency responders be impaired or restricted'

  • Will any fire detection or alarm systems be impaired'

  • Will any part of the fire suppression or sprinkler system be impaired'

  • Will any smoke/fire walls, doors, or assemblies be compromised'

  • Will the fire safety of personnel in adjacent areas be affected'

  • Will it be necessary to install temporary construction partitions'

  • Will the project result in the accumulation of debris and/or materials and increase the combustible load in the work area'

  • Will the project activity include significant ignition sources (ex: cutting, welding, soldering, or other activities utilizing an open flame)'

  • Will the project activity present any other safety-related hazards'

Answers to these questions are used to develop a plan to address life safety code deficiencies. All participants of the assessment, including the affected department in the hospital, will review this plan and sign off prior to commencing the maintenance work or construction project. Once the assessment is complete, the information is loaded into an ILSM database, to efficiently manage the information. The ILSM assessment is a living document and will include updates as the project progresses.

ILSM Compliance Checklist

OK, the assessment is complete and the project is underway. The next step is to monitor compliance with the Interim Life Safety Measures that have been implemented. The ILSM Compliance Checklist is a tool that can be used to assist you with monitoring and documentation of project ILSM performance.

I recommend a daily walk of the project to evaluate compliance. However, if your schedule does not permit a daily walk, at a minimum you should walk and document your observations weekly. Remember, you are in control. If you do not have time to walk the project everyday, require your contracted partner to monitor and document observations daily. Establishing your expectations for the ILSM program early in the project will pay off over the long run.

When developing your checklist, you should make your observations and monitor the following points:

  • Monitor to ensure exits are free and unobstructed. Also, make sure the construction area exits are inspected daily and the contractor maintains an egress log.

  • Monitor to ensure access to emergency services and that entrance and exit discharges are unobstructed. Encourage your contractors to avoid propping or wedging open doors; this is an all too common compliance issue in a health care setting.

  • Monitor your exterior access and make sure that you have clear access for police, fire, and other emergency responders.

  • Monitor the fire alarm system and ensure it is in working order. Where deficiencies are noted, ensure a fire watch is provided. Make available additional fire extinguishers and ensure personnel are trained in the healthcare policy for fire extinguisher use. If temporary construction partitions have been installed, ensure they are maintained to resist the passage of smoke and dust.

  • Monitor the smoking policy and ensure personnel working in your facility comply with the requirements to smoke and use tobacco products in designated areas that have been set up on the exterior of the building.

  • Monitor housekeeping conditions and ensure construction debris is removed promptly. Ensure equipment, tools, and materials are stored inside the construction zone and not in the hallway or in public areas.

  • Review all temporary exit signs and project signs and ensure signs are maintained in a good condition.

  • Monitor evacuation routes, access control, and require emergency information to be updated as conditions change.

  • Monitor hot work operations and ensure the facility hot work procedure is implemented. Require contractors to train fire watch personnel.

  • Inspect fire extinguishers as required and ensure access to extinguishers is not obstructed.

  • Require contractors to clearly identify extinguisher locations.

An effective ILSM program also includes a training program for the contractors working in your facility. I suggest tracking and trending the information you have collected from your observations. Trending the data, allows you to focus your training program on issues in need of improvement. Sharing this data with the contractors and facilities maintenance personnel will help facilitate continuous learning and achieve improvement.

ILSM Closeout Procedure

Up to this point, we have done a nice job starting the project and monitoring work activities and conditions as the project progressed. Now it is time to turn the space over to the user group. Prior to doing this, we want to make sure that all life safety deficiencies have been corrected. Consider documenting this on a closeout checklist.

The closeout checklist is a good way to close out maintenance and construction work and document that the project is ready to be turned over. The following points should be covered on your checklist:

  • Require all exits to be free and unobstructed.

  • Ensure all exit signs are operational and installed as designed. Require the contractor to remove all temporary signs installed during construction.

  • Ensure all access to emergency services are restored.

  • Require documented maintenance acceptance testing for smoke/sprinkler systems when the project has modified or installed new systems.

  • Ensure the area is equipped with the appropriate number of fire extinguishers per code and design.

  • Require contractors to remove all construction materials and equipment.

  • Ensure all emergency evacuations signs are installed and updated.

  • Require all ceiling tiles to be installed.

  • Ensure space is cleaned and ready for occupancy.

  • Require any other safety related hazards or conditions to be removed prior to accepting the area.

The closeout checklist should be completed when all parties who participated in the pre-project assessment are available to make a final walk of the project. When developing your checklist consider designing questions that require each to be answered affirmatively prior to allowing the space to be occupied.

An effective ILSM program will contain all three of the programs that we have discussed - preplanning, implementation, and closeout. Once you have developed your program, make sure that you kick the program off with a comprehensive training program. The success of your program depends on how well you communicate the importance of the ILSM program to the individuals whose work impacts the life safety of the patients, staff, and visitors in your facility.

The Author

Randy Gieseking (email) is the Account Manager for Safety Management Group's Health Services Group. Randy received his Bachelor of Science Degree in Occupational Health and Safety Management from Indiana State University in December 1992. Following graduation, Randy was a safety consultant for Heritage Group Safety Services (Indianapolis), served as the Environmental Health and Safety Coordinator for Reynolds Aluminum (Auburn) and later became the Regional Environmental Health and Safety Manager for Reynolds Auburn and Lebanon (VA) facilities. In August 1998, Randy joined Safety Management Group and provided consulting services for a local Health Services provider and a nationally recognized pharmaceutical conglomerate.

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