One of the most asked questions of hospital leaders is “How can our hospital avoid getting requirements for improvement (RFIs)?” Mark Pelletier, The Joint Commission’s Chief Operating Officer for Accreditation and Certification Operations, had a simple answer in an article he wrote: “Take a good look at your environment of care and life safety areas.” Although the regulatory landscape has shifted significantly since Pelletier wrote those words back in 2014, environment of care and life safety remain the heaviest cited areas during a survey to this day.  

Your environment of care — particularly the physical environment — have tremendous impact on patient experience. On the surface, that mostly seems like ensuring cleanliness and quietness. But think bigger.
Conducting a complete compliance review on a regular basis can help you maintain a pulse on how healthy your physical environment is. This can also enlighten you on potential problem areas that should be addressed prior to a surveyor walking through your doors. Perhaps your greatest challenge is that, outside of the facility director and some technicians, few people truly understand how the Life Safety Code impacts the physical environment, how it all fits together, and what dollars and skill sets are needed to maintain it properly. The exercise of evaluating the current state of compliance will allow you to gain a better understanding of what it will take on an on-going basis and in turn putting you in a better position to always be survey-ready.
In addition to on-going compliance reviews of your facility to ensure compliance, patient safety and satisfaction, some of our best practices are exactly what Pelletier advises facilities leaders to do:
  • Unblock corridors so rapid response isn’t delayed or impeded when/where needed.
  • Don’t rely on external service contractors to ensure work is done appropriately, safely, and documented accurately.
  • Conduct and document drills.
By doing, at the minimum, these three best practices your facility has a higher rate of being successful. However, a big component in all of this is ensuring that the teams within a facility are communicating with each other.  The environment of care involves several teams throughout a healthcare facility and because of that, many times assumptions that another team is handling a particular area can be the greatest collapse in any process or best practice.  That is why it is so crucial for these teams to meet regularly to ensure the environment is safe for patients, visitors and staff.
To help facilities leaders meet the joint goals of compliance, patient safety and satisfaction, The Joint Commission and ASHE have partnered to offer guidance on the “eight most challenging” LS and EC standards:
  • Utility Systems
  • Means of Egress
  • Built Environment
  • Fire Protection
  • General Requirements
  • LS Protection
  • Automatic Suppression Systems
  • Haz Mat/Waste Management
You’ll find that guidance on The Physical Environment Portal, and might also benefit from ASHE’s complimentary guide, “Improving the Patient Experience Through the Health Care Physical Environment.”
It only takes a blocked corridor or absent permit to derail your compliance and downgrade a patient’s experience. Use the resources available to you, and don’t hesitate to ask for help from those who have a solid record of achieving the results you’re after.