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Copyright ? 2013 The Joint Commission. This article first appeared in Environment of Care? News, December 2013. Reprinted with permission. No part of this article may be reproduced or transmitted in any form or by any means without the written permission from The Joint Commission.
The Joint Commission (TJC) has identified the need to increase the field's awareness and understanding of the Life Safety Code?.* To address this need, Environment of Care? News publishes the column Clarifications and Expectations, authored by George Mills, director of the Department of Engineering at The Joint Commission. This article clarifies standards expectations and provides strategies for challeng- ing compliance issues, primarily in life safety and the environment of care, but also in the vital area of emergency management. You may wish to share the ideas and strategies in this column with your organization's leadership.
To fully protect patients, staff, and visitors during a fire, a healthcare organization must have the appropriate equipment and building features-and they have to function correctly and reliably. That means maintaining them. Environment of Care Standard EC.02.03.05 talks about how and with what frequency healthcare organizations should maintain fire safety equipment and building features. Note that this standard does not require organiza- tions to have all the specific equipment and features discussed in the standard. But if an organization does have such equipment, the standard's requirements apply.
Recently, compliance with Standard EC.02.03.05 has become an issue for some organizations, making the standard one of the top five environment of care (EC) compli- ance challenges organizations face.
This article addresses the first four ele- ments of performance (EPs), discussing each and suggesting an approach for assessing compliance.
EP 1-Signal Devices
At least quarterly, the organization tests supervisory signal devices (except valve tamper switches and water flow devices), as required. The completion date of the tests is documented. Note: For additional guidance on performing tests see NFPA 72, 1999 Edition (Table 7-3.2).
EP at a Glance
The intent of EP 1 is to make sure that organizations maintain all required supervi- sory signal devices (except valve tamper switches) and test them quarterly. You must document evidence of testing.
In the context of this EP, the scope of ?supervisory signals? is limited to those referenced in NFPA 72-1999,...