The Fire Protection Podcast: Episode #60 – Safeguarding Healthcare: The Joint Commission’s Vital Role in Fire Protection with Jim Kendig

oint commission, what we do and how we do it and all that stuff. So our mission obviously is to continuously improve healthcare for the public in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe, effective care of the highest quality and value. And of course, our vision is that all people always experience the safest quality, best value healthcare across all settings and locations.

Jim Kendig: We do this by setting quality standards, evaluating organization’s performance, providing an interactive educational experience that provides innovation solutions and resources to support continuous improvements. So we are called the Gold Standard and there’s a reason why we are called the Gold Standard. Seeking Joint Commission accreditation requires some diligence on the customer’s part as well. We set the global standards, we shape the best practices and establish the most rigorous standards to raise the bar of performance. We have unmatched reach and insight. We work with tens of thousands of organizations giving us a powerful perspective into delivery of healthcare around the world. Not only the United States but around the world. Credit organizations have that ability.

Jim Kendig: We’ll give you an intensive review. The Joint commission surveyors are amongst the most experienced in the business and come from a variety of healthcare industries. They are matched with your organization based on their background. For example, our academic medical centers get academic leaders and physicians and nurses, whereas our critical access hospitals get folks that have worked with critical access hospitals in their previous employment so they understand the role of those organizations. So again, we set the gold standard. Again, a lot of other critical organizations are available, but we believe we provide the best of value and the gold standard for accreditation for deemed status. Deemed status means getting support from CMS Medicaid. Medicare non deemed would be something like the Veterans Administration or state hospitals. Perhaps we help you attract the best personnel. Joint commission accreditation can attract qualified personnel who prefer to serve in joint commission accredited organizations.

Jim Kendig: We can accelerate progress through collaboration and communication. We’ll help you connect with like-minded organizations and facilitate knowledge sharing to increase awareness and inspire action on issues affecting the quality and safety of patient care. We’ll push you beyond accreditation through our certification programs and affiliates. We provide practical tools and resources to support your continued improvement to help you maintain performance excellence not only after accreditation but during accreditation and pre accreditation. So it’s across the board. We want to partner with you and walk shoulder to shoulder to improve healthcare opportunities in your communities. Who do we accredit? Well, we include continuum of care. That includes hospitals, critical access hospitals, doctors’ offices, nursing homes, office-based surgery centers, ambulatory surgery centers, laboratories, behavioral health providers and providers of home care services as well. We also have disease specific certifications as well for those seeking disease specific certifications.

Drew Slocum: Nice. Yeah, I’ve seen, just to interrupt you quickly, Jim, we deal a lot in fire protection with our software solution and I think 90 plus percent of any healthcare fire protection inspection is always joint commission. So you guys are definitely the gold standard, have a really nice rigorous process to make sure your T’s are crossed and your i’s are dotted.

Jim Kendig: It’s all about the patient, right? So the most important piece of medical equipment you can have is the building that can’t function. Critical pressure relationships are vacuum, electricity, plumbing, sewage power or water. If you can’t provide that to our clinical leaders, we can’t take care of patients well, right? So that’s all about the patient.

Jim Kendig: Let’s talk about some of the leaders at the Joint Commission. My name is Jim Kendig and I’m a field director for the Life Safety Code Surveyors. I’ve been on with the Joint Commission for about 13 years now and about a decade of being the field director became the first field director ever over the life safety code surveyors. We used to report to physicians and nurses. My colleague Tim Mark Judd, he’s also a field director for Life Safety Code surveys. We split about 45 surveyors each. So he has 45 and I have 45 as well. Herman McKenzie, he’s our director of the Physical Environment Department. You may have recalled that he was a part of SIG standards interpretation group. Now it’s the physical environment department and it’s part of accreditation and certification operations, which is a CO. That’s where all the surveyors sit, the reviewers, the account executives, all the folks that are forward facing to our customers.

Jim Kendig: We’re going to cover a couple different things here that Drew asked me to cover. So preparing for a survey EC 2 35, which is part of our document review, facility orientation building tour, top five life safety code findings and some additional information. Dr. Jonathan Perlin, our new CEO, created this to provide frontline staff and understanding of the Joint Commission accreditation survey process. Again, on the left side, where do standards come from? And while we have them coming from CMS, OSHA of course, and the Joint Commission, it talks about the survey experience as well. So this was designed to be provided to frontline staff to understand joint commission and how to be a credit organization. So please share this with your customers, colleagues, et cetera. Let’s talk about preparing for the survey. Preparing for the survey, some resources we have are the surveyor activity guide or what we affectionately call the sag, the survey activity guide.

Jim Kendig: The SAG is provided free to our credit customers in that it talks about how we survey various elements of the survey process. There is a kitchen checklist that we develop to make you successful. Two pages for clinical, one page for the life safety code surveyor. So we’re actually giving you the information to make you successful. So when you’re on survey, we’re going to walk through with that checklist as well. And we’ll look at the fire drill matrix a little bit. This gives us an opportunity to provide you a resource and fill it out for us to take a look at your fire drills very, very quickly instead of flipping over a white piece of paper, drawing all kinds of columns, et cetera. So we don’t want to take time to do that. So there is a fire drill matrix there. Standards and elements of performance can be found in the various manuals we have or hospital critical access hospital, ambulatory surgery centers, behavioral health nursing homes, or NCC program, et cetera. Perspectives is a monthly publication from the Joint Commission that gives you updates and is the Go-to document for information on a monthly basis. Mock surveys, many, many folks use joint commission resources and others to help them during mock surveys to prepare for a survey and of course www joint commission.org you can provide resources there.

Drew Slocum: Hey Jim, just a quick question and sorry to interrupt. How often do the surveys happen? Is it a certain cycle?

Jim Kendig: Yeah, every three years. So it’s a prenatal survey. Now there are other survey events for early survey options. There’s extension surveys. Let’s say you just build a 300,000 square foot heart center. You attach it to the billing. Well, we would take a look at that as an extension survey and assign a clinician and a life safety code survey because it’s never been surveyed before and it’s just recently built, so we would send some folks out to take a look at it. But your normal full unannounced survey is every three years or what we call a triennial survey. Perfect.

Jim Kendig: Talk about the facility orientation is usually from eight to 9:00 AM and that’s where the life safety code server gets, what the director of facilities and perhaps his team. And we take a look at the fire alarm, the fire alarm paddle that serves the fire alarm, and of course the breaker that is a paddle that serves the fire alarm system. So we want to make sure that it reads the breaker’s red. We also want to know where it served from and also we’re going to take a look at that life safety branch to make sure nothing’s inappropriately assigned to the pedal there or to the branch. So we’re going to look at the fire alarm pedal breaker for supervisory signals or troubles. We’re going to take a look at the fire pump, determine whether it’s an electric or diesel. We’re also going to check the number of spare sprinkler heads and the wrenches to replace them.

Jim Kendig: So we’re going to check that and make sure that that room is not in excess of heat over a hundred degrees Fahrenheit. We’re going to take a look at the generators or generators. There may be one, there may be many, right? And they may be scattered around the campus depending on when they were installed. And of course as the building gets renovated and updated bulk oxygen, taking a look at that per NFP 55, we’re also going to do an orientation to the light safety drawings. We’re looking for shoots. We want to see smoke compartments, suites, architectural suites. So we’re trying to get an orientation of the building. We’re going to take a look at your written fire response plan, for example, to determine what licensed practitioners have them do in that written fire response plan. And it can turn off the medical gas zone valve.

Jim Kendig: Years ago when we had NFV 99 99, it actually had information in the appendix about who suggested, of course it’s in the appendix, who could turn off the medical gas zone valves. We’re going to take a look at your interim life safety policies. We’re going to provide you three resources, the fire drill matrix, a list of URLs for additional information, and also the list of I LSMs the 15 I LS M. So if we find something or cite something that cannot be corrected immediately, you would implement ILSM and it’s up to you, the organization or the customer to choose that ILSM from those resources. Three questions we ask during the orientation, what type of fire stop do you use? It could be a hill, TSTI 3M, anything like that. We just want to know when we go up in the ceiling, what we’re going to see in addition, the follow-up question is how are you training your staff on the application of the fire stop material?

Jim Kendig: So Drew, I think this is head on. What do you guys talk about a lot? So the first question we ask is what type of fire stops? How do you train your folks? I even had security trains every year. I bring in whatever vendor I had, bring ’em in and they’d do a 90 minute session. We’d go over the technical bulletins and take a look at the application of that. The next question we ask is, can we access the interstitial space above the drop in ceiling? Some organizations require us to use a HEPA system where we put it up to the ceiling and only then can we remove the ceiling tile, right? Interesting. Making sure that, again, we don’t open ceiling tiles in ORs, transplant units, ICUs because we don’t want dust and debris coming down and getting someone sick with aspergillus or something like that. So we ask them about the access to the interstitial space above the drop in ceiling. And the last question is, what are you using for a high level disinfection? The reason why we ask that as engineers, we want to make sure that they have the correct number of air exchanges for the particular product they’re using so we don’t get folks sick, right? Right.

Drew Slocum: It’s all about the patient

Jim Kendig: Billing tour. K one, we talked about the facility orientation document review in the appendix. We go through LSO 1 0 1, 0 1 EP three, which is the orientation to the drawings, making sure it has certain elements. We typically go to EC 2 35. That’s a list of 28. Inspection, testing and maintenance, whether it be fire alarms, sprinkler systems, fire department connections, et cetera, dampers, all those things. We take a look at the inspection, testing and maintenance activities after that, which takes about an hour and a half or two hours. We’re going up to the ORs. We’re going to check the critical pressure relationship barriers in the ORs, the C-section rooms, SPD, sterile processing department. Why do we do that on day one? Well, it allows the organization to fix it. If we find something that’s inappropriate, for example, or one is negative, it should be positive, right? So we want to make sure that that flow of air is coming out not in.

Jim Kendig: After that, we usually go to lunch and then we start at the top. We work our way down. We start the HEA stop or helipad at the top NFPA, I think it’s four 18 if it’s new. And then we just work our way down. We also look at the exhaust NFPA 45 under 13 and 13 and talk about specific requirements for the hood exhaust or the exhaust on the roof from laboratories. And 13 A or a 13 has specific language that’s recommended from NFPA 45. So we start at the top, we start at the roof if we can and then work our way down. Going to 10, 9, 8, 7, 6, 5, 4, 3, 2, 1, basement sub basement, all that kind of stuff. We have a hard stop at the end of day one. This is to review with the group that we’ve been with all day, any IOUs, right? So you couldn’t find a particular document, things that we found on the building tour that were scored and things that were found on the building tour that aren’t scored that maybe we have to do some homework or you don’t have to do some homework to take a look at. So at the end of the day summary day two, we do a morning briefing out briefing with our team. After that we meet with our facilities group and we look at IOUs, talk about the continuation of the building tour, and then of course there’s an exit or interim exit. Typically about 90, 95% of our surveys are two days. Once you get above 1 million square feet to go for three days.

Drew Slocum: Hey Jim, I got a quick question on that, just documentation in general. Is there any best practices that you’ve seen just to make sure everything’s ready for you guys documented digital paper. Obviously organization is key. You don’t want to be fumbling through everything.

Jim Kendig: That’s a good question we get often. So it could be paper, it could be electronic, it could be a mix of both. But the problem is if you don’t have someone that drives the electronic system, it could be very cumbersome. You could be there for four or five hours at which time we’re going to say you really need to find somebody to drive this system because we don’t have that time to waste. So it could be any format you want. It could be an electronic paper combination, but make sure that you have someone that can drive that very efficiently. So we want to be efficient with our time. So no matter what medium you’re using, we want somebody that can drive that quickly.

Drew Slocum: That’s a great point.

Jim Kendig: I pulled together the top five life safety findings from January 1st, 2024 up until this week. So let’s go through those real quick. LS 2, 1 35, EP four. This is piping or other things resting upon a fixed to or draped across the approved automatic sprinkler system. So if you couldn’t put a business card through it, you have some HVAC ductwork resting on that, we don’t want that weight of the HVAC duct work on the approved automatic sprinkler system or anything. For example, something tied to it. LS 2 1 10, EP 11 are far rated. Doors within walls and floors have the appropriate hardware on there and positively latch upon closing LS 2, 1 34, EP nine, the ceiling membrane is installed and maintained. So we’re walking down the hall and we see 3, 4, 5, 6 ceiling tiles removed. Well, there’s no suppression or detection systems above the interstitial space above the drop in ceiling, right? So we want to make sure all products of combustion, fire, heat, et cetera, are maintained below that membrane. So that’s being scored and there’s a different score between cold ion rooms and that’s very, very important. We don’t want that hot air products of combustion above that because it takes longer for the suppression system, for the detection system to activate

Jim Kendig: LS 2 1 10, EP 14, this is penetration. So we have a penetration through a particular firewall. Then we talked about our discussion about the fire and typically what we see is that draw, that these conduits are 99% full. And if you look at some of the technical bulletins from some of the manufacturers of fire, they say about 46% full. But what’s amazing with these vendors is that they’re coming up with unique ways where they have collars and can take care of issues already there. And so I got to applaud our firestop contractors. They’re really doing a great job coming up with solutions to address these issues. Interesting. And lastly, LS 2 1 30 EP 13. All corridor doors are constructed to resist the passage of smoke, et cetera. So that rounds out the top five and we typically, when we speak at larger organizations, we can speak at your organization virtually in person, et cetera, and we customize our discussions around what you want to learn. So this was LS based. We also have the top five environments of care, top five emergency management, top five security, and workplace violence as well. So this really focused on the life safety findings.

Drew Slocum: Yeah, I like that. You mentioned before about those questions that you ask when you asked the question about fire stop, do your questions over time, have they changed because maybe you find more things out that, hey, I want to be ahead of this, so I’m going to ask that question.

Jim Kendig: So sometimes in that top, let’s go back to it real quick. So those top five we actually look at, we’re really in the top 10. They switch places, but we’re seeing more and more. I’ve just been on some recent surveys where they’re doing a better job of penetrations where they have zero penetration because they have an above ceiling permit process, right? So the contractor vendor that’s pulling the wire or the security vendor or the IT vendor, they have a process in place to go behind ’em and check that all those penetrations were addressed, et cetera. So we’re starting to see much better use of the above ceiling permits, which would reduce the number of number four there. The penetrations on 2 1, 10, 14.

Jim Kendig: So just want to give you some idea on the safer matrix. Here’s some definitions. This comes from our accreditation manual page ACC 46. So this is kind of some of the definitions and then when we apply it, we apply it to the safer matrix scoring, and again, this is 1 1 24 to 3 25, 24, and you can see an immediate threat to health and safety. This was related to LS 1 21, EP one. The organization did not have ILSM and ARM like safety measures applied for a significant life safety issue. Whether it be the sprinklers are down, the sprinklers are down, the fire alarm is down, or a combination of both. So this was an immediate threat to health and safety. So high is 1.1%. Moderate is about 18, 19% low is about 80%. That’s exactly where we want to be in the low limited pattern and widespread, right? We want to be limited. These issues are not impacting the patient. So as you go top right up into that 0.0%, that reddish color far right, that’s when you have the ability to impact patient safety. We typically see infection control scores in the high area and the modern area. So as you go up the safer matrix, you have an increased opportunity to impact patient safety.

Jim Kendig: Just want to give you some idea on the average findings during a survey. So you can take a look at here that we had a couple of different things we had back in the day, 2014 to 2016. We had C categories as opportunities for improvement. They were in the back of the report and didn’t really count. Then we had it from 2017 to 2019. We had safer, which I just illustrated, and the C it cited thing. Then we had covid from 2020 to 2022, and as we know, the public health emergency ended 5 11, 20 23. So we’ll see some more data about 2024 as well. But you can see the average number of findings per survey.

Jim Kendig: What’s new in trouble spots. We have a new sustainability certification. This was led by my colleague Tim Marky John, the other field director for the life safety code surveyors. So effective January one, you could get a sustainability certification and I think the state of Massachusetts, all the hospitals are seeking that, I believe, but I may have misheard that. But anyway, this is available to organizations that want to get this sustainability certification either as a system or individual hospitals. So you can get additional information as you can see in the article. And this was published in the Environment care news, February of 2024 on page six, and during our annual survey conference in January, all the Lake Safety Code surveys were trained to survey the sustainability certification at our annual conference. Just a plug for our 2024 emergency magic conference. It’s in Orlando, Florida, June 19th to 20. If you’re interested in participating,

Drew Slocum: This is right around NFPA. And if PA is doing their conference in Orlando at the same time, oh cool.

Jim Kendig: Tethering and chalking at wheels. This comes up often with Drew as far as when we get in the kitchen and start surveying. So we take a look at NFP 54, 20 12 9 6 1 2. So it talks about limiting by restraining devices in accordance with the connector and appliances, manufacturers, installation structure. So basically if it comes with it and the manufacturer requires it, the tether has to be in place, right? So we don’t damage some part of the equipment. Then of course chalking wheels is an NFP 96, 12 1 22. And again, we want to make sure that the positioning of the device, whether deep fat fryer, stove, oven, whatever is positioned in relation to the extinguishing equipment that is required by the installer or servicing agent. So we just want to provide some information on this. It is a focus area because where is the number one location of fires in healthcare? Kitchen, kitchen probably. Yeah. Yeah. NFPA says the kitchen. So we want to spend special attention on arch kay extinguishers, NFPA 10, 2010 and 30 linear feet from the deep fat fryers, making sure our kitchen suppression systems are maintained, the baffles, all those types of stuff in the kitchen.

Jim Kendig: Reminder about the 18 inch rule. Basically we come down from 18 inches from the diffuser and we draw a plane across the room. And you can see that this one here in the middle, the okay is the finest blow up, but we put a box on top of a shelf that intrudes upon the 18 inch plane. That would be a finding as well as the shelf, the entire shelf on the left that goes all the way through to the plane. So 18 inches down from the diffuser and we draw a plane across the room and anything in that plane is considered out of compliance. Of course, we know that fire, or excuse me, shelving along the wall can enter the plane. The 18 inch plane. However, the sprinklers cannot be directly overhead. That’s a shelving unit on the wall. Yep. Yep.

Jim Kendig: CMS validation. We used to get the CMS validation surveys from either state agencies or CMS. They would come out about prior to 60 days elapsing to do a survey to see what we missed now. But we have CMS actually observing surveys concurrently when we’re surveying. So not only do you have a joint commission team there, but you have a CMS team that’s looking and evaluating the joint commission team. So that’s a new validation process. These validation events are reported to Congress every year for all accrediting bodies. Fire drill, I talked about the fire drill matrix. So we added a section there, requiring annual fire drills for the ORs and hyperbarics. So this is the fire drill matrix that we develop that we give organizations to fill out upon our arrival. And we’re looking at four quarters, not rolling four quarters, but four quarters. Just a reminder about hyperbaric facilities and fire drills. So take a look at 99 14 2 4 5 4 14 2 4 5 4 1 about using occupants, although it’s supposed to be measured as far as time, but doesn’t tell you what an acceptable time is. A reminder, a lake safety code survey has been added one day each for freestanding emergency departments and ambulatory surgery centers. All we do is the hospitals and critical access hospitals. If they have an ambulatory surgery center or free-standing DD down the road, we’re going to send the life safety code surveyor down there after a quick document review to evaluate that space. Typically it’s a lot smaller, 10 20, 30,000 square feet so we can do the billing tour very quickly in those environments. That is the summation of my presentation. Drew,

Drew Slocum: That was awesome. I learned a lot. I know we talked before this and I think just in general, I think where we sit in a lot of the audience that I talk to is like they’re doing fire protection systems, wide variety for commercial facilities, industrial, but a big part of the business is healthcare. And there’s sometimes they don’t understand the whole process of the whole survey and all that. They’re being asked by their clients, the healthcare facility, but sometimes they don’t understand why. Obviously if they’re up and up, they get it. So yeah, this is great to learn about. Even those findings, those are great to find and data is always super powerful with making efficiencies down the line, making sure things are safer, collecting that data is a big thing and I love how you guys are obviously constantly tracking that. So

Jim Kendig: I appreciate the opportunity to share some thoughts from the joint commission. And if you have any questions, here’s our contact information on the last slide, so feel free to reach out to us if you have a question, comment, or concern. We don’t get involved in a lot of construction or renovation activity. Obviously renovations chapter 43 NFPA 1 0 1 2012, but we get involved after the construction renovation, so we don’t provide guidance to typically architects and things like that. I mean they can read the code as well as we can and are probably very proficient at applying the codes. So the certificate of occupancy by the state, county, city, and of course then we come in and do our surveys accordingly, but the TRI survey is an opportunity to shine and we want our customers to walk shoulder to shoulder with us to be very successful.

Drew Slocum: No, this is great. I did have one question. So I talked to my pal, Greg Berts, and he actually recommended you to come on the podcast and chat a little bit, so I appreciate that. I chatted with him a little bit ago last week and he made a kind of comment about healthcare facilities before the pandemic. They had equipment that was aging out and then obviously you had the pandemic and obviously that equipment got even more used, obviously with a lot more use out of that. So a lot of healthcare facilities are in this spot where you have this older equipment, not just fire protection, but throughout the building. So it’ll be interesting to see of how healthcare’s facilities are going to, do they replace that equipment or how do they upgrade it with the struggles they’ve been having over the last

Jim Kendig: Few years? Yeah, certainly Covid has had a financial impact on most organizations as you’re reading Becker’s and other things like that. So as part of that capital planning process, and again, taking an inventory of your systems and their age and expected life expectancy and planning for that in the future. So I’m sure forward thinking facilities directors have that and are planning 3, 5, 10 years down the road, 15 years down the road. And of course as we renovate, chapter 43 comes into play and so does the code. So when we do a substantial renovation, we’re required to bring everything back up to code, the number of air exchanges and all that kind of stuff. So there is some pressure from chapter 43 depending on the scope and size of that particular project, that’ll have a huge impact.

Drew Slocum: That’s great, great, great insight. Well, thanks again, Jim. This has been great. Again, a lot of education for us out there and the fire and security industry and looking to get some feedback just from our listeners out there. And again, appreciate all the help here.

Jim Kendig: Alright man. Talk to you soon.

Drew Slocum: Talk to you soon. Thanks Jim. This has been episode 60 of the Fire Protection Podcast powered by Inspect point. It’s always a fun one to get out. I wanted to thank my guests again, Jim Kenga of From the Joint Commission coming on, kind of explaining the whole process behind what they’re looking for in an audit, in a survey at these healthcare facilities. So again, please like and subscribe, give me some comments on how we’re doing with the podcast. So thanks again. See you soon.