Construction projects within a healthcare setting can create multiple impairments and danger to patient safety. From small repairs on building systems to complete renovation projects, facility managers need to ensure that their policies and procedures for managing all types of construction projects adequately protect the patients within their facilities. To do this, implementation of Interim Life Safety Measures (ILSM) needs to be assessed and utilized to prevent life safety issues. But how do you know when and where to use ILSM, and why should you?
Interim Life Safety Measures (ILSM) are measures that are undertaken outside the normal operations of a facility to provide for the safety of the patients and staff within the building. Normal life safety measures and systems include things like fire suppression systems, fire alarm, and exiting pathways through stairwells or other means. When construction projects impede the function of those systems in such a way that could cause harm to a person in the event of an emergency, then Interim Life Safety Measures need to be taken. ILSM are incorporated into the project from start to finish and are usually the first thing done on a project and the last thing removed from a project. However, life safety issues do not only stem from construction projects; ILSM can also be used in the event of a breakdown in equipment or schedule maintenance on systems.
When any suspected life safety concern arises, the first thing that must be done is to do an assessment of that concern. Ask questions regarding the work; will there be large amounts of debris or dust created by this work? Will any life safety barriers (walls, doors, etc.) be breached as a result of this work? Will this work impair any life safety systems, and if so for how long? Once information about the job is determined and assessed, then ILSM can be implemented per direction from your company’s policy. ILSM policy should be based on the guidelines from CMS and be easily identifiable such that when typical life safety measures are breached, what ILSM to be implemented are clear.
CMS gives 14 standards for ILSM that should be included in company policy during work. These standards include things like no smoking during work, making sure exit routing is free from obstacles during work, and using temporary means of fire observation if fire alarm systems are impaired for more than four hours at a time. Again, use of these measures falls back to guidance by the hospital’s ILSM policy. This policy should clearly state what measures should be used and when they should be implemented. The standards from CMS should only be a baseline for measures against impairments of life safety systems, and hospitals should craft their own policies to follow during construction project.
Once the decision to implement measures is made, these steps should be taken immediately and should be thoroughly approved before work takes place. During the work, measures should be monitored on a basis determined by the hospital’s ILSM policy. Some measures, like have a manual fire watch if a fire alarm system is down for more than four hours, should be monitored constantly by a competent person, either an employee of the hospital or a trusted contractor. Other measures can be monitored on a daily, weekly, or as-needed basis, as set out in the policy.
As you can see, the most important aspect to correctly and safely used Interim Life Safety Measures is to have a complete and thorough policy written by the hospital that clearly states when and under what conditions ILSM must be used and implemented. Hospital engineering should work with risk management, hospital administration, and other concerned parties to make sure that this policy supports the protection of the hospital’s patients and staff when life safety systems are offline.
COREY JP CUNNINGHAM 