Fire & Life Safety | .accreditationqualitycenter

Inside Accreditation & Quality

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Issue

Fire safety may trump ligature risk, but surveyors likely will want both

December 17, 2019

Environment and Facilities, Fire & Life Safety, Accreditation & Survey Preparation, Behavioral & Mental Health

The Joint Commission’s (TJC) newest engineering director, Herman A. McKenzie, MBA, CHSP, told hospital leadership that life safety (LS) trumps ligature risk. But be prepared to not have a choice. ...

Patient Safety Monitor Journal

- Volume

Issue

How not to run out of water

December 20, 2025

Environment and Facilities, Fire & Life Safety, Policies and Procedures

Running out of water in an emergency is not something a hospital wants to think about. However, recent events have shown that it can and does happen: ...

Inside Accreditation & Quality

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Issue

Expect the next decade to focus on coping with new technology and old problems

December 10, 2019

Accreditation & Survey Preparation, Natural & Manmade Disasters, Environment and Facilities, Infection Control, Leadership & Finance, Fire & Life Safety, Patient Safety, Policies and Procedures, Quality & Errors, Behavioral & Mental Health, Workplace safety

Healthcare compliance changed quite a bit in the last decade. For one thing, fire safety moved into the current millennium with the adoption of the 2012 versions of NFPA 101 Life Safety Code® (LSC) an...

Inside Accreditation & Quality

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OSHA announces two new protocols for respirator fit testing

October 29, 2019

Environment and Facilities, Fire & Life Safety, Policies and Procedures

On September 26, OSHA added two new protocols for ensuring employees’ respirators fit properly. ...

Inside Accreditation & Quality

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TJC, other AOs told to step up on finding EoC, LSC violations

December 20, 2025

Accreditation & Survey Preparation, Environment and Facilities, Fire & Life Safety

Expect CMS to continue its crackdown on The Joint Commission (TJC), HFAP, and other accrediting organizations (AO) for fire safety and physical environment oversight. ...

Inside Accreditation & Quality

- Volume

Issue

Time to remind staff about the fire dangers with decorations

December 20, 2025

Environment and Facilities, Fire & Life Safety

It’s October, so it’s about time to dust off the Scrooge costume for Halloween. ...

Inside Accreditation & Quality

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Issue

Ensure empty O₂ cylinders are stored separately and policies are clear

December 20, 2025

Environment and Facilities, Fire & Life Safety, Accreditation & Survey Preparation

TJC has recently highlighted a Frequently Asked Question (FAQ) on storage management that clarifies storage of partial cylinders. ...

Inside Accreditation & Quality

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Issue

2019 quality review highlights common problems with ligature risk, IC, fire safety

December 20, 2025

Environment and Facilities, Infection Control, Fire & Life Safety, Quality & Errors, Behavioral & Mental Health

Ligature risk, building safety problems, and infection control were among the top problems identified by Healthcare Facilities Accreditation Program (HFAP) surveyors last year, according to the recent...

Accreditation & Quality Compliance Advisor

- Volume

Issue

New TJC building and antibiotics requirements for 2020

December 20, 2025

Environment and Facilities, Fire & Life Safety, Accreditation & Survey Preparation, Quality & Errors

Two new requirements from The Joint Commission (TJC) for the Life Safety and Medication Management chapters go into effect January 1, 2020. ...

Inside Accreditation & Quality

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Avoid citations, paperwork: Tackle most challenging Joint Commission standard with facilities team

December 20, 2025

Accreditation & Survey Preparation, Fire & Life Safety

Ensure your facilities team has the resources they need to clean, repair, or replace sprinkler heads to reduce the number of citations—and the amount of paperwork—you may face on your next accreditati...

Subscribe to Fire & Life Safety

Fire safety may trump ligature risk, but surveyors likely will want both

How not to run out of water

Expect the next decade to focus on coping with new technology and old problems

OSHA announces two new protocols for respirator fit testing

TJC, other AOs told to step up on finding EoC, LSC violations

Time to remind staff about the fire dangers with decorations

Ensure empty O₂ cylinders are stored separately and policies are clear

2019 quality review highlights common problems with ligature risk, IC, fire safety

New TJC building and antibiotics requirements for 2020

Avoid citations, paperwork: Tackle most challenging Joint Commission standard with facilities team

Resource/w tools selected

STET CMS & tools

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OSHA Medical Facilities Update - November 2023

Tab 2, Medical Facilities OSHA Manual- August 2023

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