The American Society for Healthcare Engineering (ASHE) realizes that changes within the physical environment have created additional demands on the limited resources available to health care facility managers.

With this in mind, ASHE brought together a task force to develop tools and strategies to help health care facilities professionals more efficiently use the resources they have available while still providing a safe environment.

A great example of these demands placed on health care’s physical environment is the increase of life safety citations and the need to document interim life safety measures (ILSMs) for each life safety citation. Joint Commission-accredited facilities must have an ILSM policy to address situations when life safety deficiencies are discovered [see LS.01.02.01].

While Element of Performance 1 (EP1) requires that deficiencies be assessed for when ILSM’s will be implemented, it does not require that ILSMs be implemented for every deficiency. So, how would one properly document if one is not required?

Patrick Rhinehart, manager of compliance, engineering/facilities, at Northside Hospital in Atlanta and a member of the ASHE task force, helped to create a life safety risk assessment tool to assist facility managers in addressing this issue.

The tool, a matrix of risk tolerance, allows for an organization to document the severity of occurrence and the impact of a deficiency. It can be used to address life safety deficiencies such as fire/smoke door failures, improperly mounted fire alarm pull stations, missing escutcheon plates, fire/smoke barrier penetrations and excessive travel distances to an exit. Severity of occurrence is determined by the severity of the deficiency and the probability that it will have one of four safety impacts, from likely to have minimal impact to likely to cause major injury or death. The impact of deficiency, which also is organized into four categories, is determined by the extent of the deficiency’s reach, from facilitywide to short duration.

By cross-analyzing these two factors and plotting them on the life safety risk assessment tool, facilities can determine if the deficiency is a high, medium or low risk. Assessing these factors can help a facility manager to determine whether an ILSM is a high priority or whether an ILSM is even required. Deficiencies identified as short-duration that can be corrected within the shift it is identified can be recorded as not needing an ILSM.

Having a tool to document the risk of life safety deficiencies will help health care organizations justify their usage and implementation of ILSMs.

It is available to ASHE members at