Alternative Life Safety Measures

Q: Our hospital has a few offsite locations – family practice clinic, occupational health clinic, and soon to be an urgent care clinic.  It is my understanding that these facilities are considered a business occupancy.  They are not licensed as a department of our hospital.  Do they need Interim Life Safety Measures (ILSM) for construction projects?

A: Yes, all construction projects should be evaluated for Alternative Life Safety Measures (ALSM), also known as Interim Life Safety Measures, regardless in what building they are conducted. This is a requirement of section 4.6.10.1 of the 2012 Life Safety Code, to evaluate any impairment of a life safety feature for consideration of implementing compensating measures. Even if an accreditation surveyor does not make an onsite assessment of the facility, the organization is still obligated through section 4.6.10.1 to conduct an ALSM risk assessment.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.