ILSM Implementation

Q: During our last survey the life safety code specialist discovered that 2 of our stairwells were deficient as far as the fire-rating. The contractor did a lousy job as far as the 2-hour rating in 1985 and I guess no one caught it since then, including myself! So 30 years later thanks to the sharp eyes of our surveyor, we will fix it and it’s not going to be walk in the park. My question is: Do we need to do fire watch and additional ILSM fire drills be sufficient?

A: You have an apparent Life Safety Code deficiency. You must assess that deficiency for alternative life safety measures (aka Interim Life Safety Measures, or ILSM), in accordance with your ILSM policy. This is a must, regardless who your accreditation organization is. This assessment must be made on the day that you discover the LSC deficiency.

Your ILSM policy must dictate what measures you will implement (if any) for what particular LSC deficiency. It is important to understand that the policy decides what measures to implement; not a person. In other words, it is pre-determined in the ILSM policy what interim life safety measures will be implemented long before the deficiency is discovered. This removes the human element of making the incorrect decision. It also eliminates the common problem that only the Safety Officer can decide what ILSM to implement. Once it is identified in the ILSM policy, anyone can implement the proper measures.

That said, a Fire Watch is usually reserved for a deficient fire alarm system or a deficient sprinkler system, so typically, a Fire Watch would not be implemented for a defective stairwell construction. Additional ILSM fire drills are a possibility, but usually additional fire drills are implemented when there is a change in exiting that staff needs to be aware of. If this stairwell is closed or an alternate egress route is indicated, then I could see additional ILSM Fire Drills would be appropriate.

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.