Q: Is the Life Safety Surveyor a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?”
A: No, the Life Safety Code Surveyor that the accreditation organizations use is not a mandate or a requirement by the Centers for Medicare & Medicaid Services (CMS), or any other arm of the government. It is more of an indication that evaluating the hospital’s compliance with the Life Safety Code requires specialized skills that previous surveyors simply did not have. In 2004, the Government Accountability Office (GAO) published a report that indicated The Joint Commission needed improvement in the assessment of hospitals for compliance with the Life Safety Code. To their credit, the Joint Commission agreed and decided to hire Life Safety Code specialists and make them surveyors and put them on the survey team. The new LSC surveyors began surveying in January, 2005, for hospitals with 200 beds or more, and it was a huge success. Hospitals actually liked being inspected by knowledgeable surveyors and in 2008 the LSC surveyors were expanded to survey all hospitals, including Critical Access hospitals. When Det Norske Veritas Healthcare, Inc. (DNV) started surveying hospitals in 2008, they immediately recognized the need for surveyors with specialized skills in the Life Safety Code and included them in their surveyor compliment. And Healthcare Facilities Accreditation Program (HFAP) has decided to include surveyors with life safety skills as well.