Components You Need for an Effective ILSM Program

By Safety Management Group

Unlike many types of businesses, hospitals and other healthcare facilities don’t have the luxury of shutting their doors when there is a need for construction or renovation.

During normal operations, a long list of Life Safety Measures protects the safety of patients, visitors, and workers. When construction, renovation, or maintenance projects create additional complexity, a new level of safety activities must be added. Called Interim Life Safety Measures (ILSM), these steps are incorporated to address issues created by the work activity. The Joint Commission and the National Fire Protection Association require ILSM to compensate for hazards caused by construction activity or other deficiencies to the Life Safety Code.

An effective ILSM program provides protection without disrupting patient care and hospital operations. We’ve found that the most practical programs involve six steps. We’ll examine each and describe how they may impact the life safety of your patients, staff, and visitors. (While this type of planning applies to many types of healthcare facilities, we’ll use “hospitals” for simplicity.)

1. Pre-Construction Risk Assessment
Before work begins, a Pre-Construction Risk Assessment (PCRA) identifies the overall risks the project will create for patients, staff, and contractors. A thorough PCRA focuses on the systems within the hospital, as well as how construction-related activity may affect patient safety. It calls attention to areas in which an ILSM assessment should be performed.

The PCRA should be developed by representatives from the hospital safety staff, the contractor(s) or maintenance team, and the hospital’s project manager, focusing on questions such as:
– Will noise generated by the project impact departments or units? Any affected departments should be notified and measures taken to reduce noise to acceptable levels.
– Will vibration created by the work affect departments or units? Here again, departments should be notified, and steps taken to mitigate vibration.
– Have emergency procedures for accidental events that could impact life safety or patient care been established and posted? Procedures should include emergency contact information, locations of main valves, switches, and controls, and plans for any unexpected outages.
– Will any system requiring an ILSM assessment be taken out of service (even briefly) during the project? That includes fire alarms, fire suppression, and electrical service systems powering any life safety locations and equipment, as well as any system whose disruption creases a life safety code deficiency. Fire alarms and fire suppression outages also require utility shutdown notifications.
– Will any of the systems that require utility shutdown notifications be out of service at any time? This list may include:
• Domestic Water
• Medical Gas
• Sewage
• HVAC
• Elevators
• Pneumatic Tube System
• Building Management System
• Deionized Water
• Card Reader Access Controls
• Security Cameras
• Information Services Cables/Wi-Fi
– Will the project require any abatement of asbestos or other hazardous materials?
– Will the contractors use any hazardous chemicals for which fumes and odors must be controlled (or alternate products specified)?
– Is the work classified as a B, C, D or E project type? If so, an Infection Control Risk Assessment is needed.

2. Interim Life Safety Measures assessments
Any system or element that could create a life safety code deficiency requires an ILSM assessment. Questions that should considered include:

  • Will any egress pathways or exits be altered or obstructed?
  • Will access to emergency services and for emergency responders be impaired, restricted, or rerouted?
  • Will any fire detection or alarm systems be impaired?
  • Will any part of the fire suppression or sprinkler system be impaired?
  • Will any smoke/firewalls, doors, or assemblies be compromised?
  • Will the fire safety of personnel in adjacent areas be affected?
  • Will it be necessary to install temporary construction partitions?
  • Will the project result in the accumulation of debris and/or materials and increase the combustible load in the work area?
  • Will the project activity include significant ignition sources (e.g. cutting, welding, soldering, or other activities involving an open flame)?
  • Will the project activity present any other safety-related hazards?

Once the team has answers to these questions, they can develop plans to address life safety code deficiencies. All participants involved in the assessments, including any affected hospital departments, must review these plans and sign off before work begins.

3. Implementing the ILSM plans
The completed assessments and plans should be loaded into an ILSM database for more efficient management, and copies should be shared with contractor supervisory personnel and the appropriate hospital managers. Plans should also be posted in highly visible and readily accessible locations on the site, so contractor staff can refer to them during the course of the project. You may also wish to make copies available to local first responders.

An ILSM assessment is a living document that will need to be continuously updated as the project progresses. As the plan is updated, revisions should be posted as necessary and circulated to all parties, with a record of when they were received.

4. Contractor and Staff Training
ILSM programs should address project-specific training for contractors and maintenance personnel, who need an understanding of the systems that are in place to protect patients and how their work could compromise those systems. They must grasp the seriousness of the ILSM plan.

Hospital staff members also need safety training so they understand any ways in which their familiar life safety systems may have been (or will be) altered, based upon the specific details within the PCRA.

It’s also important to ensure that the staff is thoroughly familiar with basic emergency procedures. They need to understand the RACE (Rescue, Activate, Contain, Extinguish) concept for dealing with emergencies, and the PASS (Pull, Aim, Squeeze, Sweep) process for using fire extinguishers. The nature of the project and the specific details of the ILSM plans, may require instruction in other emergency procedures.

Even if staff members or contractor personnel have been through similar construction projects, it is critically important to repeat training. Human memories are imperfect, and repeated training is the best way to ensure that the correct actions will be taken instinctively in a crisis situation.

Training should not be a one-time event that occurs only at the beginning of a project. Use the information from walk-throughs to determine ways to focus training efforts. Sharing this information with contractors, maintenance personnel, and hospital staff will foster continuous learning and enhance safe practices.

5. Verifying compliance
Once the project is underway, shift the focus to monitoring compliance with ILSM measures. An ILSM Compliance Checklist is a practical, effective tool that simplifies monitoring and documentation.

At minimum, observe and document ILSM compliance through a daily walk-through. Large or complex projects may even benefit from more frequent walk-throughs. Walk-throughs in the early stages of the project are particularly important because they quickly establish expectations for compliance.

The ILSM Compliance Checklist should address all pertinent items, such as:

  • Are exits free and unobstructed? Construction-area exits should be inspected daily, with the contractor maintaining an egress log.
  • Is access to emergency services and entrance and exit discharges unobstructed? Encourage contractors to avoid propping or wedging open doors.
  • Is there clear exterior access for police, fire, and other emergency responders?
  • Is the fire alarm system working? Where deficiencies are noted, ensure that a fire watch is provided. Provide additional fire extinguishers and ensure that personnel are trained in fire extinguisher use for healthcare facilities.
  • Are fire suppression systems functioning properly? If not, ensure that alternate means of responding to fires are in place and assign properly trained firewatch personnel as needed.
  • Have temporary partitions been installed safely and correctly so that they provide the desired protection (access, noise, dust, etc.)?
  • Ensure that personnel working in your facility comply with the requirements regarding use of tobacco products.
  • Monitor housekeeping conditions and ensure that construction debris is removed promptly. Equipment, tools, and materials should be stored inside the construction zone and not in the hallway or in public areas.
  • Are all temporary exit signs and project signs maintained in a good condition?
  • Make sure that evacuation routes, access control, and required emergency information are updated as conditions change.
  • Monitor hot work operations and ensure that the facility’s hot work procedure is implemented, with properly trained firewatch personnel on hand.
  • Inspect fire extinguishers and ensure that access to them is not obstructed. Contractors should clearly identify extinguisher locations.

6. Closeout Procedures
As the project nears the end, you’ll need to verify that all life safety deficiencies have been corrected before turning the newly constructed or renovated space over to the hospital department or other user groups.

A closeout checklist is particularly helpful for documenting that the project is ready to be turned over. Checklists can address common issues such as:

  • Are all exits to be free and unobstructed?
  • Are all exit signs operational and installed as designed, and has the contractor removed all temporary signs?
  • Ensure that all access to emergency services has been restored.
  • Verify and document that maintenance acceptance testing for smoke/sprinkler systems has occurred when the project involved modifying or installing new systems.
  • Ensure that the area is equipped with the appropriate number of fire extinguishers.
  • Have contractors removed all construction materials and equipment?
  • Have all emergency evacuations signs been installed and updated?
  • Verify that all ceiling tiles have been installed.
  • Ensure that spaces are clean and ready for occupancy.
  • Remove any other safety related hazards or conditions prior to accepting the area.

All parties involved in the pre-project assessment should participate in the walk-through for the closeout checklist, and all questions must be satisfactorily answered and issues resolved before the space may be occupied.

One final thought
Be sure that your ISLM program incorporates comprehensive training for everyone on the site. The success of your program depends on how well you communicate its importance to the individuals whose work impacts the life safety of the patients, staff, and visitors.

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