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Interim Life Safety Measures Revisited:

Steps
FOR AN EFFECTIVE PROGRAM

By Kenneth R. Haber, MPA, FACHE, CHSP-FSM

Joint Commission Resources
Environment of Care® Consultant

www.jcrinc.com
 T here appears to be much confusion in hospital safety, engineering and facilities departments
about what is required in National Fire Protection Association (NFPA) and The Joint
Commission Standards to meet a compliant Interim Life Safety Measures (ILSM) program.

The intent is to provide a completely safe environment for all occupants in the hospital at all times, and
especially during times of construction or repair.

Designing an effective ILSM program is a result of a sound risk assessment process and continual updating and
fine tuning of existing life safety program procedures. To help develop and maintain an effective ILSM program,
this six part approach is offered as a primer to identify key concepts.

The purpose of an ILSM program is to mitigate potential untoward fire and smoke conditions at all times when
features of life safety are deficient, compromised or removed from service due to construction, maintenance,
or breakdown/repair. ILSM is not about regulatory requirements, it is about protecting patients and all others
providing care and services who might be unable to easily evacuate. A sensible and safe ILSM program will meet
regulatory requirements as long some basic concepts are followed.

These concepts include:
4A Statement of Conditions, to be a living assessment process that gets
updated regularly based on changes in life safety features in the environment
4 Hazard surveillance tours/safety rounds
4Life safety compliance rounds or Building Maintenance Program (BMP)
4Work orders requests
4Planning and implementation of construction projects
4Day-to-day system breakdowns
4“Trouble” messages from fire alarm panels
4Planned maintenance, inspections and upgrades
4Required repairs identified from periodic maintenance and inspection
Some of the hospital building and alarm features that
protect occupants from fire safety hazards include:
4Exit signs
4Extinguishers
4Fire Alarm Systems – smoke detectors, duct detectors, etc.
4Means of egress
4Fire and smoke doors
4Suppression systems such as sprinklers, Ansul, and pre-action systems
4Compartmentalization; hospitals are built in compartments for horizontal
evacuation to defend in place
The most critical features that protect occupants from
fire safety hazards and would cause a major immediate
threat to occupants, if compromised, are:
4Fire Alarm Systems (out of service for 4 or more hours)
4Sprinkler Systems (out of service for 4 or more hours)
4Master Gas Alarm Panels
4Emergency Power Systems - Generators
4Compromised exit
Developing a Successful ILSM program in 6
Components.
Note that the first 3 steps should be completed prior to starting any work
and measures selected must remain in place until an impairment or
compromise of a feature no longer exists.
1 Assessing the situation
2 Developing and reviewing possible interim measures based on
the assessment
3 Developing and implementing the measures to be put in place
4 Regularly monitoring the interim life safety measures in place
5 Following up on any concerns identified during the monitoring process
6 Reporting trends and concerns to the EOC
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Interim Life Safety Measures Revisited:
Step 1 | Assessing
Continual assessment of potential
risks and mitigation is the central
challenge of all successful Environment
of Care, Life Safety and Emergency
Management programs in hospitals.
The main theme for developing
effective programs is to continually
evaluate existing and future conditions
and to develop strategies to minimize
potential risk. Safety and Life Safety
management programs are not a
“standard operating procedure”
methodology as much a continual
critical thinking exercise. What could
go wrong? What is wrong with this
picture? How can untoward events
be prevented?
It is strongly recommended to develop
two approaches when assessing interim
life safety concerns.
The first assessment, called the Pre-
Qualifying ILSM Assessment (PQIA),
is used for day to day breakdowns,
scheduled work, and other common
small scale events. This assessment,
on page 5, should never be used for
construction projects. The PQIA works
Steps 2 & 3 | Developing and Selecting Interim Life Safety Measures
The next step in the ILSM process
is the development of potential
mitigation, prevention or abatement
strategies. The selection of measures
shouldn’t occur until alternatives are
known. ILSM, ICRA, Pre-Construction
Risk Assessment (PCRA) and other
decisions regarding actions should result
from team review. As an example, for
construction projects it is suggested
to include in the decision process the
safety department, the hospital’s project
manager, the construction company,
in-house engineering, and potentially
architects, engineers, and local occupants.
6 STEPS FOR AN EFFECTIVE PROGRAM
very similarly to an Infection Control
Risk Assessment (ICRA) in that
hospital personnel develop a score from
a pre-populated grid of work in areas
the work is needed. There are two
pre-populated scales that each hospital
should develop based on internal
discussions and team decisions.
The first scale is the work to be
performed (see page 5). The more
complex work, i.e. - repairing a whole
zone of a fire alarm system, will have
higher scores of 3 – 4, while basic work
such as repairing one smoke detector
will get a low score. The 2nd scale
identifies the criticality of locations
(see page 5) based upon hospital
location, i.e., patient or common area.
Intensive care units and operating
rooms will have higher scores of 3 – 4,
while non-patient support areas such as
the billing office will have lower scores
of 1 – 2. After identifying the life safety
compromise on the form, the individual
completing the assessment will select
from a chart the work type score and
the location score and multiply the two
numbers. A total score of 7 or below
Hospital ILSM policy should define
how this selection of measures process
works. Many hospitals omit this
process definition phase from their
policy. As part of the ICRA most
hospitals determine a risk level and
then have pre-populated strategies
to address the various risk levels. It is
strongly suggested that the same type of
defined approach for ILSM selection is
identified in the hospital’s ILSM policy.
Policies can include as much or as little
flexibility in the selection of measures
process as agreed to by the hospital’s in-
house experts and oversight committee.
Joint Commission standards pre-define
requires no further action as there is
minimal discernible risk. A score of 8 or
above requires a more comprehensive
assessment (Full ILSM Assessment –
“FIA”) to be performed and interim
measures to be put in place.
The second type of ILSM assessment
is a traditional grid with assessment
elements in one column and potential
mitigation elements in the other.
In this way, assessed compromise is
matched with strategies to address risk.
For example, if during construction
there is going to be a “bump out”
that impedes a corridor, it is strongly
recommended to put measures in place
to compensate for the reduced corridor
width. Measures based on hospital
policy could include local education
of occupants affected, extra fire drills,
extra exit signage, photo-luminescent
tape on the temporary walls, or other
accommodations.
The key in both types of ILSM assessments
is not to assign measures until an assessment
is completed.
some actions required for sprinkler and
fire alarm systems out of service for
more than four hours (LS.01.02.01, EP
1) and compromised exits (LS.01.02.01,
EP 2). Regardless of the assessed
concern, it is required that the practice
in the field matches the written policy.
The selection of interim measures needs
to be documented in a defined process,
whether it is a construction permit, a
PCRA form, an ILSM form or by what
is identified in the hospital’s policy.
Before work starts, the hospital must ensure that
all interim life safety measures are in place.
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Interim Life Safety Measures Revisited: 6 STEPS FOR AN EFFECTIVE PROGRAM

Step 4 | Regularly Monitoring Interim Life Safety Measures in Place

Once work begins, and as defined in
policy, the hospital should monitor the
selected ILSM measures for adherence.
Construction work should have daily
monitoring by the contractor and at
least weekly monitoring by the hospital’s
safety department or other identified
group as specified in the hospital’s
ILSM policy.
Data collected during monitoring
is always useful for reporting trends
in Step 6, but most importantly for
immediately identifying and correcting
any deficiency or any safety issue that
is identified during inspection rounds.
The form should identify issues noted
and steps to correct after inspection.
Many hospitals use a standard
monitoring pre-printed form with
10-12 criteria. The disadvantage of a
pre-set form is that ILSM is likely a
different configuration of measures for
each event. One standardized form is
either frequently missing an identified
mitigation measure or includes more
measures than need to be monitored.
Additionally, many hospitals include
PCRA, ICRA and ILSM monitoring
on one form.
There is no prescribed format for the content of
the monitoring form other than to ensure that the
measures identified are in place when inspected.

Step 5 | Following up on any Concerns Identified During the Monitoring Process

All monitoring should be documented
with identified non-compliant issues
followed up in writing, to “close the
loop,” as defined in the hospital’s
policy. A scored assessment document
will allow hospitals to trend objective
measures and set goals for improvement
efforts. Deficiency trends can be The goal is to continually assess the
addressed through education, vendor effectiveness of the ILSM process and improve
relations, and other follow up efforts. results, strategies, monitoring and other elements
Daily contractor monitoring can be as needed to ensure a safe environment.
compared to in-house monitoring to
spot check on the effectiveness of the
overall process.

Step 6 | Reporting of Trends and Concerns to the Environment of Care Committee

As the oversight committee for life
safety, environment of care and
emergency management in most
hospitals, the EOC Committee should
be kept informed of results of on-going
assessment activities, ILSM in place,
and any concerns or actions needed to
improve the overall program. A monthly
EOC Committee report regarding
ILSM can include the locations where
ILSM is in place, compliance with
daily and weekly monitoring activities,
most common trends from monitoring The 6 step ILSM process is an effective strategy
activities, and suggested improvements for managing what can be a multi-faceted
to the overall ILSM program. On a complex program. Adhering to continuous risk
quarterly basis the ILSM policy can
assessment and performance improvement
be reviewed and updated with any
identified improvements. measures will help hospitals provide a safe
environment for optimal patient care.
By reporting to the EOC Committee,
hospital leadership is also aware of
activities undertaken to ensure the safety
of all occupants.

© 2013 Joint Commission Resources

The information provided herein is for guidance purposes only. Not all of the suggestions provided are required under The Joint
Commission’s standards or the Centers for Medicare and Medicaid Services Conditions of Participation (COPs), please consult applicable
standards and requirements for further any clarification.
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 Interim Life Safety Measures Revisited: 6 STEPS FOR AN EFFECTIVE PROGRAM

Scores
Value, Life Safety Deficiency, Service or Impairment Risk Score A Value: Occupancy Weight Score B
Failure, Draining or Disabling of:
Any one fire alarm initiating device 1 Anesthetizing location 4
Any one supervisory sprinkler device 1 Operating Rooms 4
Multiple sprinkler devices (more than 1 less than a whole zone) 2 Intensive care unit 4
Multiple initiating devices (more than 1 less than a whole zone) 2 Infant or Pediatric Unit 4
A fire alarm or sprinkler system or zone for 4 or more hours 4 Psychiatry 4
A fire alarm or sprinkler system or zone for less than 4 hours 3 Emergency Room 4
The off-site notification feature of a fire alarm zone or system for 4 or more 3 MRI 3
hours for scheduled work General Patient Care Unit 3
the off-site notification feature of a fire alarm zone or system for less than 4 3 Ambulatory Patient Care Area 2
hours for scheduled work
Business Occupancy 1
Water storage tank low water or temperature alarm failure 3
Ancillary support (Business) 1
A main drain from the sprinkler system 3
Ancillary Support (Healthcare Occ) 2
A standpipe or sprinker connection for FDNY 3
Food Service Main Kitchen 2
A dry pipe extinguishing system 3
Sterile Storage area (Patient Supp.) 2
A wet pipe extinguishing system 3
Endscopy 3
All or part of an ansul system 3
Mechanical Room/Machine Room 1
fire or smoke dampers 3
Any 1 visual or audible fire alarm notification devices, including speakers 1
More than 1 visual and/or audible fire alarm notification devices, 3
including speakers
Other Risk Issues:
Battery Operated Egress Light repair/replace/install 2
Exit Light to be installed or repaired 2
Inaccessible damper 2
HVAC system does not shut down upon a fire alarm condition 3
Broken rolling or sliding doors 3
Broken fire or smoke doors 2
Penetration in fire wall 3
Penetration in smoke wall 3
Corridor door latching problem 2
Compromised smoke or fire compartment 2
Blocked exits due to repairs needed or other physical hazard 4
Removal of ceiling tiles for 4 or more hours in sprinklered space 4
Cutting metal 1
Welding, brazing, soldering 2
Smoke or fire Door (or chute door) missing rating 1
Deck Missing Fire Proofing 2
Light lens cover missing in egress path fixture 1
Additional Value, Life Safety Deficiency, Service or Impairment
Risk Score:
© 2013 Joint Commission Resources
Other issues posing threats from immediate fire and smoke: (fill in issue)
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 Interim Life Safety Measures Revisited: 6 STEPS FOR AN EFFECTIVE PROGRAM

Interim life safety measures program

pre-assessment form

All Construction Projects Require A Full ILSM Assessment (No Pre-Assessment Is Required In The Case Of Construction)

Person Submitting Form: Date:
Issues to be considered: Work Order #:
Life Safety Compromise / Impairment:

Location:
Building: Floor: Room:
Other Identifying Information

Reviewed / Evaluated By: (Print) Date of Finding:

Value and Weighting Metric Scoring: (select “Value and Occupancy Weight” from chart)

X =

(1 2 3 4 ) (1 2 3 4 )

VALUE WEIGHT RISK SCORE

Evaluation Levels- Check “A” or “B” Below

A (risk score of 1 to 7 ) No Further action required
B (risk score of 8 to 12) Full ILSM assessment required

Date: Signature:

© 2013 Joint Commission Resources

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