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Bridging the Gap: Understanding the Interconnection Between the Physical Environment and Life Safety in ACHC Standards

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November 18, 2024

Your physical environment – your patients’ and employees’ environment – plays a big part in the safety and well-being of all. That’s why the Physical Environment and Life Safety chapters of the ACHC Accreditation Requirements are closely related, even though they are separate.

This connection is especially clear when you review the Centers for Medicare & Medicaid Services (CMS) State Operations Manual. The CMS manual mentions the National Fire Protection Association (NFPA) 101-2012 Life Safety Code and the NFPA 99-2012 Health Care Facilities Code. In July 2016, CMS adopted the 2012 editions of NFPA 101 and NFPA 99. Both codes also reference several other NFPA codes in Chapter 2 of NFPA 101 and NFPA 99.

Conditions of Participation

Facilities that are deemed pursue and accept reimbursement from CMS. As part of that mutual agreement, CMS sets conditions that hospitals must meet to participate in reimbursement for healthcare services. These conditions are known as Conditions of Participation (CoPs).

The Condition of Participation standard in the Physical Environment chapter reads:

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment, and for special hospital services appropriate to the needs of the community.
When reviewing the ACHC Accreditation Requirements, you’ll identify connections between the two chapters throughout. For example:

Physical Environment Life Safety Chapter
Fire Safety Control Means of Egress
Fire Alarm Systems
Fire Suppression Systems
Fire Safety Systems
Utility Systems Building Systems
Operating Features
Standard 11.00.02: Required Plans and Performance Standards – The hospital shall maintain written plans for the following areas:

  • Building Safety
  • Building Security
  • Hazardous Materials and Waste
  • Fire Safety Control
  • Medical Equipment Management
  • Utility Systems Management

Plans are reviewed and approved at least once every 12 months by the organization’s committee that oversees safety in the environment.

Standard 03.00.02: Required Plans and Performance Standards – Under ACHC’s Accreditation Requirements for Critical Access Hospitals, the CAH maintains written plans and performance improvement standards for the following areas:

  • Building Safety
  • Building Security
  • Hazardous Materials and Waste
  • Fire Safety Control
  • Medical Equipment Management
  • Utility Systems Management

Plans are reviewed and approved at least once every 12 months by the organization’s committee that oversees safety in the environment. The annual review is documented.

What Is a Management Plan?

Management plans establish a structure for overseeing the physical environment. These plans should encompass the extent and goals of risk assessment and mitigation, delineate the responsibilities of individuals or teams, and establish specific timeframes for the activities outlined in the plan.

Management plans will typically be structured similarly, using the same essential components. For example, the fire safety management plan might be outlined like this.

What Is Meant By “Program”?

A program is the overall coordination of policies, procedures, and activities related to a specific function. In this chapter, programs encompass all activities to provide a comprehensive approach to potential or actual environmental risks.

ACHC requires that management plans be reviewed and approved annually by an oversight committee (such as a Safety Committee), and associated policies must be reviewed and approved at least every three years.

The Bottom Line

By understanding the connection between the physical environment and life safety, organizations can effectively manage their overall programs, ensuring that the hospital is constructed, arranged, and maintained to keep safety top of mind and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This holistic approach is essential for creating a safe and supportive environment for patients and staff.

About the Author

Richard L. Parker, MBA, CHFM, FACHE, FASHE, serves as ACHC Associate Director, Life Safety and Physical Environment. Richard has more than 25 years of experience in engineering, construction, security, environmental services, food and nutrition services, patient transport, laundry and linen services, and communications in hospital settings. He is a Fellow of the American College of Healthcare Executives (FACHE) and a Fellow of the American Society for Healthcare Engineering (FASHE), for which he is an active participant in the Arizona chapter.

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