The document discusses SiteFM's webinar on interim life safety measures (ILSM). It provides an agenda for the webinar which includes introductions, a 40 minute presentation on ILSM, next steps, and a question and answer session. It also provides background information on SiteFM and the qualifications of the webinar faculty member.

1. The Standard for Healthcare Facility
Management Compliance
SiteFM's Education Webinar Series
Interim Life Safety Measures
Host:
Martyn Buffler
Vice President, Sales and Marketing
Email: mbuffler@sitefm.com
Phone: 512-480-0883 x125
SiteFM
Faculty:
Tom Zahorsky CHFM, CHSP-FSM
Vice President of Client Services
Email: tomz@sitefm.com
Phone: 281-362-1686
SiteFM
Copyright @ 2014, SiteFM. All rights reserved.

2. Thank you for joining us today!
Agenda
• Introductions (5 minutes)
• Presentation (40 minutes)
• Next Steps (5 minutes)
• Q&A
Housekeeping
• We will be in webinar mode – all lines muted
• Please enter questions in the control panel

3. About SiteFM
SiteFM is Exclusive to Healthcare
• Based in Austin, TX for 22 years
• Over 400 facilities across the US using SiteFM
• SiteFM Work Order / Compliance Manager
• SiteFM Space and Life Safety Drawing Management
• SiteFM Vision – RTLS and Critical Asset Monitoring
and Equipment Location
Healthcare Facility Management Experience
• Healthcare FM Experience on Staff
• Partnerships with Industry Leaders
• Compliance-Focused Solutions
“Technical knowledge of hospital
operations, codes and regulatory
standards, the IT design team, and
customer support truly set SiteFM
apart from other vendors. The
management of a complex medical
facility can be greatly enhanced by
forming a partnership with the
SiteFM team “
Northwest Hospital and Medical
Center / UW Medicine
Jim Ellis
Compliance Manager and
Fire Marshal

4. SiteFM Compliance Manager
The latest mobile software technology is integrated in the NEW SiteFM program,
providing unprecedented work order mobility and efficiency for all types and sizes
of healthcare facilities.

5. SiteFM Vision
Environmental Monitoring & Asset Locating
SiteFM Vision improves healthcare facility workflow, operational visibility and
profitability by creating a healthcare based, scalable system with comprehensive
asset locating and environmental monitoring.
This comprehensive system empowers hospitals to increase staff -facility efficiencies
and improve documentation & reporting – while boosting customer service.
“95% of healthcare facilities
utilizing RTLS have realized
operational efficiency gains.”
-Recent KLAS report

6. Life Safety Drawing – Creation and Hosting
SiteFM will review and assist you with updating your Life Safety Drawings
Deliverables
• Review of existing
Life Safety Drawings
• Creation/Update to
all specified Life
Safety areas
• Printed Life Safety
and SOC floor
plans, along with
CAD files
• Free Hosting –
Online web access

7. We proudly serve many of the premier healthcare
networks in the United States.

8. Value to Attendees
• Please submit questions during the presentation to be read
during the Q&A session at the end of the presentation.
• To receive a copy of the slides, fill out the post-webinar
survey and a SiteFM team member will follow up with you.
• SiteFM offers a free CMMS data analysis and/or an expert
review of your Life Safety Drawings.
• Stay connected with SiteFM for future webinars.
•Sign up for a product introductions/demonstrations for:
- SiteFM Work Order Manager
- SiteFM Space and Life Safety Drawing Services
- SiteFM Vision – Asset Locating and Monitoring
www.SiteFM.com

9. Faculty Background
Tom Zahorsky CHFM, CHSP-FSM
• VP of Client Services, SiteFM
• 35+ Years in Healthcare Facilities Management
• Former Joint Commission Life Safety Surveyor
• Former OSHA Voluntary Protection Program
(VPP) STAR Worksite Coordinator

10. Objectives
To increase participant’s understanding of:
• What ILSM is
• The reasons for ILSM
• When to Assess ILSM
• The ILSM process
• ILSM Implementation
• Fire Watch, When and Hos
• Documenting ILSM

11. Self Test
• Today’s program will start a bit differently.
• The following self quiz will help you assess
your knowledge of ILSM Requirements.
• There will be 10 questions.
• We will review the answers at the end of the
program.

12. Self Test
1. Hospitals are different from most
occupancies in that building occupants
cannot get up and leave in the event of a fire.
The strategy to address this is called -
a) Fire Drill
b) Disaster Drill
c) Evacuation Plan
d) Defend in Place

13. Self Test
2. The Fire Safety Triangle includes the following -
a) Detection, Suppression, Containment
b) Detection, Extinguishing, Evacuation
c) Detection, Compartments, Fire Walls
d) Fire Alarm, Sprinkler, Fire Extinguishers

14. Self Test
3. Detection is accomplished by the -
a) Sprinkler system
b) Fire and smoke barriers, doors and dampers
c) Fire Alarm system
d) Code Red Plan

15. Self Test
4. Suppression is accomplished by -
a) The Sprinkler system
b) Fire and smoke barriers, doors and dampers
c) Fire Alarm system
d) Code Red Plan

16. 5. Containment is provided by -
a) Sprinkler system
b) Fire and smoke barriers, doors and dampers
c) Fire Alarm system
d) Code Red Plan
Self Test

17. 6. ILSM evaluates the impact of the
impairment and provides an alternate means
of maintaining Life Safety.
a) True
b) False
Self Test

18. 7. The reason for ILSM is -
a) To recognize the impact of Life Safety
deficiencies or impairments
b) To compensate for identified deficiencies or
impairments
c) To maintain the level of Life Safety normally
required in a Healthcare or Ambulatory
occupancy
d) All of the above
Self Test

19. 8. ILSM must be assessed when (all that apply) -
a) Considering construction
b) A Life safety deficiency is found that cannot
be corrected in the same shift in which it is
discovered
c) A Life Safety deficiency cannot be corrected
within 45 days
d) A PFI will be in effect for more than 6
months
Self Test

20. Self Test
9. Acceptable alternatives for addressing Life
Safety deficiencies include (all that apply) -
a) Repairing the problem during the same shift
in which it was discovered
b) Making a 45 day work order
c) Assessing for ILSM and making a 45 day
work order
d) Assessing for ILSM and creating a Plan for
Improvement (PFI)

21. Self Test
10. All ILSM assessments must be documented -
a) True
b) False

22. Self Test
Good luck.
Watch for answers throughout today’s program.
We will begin with
What are Interim Life Safety Measures (ILSM)?

23. INTERIM LIFE SAFETY MEASURES (ILSM)
What are ILSM?
– A series of 14 administrative actions provided
by The Joint Commission in the CAMH manual
– TJC Standard LS.01.02.01 EP 1-14
– One of two standards in Life Safety that can
jeopardize accreditation severely

24. INTERIM LIFE SAFETY MEASURES (ILSM)
What are ILSM?
– Assessment and steps required to temporarily
compensate for Life Safety deficiencies per
NFPA® 101 Life Safety Code® (LSC)
deficiencies (2000 edition)

25. INTERIM LIFE SAFETY MEASURES (ILSM)
What are ILSM?
– A means of maintaining a continuous level of
Life Safety in spite of impairments of Life
Safety building features

26. The Reasons for ILSM
– First understand that Healthcare is a “Defend
in Place” occupancy
– Provision of a safe patient care environment
relies on the fire safety triangle
Containment

27. The Reasons for ILSM - Detection
• Smoke Detectors
• Heat Detectors
• Duct Detectors
• Water Flow Switches
• Pull Stations
• The Fire Alarm System
– Detection
– Notification
– Control

28. The Reasons for ILSM - Suppression
• Fire Protection System
• Water Based – “Sprinklers”
• Kitchen Hood Suppression
• Other Gaseous Systems
• Portable Fire Extinguishers
• Fire Hoses (if in place)

29. The Reasons for ILSM - Containment
Containment is the concept of using various building
components (fire rated walls and doors, smoke barriers,
fire rated floor assemblies) to prevent the spread of fire
and the products of combustion.
These features help to protect
occupants from smoke and fire as
well as to provide a safe means of
egress to an area of refuge or
approved exit.

30. • Confining the fire/smoke to the:
– Room
– Smoke Compartment
– Floor
– Building
The Reasons for ILSM - Containment

31. • Walls properly installed and sealed at
construction joints (especially top of wall)
• Walls maintained to be free of unsealed
penetrations
• Walls with all openings properly protected
– Doors
• Fire Doors
• Smoke Doors
• Corridor Doors
• Horizontal/vertical fire doors
– Windows
– Ductwork (dampers)
The Reasons for ILSM - Containment

32. – If any of these attributes are impaired, the risk to Life
Safety is increased
– ILSM evaluates the impact of the impairment and
provides an alternate means of maintaining Life Safety
Containment
The Reasons for ILSM

33. • To recognize the impact of Life Safety
deficiencies or impairments
• To compensate for identified deficiencies
or impairments
• To maintain the level of Life Safety
normally required in a Healthcare or
Ambulatory occupancy
The Reasons for ILSM

34. • One of only two standards under Life
Safety that can place the organization’s
accreditation in jeopardy
• Failure to comply may result in a
situational decision process or non-
accreditation
• When in doubt, assess
The Reasons for ILSM

35. INTERIM LIFE SAFETY MEASURES (ILSM)
The 14 Steps
1. Fire Watch
2. Signage to alternate exits
3. Written policy and assessment criteria
4. Exits inspected daily
5. Temporary fire alarm
6. Additional fire-fighting equipment
7. Temporary construction barriers

36. The 14 Steps (cont)
8. Surveillance
9. Storage practices
10. Training of those working in affected areas
11. Additional fire drills
12. Inspection/testing of temporary systems
13. Education
14. Training of all hospital staff
INTERIM LIFE SAFETY MEASURES (ILSM)

37. • 1. The hospital notifies the fire department (or
other emergency response group) and initiates a
fire watch when a fire alarm or sprinkler system is
out of service more than 4 hours in a 24-hour
period in an occupied building. Notification and
fire watch times are documented.
• For full text and any exceptions, refer to:
NFPA 101-2000: 9.6.1.8 and 9.7.6.1
(See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

38. • 2. The hospital posts signage identifying the
location of alternate exits to everyone affected.
(See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

39. ILSM Signage
• Interim Life Safety Measures in Effect:
– This exit is closed and leads to a
construction area.
– Please use alternate exits as marked.

40. Temporary
Fire Exit

41. • 3. The hospital has a written Interim Life Safety
Measure (ILSM) policy that covers situations
when Life Safety Code deficiencies cannot be
immediately corrected or during periods of
construction. The policy includes criteria for
evaluating when and to what extent the hospital
follows special measures to compensate for
increased life safety risk.
(See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

42. • 4. When the hospital identifies Life Safety Code
(LSC) deficiencies that cannot be immediately
corrected or during periods of construction, the
hospital does the following:
• Inspects exits in affected areas on a daily basis.
• The need for these inspections is based upon
criteria in the hospital's Interim Life Safety
Measure (ILSM) policy.
(See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

43. • 5. When the hospital identifies Life Safety Code
(LSC) deficiencies that cannot be immediately
corrected or during periods of construction, the
hospital does the following:
• Provides temporary but equivalent fire alarm and
detection systems for use when a fire system is
impaired.
• The need for equivalent systems is based upon
criteria in the hospital's Interim Life Safety Measure
(ILSM) policy. (See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

44. • 6. When the hospital identifies Life Safety Code
(LSC) deficiencies that cannot be immediately
corrected or during periods of construction, the
hospital does the following:
• Provides additional fire-fighting equipment.
• The need for this equipment is based upon criteria
in the hospital's Interim Life Safety Measure
(ILSM) policy. (See also LS.01.01.01, EP 3)
INTERIM LIFE SAFETY MEASURES (ILSM)

45. • 7. When the hospital identifies Life Safety
Code (LSC) deficiencies that cannot be
immediately corrected or during periods of
construction, the hospital does the following:
• Uses temporary construction partitions that
are smoke-tight, or made of noncombustible
material, or made of limited combustible
material that will not contribute to the
development or spread of fire.
INTERIM LIFE SAFETY MEASURES (ILSM)

46. • 8. When the hospital identifies Life Safety
Code (LSC) deficiencies that cannot be
immediately corrected or during periods of
construction, the hospital does the following:
• Increases surveillance of buildings, grounds,
and equipment, giving special attention to
construction areas and storage, excavation,
and field offices.
INTERIM LIFE SAFETY MEASURES (ILSM)

47. • 9. When the hospital identifies Life Safety
Code (LSC) deficiencies that cannot be
immediately corrected or during periods of
construction, the hospital does the following:
• Enforces storage, housekeeping, and debris
removal practices that reduce the building’s
flammable and combustible fire load to the
lowest feasible level.
INTERIM LIFE SAFETY MEASURES (ILSM)

48. • 10. When the hospital identifies Life Safety
Code (LSC) deficiencies that cannot be
immediately corrected or during periods of
construction, the hospital does the following:
• Provides additional training to those who
work in the hospital on the use of fire-
fighting equipment.
INTERIM LIFE SAFETY MEASURES (ILSM)

49. • 11. When the hospital identifies Life Safety
Code (LSC) deficiencies that cannot be
immediately corrected or during periods of
construction, the hospital does the
following:
• Conducts one additional fire drill per shift
per quarter.
INTERIM LIFE SAFETY MEASURES (ILSM)

50. • 12. When the hospital identifies Life Safety Code
(LSC) deficiencies that cannot be immediately
corrected or during periods of construction, the
hospital does the following:
• Inspects and tests temporary systems monthly.
• The completion date of the tests is documented.
INTERIM LIFE SAFETY MEASURES (ILSM)

51. • 13. The hospital conducts education to promote
awareness of building deficiencies, construction
hazards, and temporary measures implemented
to maintain fire safety.
INTERIM LIFE SAFETY MEASURES (ILSM)

52. • 14. The hospital trains those who work
in the hospital to compensate for
impaired structural or compartmental
fire safety features.
INTERIM LIFE SAFETY MEASURES (ILSM)

53. When?
• Prior to construction activities
– New Construction
– Renovation
– Equipment Replacement
• Prior to commencing any project that would
negatively impact Life Safety in the facility

54. • As a result of Life Safety surveys and
inspections or reported deficiencies:
– When a Life Safety deficiency is discovered
that cannot be corrected during the same shift
in which it was discovered (immediately
corrected)
– Conduct the assessment during that shift
– Document the assessment and the
conclusion of the assessment
When?

55. Managing LS Deficiencies (Brief)
• A deficiency is discovered
– Fix it now – no ILSM Assessment Required
– Create a Life Safety work order due within 45
days
• ILSM Assessment Required
– Create a PFI
• ILSM Assessment Required
– Multiple PFIs
• Evaluate the cumulative affect of all PFIs combined
– ILSM Assessment Appropriate

56. The ILSM Policy
• Establishing an ILSM Policy
– State who will assess ILSM
– State their qualifications (training/experience)
– State when ILSM will be assessed
– Make assessment process clear (if/then)
– Indicate how assessment is documented
– Indicate how ILSM activities are documented

57. The ILSM Policy

58. THE ASSESSMENT TOOL

59. THE ILSM PROGRAM
• Staff Training
– Determine target audience (affected staff)
– Develop training content
• What the shortcoming is
• What the impact of that shortcoming is
• How the shortcoming will be compensated for
• What their role is
– Conduct training programs
– Document completion of training

60. Implementing ILSM
• Implementation
– Complete evaluation sheets per project
– Select appropriate ILSM
– Select frequency for monitoring
– Monitor sites
– Document and Report findings
– Document in ILSM records

61. Documenting ILSM
• Documentation
– The Assessment itself
– The conclusion of the assessment
– Possible Work Orders
– Training Records
– Surveillance Records
– Keep these all together in an ILSM binder
– Safety Committee minutes

62. Test Answers
1. D – Defend in Place
2. A – Detection, Suppression, Containment
3. C – Fire Alarm System
4. A – Sprinkler System
5. B – Fire and Smoke Barriers, doors and
dampers
6. A – True
7. D - All of the Above

63. 6. A – True
7. D - All of the Above
8. A & B – both when considering
construction and when an LS deficiency
cannot be immediately corrected
9. All but B – if it is not corrected within the
same shift as discovery, ILSM must be
assessed
10.A – True – if it is not documented, it did
not happen.
Test Answers

64. In Review
• All ILSM Assessments must be documented
• Assess the impact of any Life Safety deficiency that
cannot be resolved (corrected) within the same work
shift in which it was discovered
• Most Life Safety work orders will required assessment
• All PFI’s require ILSM Assessment
• Assess for cumulative effect of multiple issues as the
outcome will be different than for the individual issues

65. Thank you
• Thank you for your time today
• We hope that you found it worthwhile
• Check our website for future webinars:
– www.SiteFM.com
• Encourage others to participate

66. Next Steps
• Please fill out the post-webinar survey!
• Sign up for a SiteFM product demonstration
and/or request a competitive proposal for:
•SiteFM Work Order Manager
•SiteFM Life Safety Drawing Manager
•SiteFM Vision
• Please share this information with your peers.
Thank you!
The SiteFM team…..

67. is hereby granted to
for participation in the webinar
Interim Life Safety Measures
March 20, 2014
Thomas A. Zahorsky, CHFM, CHSP-FSM
SiteFM – Compliance Management Software
____________________
Certificate of Training
Thomas A Zahorsky

68. The Standard for Healthcare Facility
Management Compliance
Questions and Answers
Tom Zahorsky CHFM, CHSP-FSM
Vice President of Client Services
Email: tomz@sitefm.com
Phone: 281-362-1686
SiteFM
Martyn Buffler
Vice President, Sales and Marketing
Email: mbuffler@sitefm.com
Phone: 512-480-0883 x125
SiteFMCopyright @ 2014, SiteFM. All rights reserved.