MSL Safer Today

From my exclusive partner in Life Safety

Welcome to Safer Today, a monthly newsletter to help MSL partners continue to create safer healthcare environments every day. The Safer Today newsletter will bring you trends and news from our experiences in healthcare environments throughout the country, and will give you deeper insights into the ways our consultants can make sure your facility is safe beyond compliance!


MSL has been focused on patient safety from its founding. The Joint Commission’s Leading the Way to Zero program as well as the Patient Safety Movement are near and dear to our hearts and inherent in our mission statement: We partner with healthcare organizations to make them safe beyond compliance.

The Joint Commission has announced that they will be placing an increased focus on scoring issues with infection prevention during construction. Specifically, they will be evaluating the following:
• Posting of the ICRA and associated mitigation plan at the construction site.
• Intact construction, with no gaps or tears.
• Evidence of negative pressure in the construction site.
• No indication of dust outside the construction barrier.
• Appropriate management of debris removal. Carts covered and wiped down prior to removal.
• Construction workers entering and exiting following appropriate protocol as described in the ICRA.
• Knowledge of staff in the area of the construction site as to easily identified issues and reporting process.

Here is the scoring breakdown for these issues:
• EC.02.06.05 EP 3
o Conditions of ICRA not being followed.
 Barrier must extend above dropped ceiling (check inside and outside).
 HEPA filters must not exhaust into a return or above dropped ceiling.
o Staff in the construction area are aware of their roles and responsibilities, but they do not take action, such as walking past a torn barrier, observing incorrect pressure.; observing dust in corridor, (etc.).
• IC.01.01.01 EP 2
o Who signs the ICRAs? The Infection Preventionist must be among the signers.
o With whom does the Infection Preventionist consult when he/she needs additional information on construction issues?
• IC.01.02.01 EP 1
o Infection Preventionist is not notified of renovation, design, or construction project.
• IC.01.03.01 EP 1
o Unsafe condition observed in construction area that was not addressed in ICRA.
o Stocking of supplies and equipment in the newly constructed area prior to terminal cleaning of construction site.
• IC.01.05.01 EP 1
o National evidence-based guidelines not in use.
• IC.01.05.01 EP 2
o No written process for ICRA and mitigation.
• IC.02.01.01 EP7
o Hospital didn’t communicate responsibilities to hospital and construction staff for infection prevention during construction.
o Staff do not know their role (e.g., walking past torn barrier, observing incorrect pressure, observing dust in corridor, etc.).
• LD.01.02.01 EP 4
o Pattern of noncompliance with ICRA requirements.

Leave a Reply