Life Safety Compliance: Understanding the Basics

By William Phillips, Owner, RITEway Building Services

One of the biggest challenges facing ASC administrators is the need to become an expert at practically everything concerning their surgery center as there is typically an expectation from their governing boards that the buck stops with them. While administrators may not need comprehensive knowledge of all aspects of surgery center management, they must understand the fundamentals of many subject areas in which they may not have a working background or experience. One such area is life safety.

“Life safety” is a phrase that administrators will come to know very well as time goes on in their career. Every licensure and accreditation survey has a component devoted to life safety. On the surface, maintaining compliance with life safety can seem like a lot of ongoing responsibility, which is made even more complicated by rule changes that occur approximately every three years.

There are many compliance items that you are able to control as part of life safety compliance and many items that you cannot control. It is difficult to control how your physical plant was designed and built. That is the fundamental foundation of how life safety compliance criteria are applicable to your facility. What you can do is ensure the operational compliance inspections and checks required for your existing physical plant are performed as closely as possible to the standards prescribed in the regulations being enforced by surveyors visiting your site. Do so regularly and your survey outcomes are more likely to be positive.

Here are some areas of focus to help improve life safety survey compliance.

Physical Plant Tour

The tour is the most important part of the physical plant life safety compliance survey. Obvious “housekeeping”—and by that I mean maintenance-related issues—must be taken care of and addressed prior to the survey. Evidence of compliance on the tour should stand out as evidence that you have a solid physical plant maintenance program in place. This will likely impress surveyors, even if you have the oldest surgery center ever built. A positive first impression speaks a lot toward your management of compliance.

Safety Officer Responsibilities

The key person relative to your general safety and life safety compliance is your safety officer. Make sure this individual is supported and encouraged. Your safety officer should make regular rounds and document everything found to be out of compliance. Simply because you document everything doesn’t mean that you have to correct or make improvements on everything that safety officer may identify as noncompliant. Rather, if a deficiency is found that may not be feasible to correct based upon your surgery center’s operations or financial constraints, it is worth documenting and recording as an action item or, in some cases, creating a life safety deficiency report on this very item. Review and document these items at your quality assurance and performance improvement meetings and send the documentation to your governing board members for their review.

Prior to any life safety survey, present this record of your perceived life safety deficiencies to the surveyor(s) to demonstrate that you are aware of issues that may be corrected by future actions. This shows the surveyor that you are on top of your life safety management compliance program.


Regardless of whether documentation is electronic or written, it must trace compliance actions from inspection of a particular device to a pass or fail determination—and if failed, a corrective action. The corrective action may be in the form of written compliance action, usually a work order. This traceable work action can refer to a single or group of devices checked, whether they be electrical receptacles, biomedical equipment or individual components on the fire alarm system. The same rules apply everywhere.

Final Thoughts

While life safety operational compliance is something that you must constantly be aware of, try not to let it become overwhelming to the point where you worry about it incessantly. All required inspections and checks must occur regularly, so implement a reminder system. Ensure documentation is complete and records are maintained in a common area for easy review and reference. This is vital to passing a survey.

And remember: The first impression of your physical plant will often drive the rest of the inspection. Good luck!

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