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Is There Low-Hanging Fruit in Your Hospital?

Ken Blackwell
Healthcare Leader, CHSP and Joint Commission Consultant

Do you know that most life safety code deficiencies that contribute to conditional-level findings are “low-hanging fruit”?  What does that mean?  I’m glad you asked.  Low-hanging fruit is “the obvious or easy things that can be most readily done or dealt with in achieving success or making progress toward an objective” (Merriam Webster Dictionary Low-hanging fruit, 2018). This means that many of your findings could be prevented if you would simply deal with the obvious, easy-to-address deficiencies on a routine basis.

For the sake of this article, I’m going to pinpoint places where low-hanging fruit is most commonly found and list simple practices for quick remediation.

  • Reduce projections into the corridor that protrude more than 6 inches from the wall
  • Eliminate placement of two soiled linen hampers stored side by side
  • Clean dirty sprinkler heads
  • Stained or missing ceiling tiles
  • Repair bent sprinkler head deflectors
  • Label all medical gas shut-off valves
  • Missing sprinkler head escutcheon plates
  • Secure all E-cylinders
Above the ceiling: 
  • Remove cables draped over sprinkler pipes
  • Replace missing cover plates on electrical junction boxes
  • Increase the frequency with which you inspect barrier penetrations
Mechanical spaces:
  • Replace missing cover plates on electrical junction boxes (This is not a typo.  Check for this deficiency in both above-ceiling areas and mechanical spaces)
  • Remove cables tied to sprinkler pipes
  • Eliminate storage of items within 3 feet of electrical panels
  • Eliminate storage of items in front of HVAC unit access doors
  • Label all circuit breakers that are in the ON position
  • Label all circuit breakers that are Not active as spares

  • Clean dirty sprinkler heads
  • Place deep fryer at least 16 inches from open flame or mount an 8-inch metal splash guard between cooking appliances
  • Mount K-extinguishers within 30 feet of cooking surfaces
  • Repair or remove all non-operational equipment

Generator rooms: 
  • Provide eyewash station if one measures the battery-specific gravity
  • Mount a remote manual stop outside of generator room
Operating Rooms:
  • Create unobstructed path to medical gas shutoff valves
  • Eliminate blocked Line-isolation panels
  • Increase the frequency with which you inspect barrier penetration above the ceiling
  • Label medical gas shutoff valves
  • Eliminate corridor clutter
  • Know whether or not your OR is a suite based on the life safety drawing
Main Fire Alarm Control Panel:
  • Check panel cover for circuit breaker label
  • Check sub-electrical panel to ensure main fire alarm control panel breaker is marked in red

In the words of Confucius, “Life is really simple. We just keep making it complicated.”  Be sure not to complicate the way you manage your facility.  Keep the simple things simple.  Identify and address your low-hanging fruit. Your healthcare facility will be a safer place for your staff, patients and visitors.
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