Developing an Interim Life Safety Measures Program

May 1, 2002 | Healthcare Risk, Quality, & Safety Guidance

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Whenever a healthcare facility embarks on a renovation or construction project that alters the physical plant and creates related hazards or causes a life safety disruption or code deficiency, an interim life safety measures (ILSM) program must be initiated. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ILSM are a series of 11 administrative actions designed to temporarily compensate for significant hazards posed by construction activities or existing National Fire Protection Association (NFPA) 101 1997 Life Safety CodeĀ® deficiencies.

This Risk Analysis provides information that can help risk managers and others develop and implement an ILSM program that will ensure the safety of their facility's occupants and meet applicable regulatory requirements and standards. This Risk Analysis also reviews JCAHO standard EC.1.5, which guides facilities in developing an ILSM program and provides practical application for assessing life safety hazards and instituting necessary occupant safety measures during construction and renovation. The 11 Interim Life Safety Measures lists the 11 ILSM administrative actions for easy reference.

JCAHO standard EC.1.5, which addresses interim life safety, states that each healthcare facility must "develop a policy for the use of ILSM that includes written criteria to evaluate various deficiencies and construction hazards for determining when and to what extent one or more of the following measures the 11 administrative actions are applicable."1

This policy should be a part of the facility's life safety plan and should include the processes discussed below for evaluating construction and renovation...

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