1. ILSMs Eugene A. Cable, P.E. Life Safety Consultants NEHES NFPA Liaison
412 Horse Heaven Road
Averill Park, New York 12018
(518)

2. Introduction Background and “Code Creep”
Real World Life Safety Factors
ILSM Standards and Policy

3. ILSM Definition
Special measures taken to compensate for increased life safety risk.
“Code Creep”: When codes and standards are enforced beyond their true intent.

4. Background 1996 In the Beginning. . . By 2004, TJC standard EC.5.50
“The organization develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®.
EP 1. Each organization develops a policy for using interim life safety measures (ILSMs).
2012, TJC standard LS
EP 3. “The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction”

5. Background Code Creep George Mills and Joint Commission presenters:
Try to stop creep by emphasizing your policy
“The ILSM review is driven by your policy”
“An ILSM policy should be in force during any situation in which a LSC violation cannot be immediately corrected” (2011 Essentials)
Rest of EP #3, “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”
Reason: Easy to just copy the standard into a policy
Reason: Ghost standard spreads quickly

6. Background NFPA 101 addresses non-compliance
Section Time allowed for compliance
Section Conditions for occupancy
No serious life safety hazard exists as judged by the AHJ.
Section Occupied during construction
“Buildings. . . shall be permitted to be occupied during construction, repair,… only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place.
The Life Safety Code acknowledges that deficiencies occur all the time.

7. Real World Life Safety Factors Life Safety Code
Redundant requirements
Total Concept (Section )
Multiple Safeguards
- Prevent Ignition
- Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate

8. Unattended patient bunches up linen on patient bed and slips hand under the pile
Series of failures

9. Multiple Safeguards: - Prevent Ignition - Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate

10. 3 X 5 Cards – Quiz

11. 1.

12. 2.

13. 3.

14. 4.

15. 5.

16. Real World Life Safety Factors
ILSM is really an effort at temporary equivalency, to introduce a non-required safety element to make up for one that is required but missing.
Difficult to decide appropriate alternative measures
FSES Equivalency methodology outlines THE major factors/parameters for life safety.

17. FSES Life Safety Factors
Patient mobility/ density/ location/staff ratio
Called the “occupancy risks”
Building safety parameters
Construction - Hazardous areas
Room Interior finish - Smoke control/ barriers
Corridor interior finish - Emergency movement routes
Corridor walls - manual fire alarm FD connection
Corridor doors - smoke detection and alarm
Smoke zone dimensions - automatic sprinklers – coverage/QR
Vertical openings
Fire Safety Requirements – no choice
Exit signs - emergency lighting
Evacuation plan/ drills - furnishings combustibility
HVAC comply 90A - fire extinguishers comply NFPA 10
Gene Cable (518)

18. Fire and Life Safety Model - Escape
Time
Time to
Detection
Notify
Occupants
Time for Smoke To Block Egress Path
Fire Development - fire growth curve
Occupants
Safely Out
Fire
Ignition
Detection
Alerted
Egress
Route
Blocked
Time Needed To Get Out
Response
Delay To
Prepare
To Travel
Safety
Margin
Gene Cable
(518)

19. Video

20. ILSM Standards and Policy
Final segment
But First – the score; ILSMS: YES or NO?
1. Self-closer broken Y: N: 23
2. Stair pipe penetrations Y: N: 10
3. Ceiling tiles missing Y: N: 39
4. Wall missing (trick) Y: N: 22
5. Electrical Transformer rm door Y: 41 N: 10

21. 1. Even if storage room, I Would not even evaluate for ILSMS – No
The five quiz examples
In my opinion anyway:
1. Even if storage room, I Would not even evaluate for ILSMS – No
2. Do the ILSM evaluation and likely yes needed
3. No evaluation needed and NO ILSMs
4. (trick) corridor wall not required in the first place, QR sprinkler and smoke detector in the open space – Yes Evaluation, but No ILSMs
5. Gave a hint, electrical room, 20,000 F arc flame potential, yes do evaluation and likely Yes

22. Accreditation Rules Situational Decision Rules in EC (trigger)
Immediate Threat to Health or Safety
Rule: Preliminary Denial of Accreditation
Failure to make sufficient progress on previously accepted PFIs (LS EP 2)
Rule: Accreditation with Follow-up Survey
Failure to develop an acceptable ILSM policy
Rule: Accreditation with Follow-up Survey

23. Failure to implement appropriate ILSMs (LS. 01. 02
Failure to implement appropriate ILSMs (LS EP 4 – 14) Direct or an Indirect finding – no rule; less serious
For EP # 4 -14, 5 are “directs”
Example: Provide additional firefighting equipment – D Conducts one additional fire drill - ID

24. Interim Life Safety Measures
Actual standard: “ The Organization protects occupants during periods when the LSC is not met or during periods of construction.”
Order of Standards (LS )
EP 1 & 2: regardless of ILSM policy
EP 3: must clearly define the ILSM policy including
Both construction related and non-compliance with the LSC
When to implement
What to do to protect occupants
EPs 4 – 14 align with policy and implementation strategies

25. EP 1 - Fire Watch
An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable.
In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled.
A scheduled activity would be an event known to and under the knowledge of and control of organization staff
a construction project
servicing or upgrading the fire alarm system or sprinkler system. 25 25

26. ILSM Evaluation Required? Yes (emphasis on occupant notification)
Service Situation
Fire Watch Required?
ILSM Evaluation Required?
Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours No
Recommended
Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area.
Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational
Yes
Rationale: During a controlled event the organization is managing the deficiency. The area would be continually monitored, and ILSM should be implemented as per policy.
Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours
● Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)
Not in all cases
Yes (emphasis on occupant notification)
Rationale: During a controlled event, the organization is managing the defi­ciency. The area would be continually monitored, and ILSM would be implemented as per policy.
● Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) 26 26

27. Fire Watch (NFPA 101 Section 9.7.6)
Can do fire watch for less than 4 hour impairment
Can be normal staffing for small scale impairment
Section A9.7.6; “involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected.”

30. EP 2 – Alternate Exits
Post signage to ID alternate exits and way to get there.

31. EP 3 – The ILSM Policy Have one
Both construction related and non-compliance LSC
When to implement
EP 3: “The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction.” “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”

32. EP 3 Policy Example # 1
SUBJECT: INTERIM LIFE SAFETY POLICY
The XX Medical Center recognizes that construction and/or renovation activities have the potential to increase the risk of injury to staff, patients and/or visitors. Because of this potential, a program of risk evaluation and mitigation strategies has been developed to minimize these risks. The following procedures will be followed during all construction and/or renovation activities that have this potential.
At the completion of the preliminary design phase and prior to beginning construction or renovation, an Interim Life Safety Measures, (ILSM), Review Checklist will be completed by the Construction Projects Manager or his designee.
Identified Life Safety Deficiencies
In addition to construction and renovation activities, interim life safety measures must be considered whenever there is an identified life safety deficiency. This could occur as a result of a periodic life safety assessment or as an item identified during a scheduled hazardous surveillance tour. Whenever a life safety code deficiency is identified a review will be conducted to determine the need for interim life safety measures.
CRITIQUE: Covers the two major bases CONCERN: Boxed self in, all defs.
Take OUT

33. Policy # 6602 Interim Life Safety Measures
Example # 2
Policy # 6602 Interim Life Safety Measures
It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features.
ILSM apply to all personnel, (including construction workers) working in Health Care, Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be warranted for incidental short-term deficiencies.
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies” Concern: Who decides: “significant” and what is “short-term” .
Add IN

34. Policy # 6602 Interim Life Safety Measures
Example # 2 addendum
Policy # 6602 Interim Life Safety Measures
(Same policy as Example # 2 with definitions)
II. Definitions:
Incidental short-term deficiencies: Minor transient deficiencies that only effect local areas, do not pose any systemic risks and will be corrected by the Maintenance department. Examples include the failure of one corridor smoke sensor which is flanked by other working sensors, dirty sprinkler heads and other deficiencies of similar magnitude.
Significant Deficiencies: Life Safety Code deficiencies that pose systemic risks. Examples include blocking of egress corridors due to construction, impairments to smoke and/or fire barriers and impairments to suppression and detection systems greater than 4 hours.
GOOD

35. Policy # 6602 Interim Life Safety Measures with definitions
Example # 3
Policy # 6602 Interim Life Safety Measures with definitions
It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features.
ILSM apply to all personnel, (including construction workers) working in Health Care, Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be warranted for incidental short-term deficiencies.
The surveyor/ evaluator identifying the deficiency determines whether or not it is a significant or incidental short-term deficiency. The Life Safety Officer should be consulted in questionable situations and can ultimately overrule .
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies” aspect Concern: None Add IN

36. EP 3 – The ILSM Policy Have one
Both construction related and non-compliance LSC
When to implement

37. EP 3 – The ILSM Policy What to do to protect occupants –EP 4 – 14
Policy example # 1
EP 3: “The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction.” “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”
Prior to the start of the project, the project details and the ISLM Review Checklist will be reviewed with the Safety Officer, an Engineering Services Representative, the XX Construction Representative and the Contractor representative. Any additions or revisions to the checklist will be noted and will be added to the project procedures.

38. Two matrix checklists

39. ILSM EP # 8
On Matrix decided to increase hazard self inspections – crawl space for combustibles
Keep the documentation of those inspections for 3 years.
If not available – Indirect finding

40. Conclusion Covered ILSM background
Real world major life safety factors
The important vulnerabilities of the ILSM policy
And some INs and OUTs for a good policy
This presentation will be on the NEHES Webb site