The Joint Commission clarifies its Technical talk ...

1 As of July 1, to be in compliance with EC , hospitals needed to have completed a four-hour gen-erator test at some point within the past 36 months and perform a similar generator run every 36 months testing approach follows the National Fire Protection Associa-tion s (NFPA) standard NFPA 110, Emergency and Standby Power testing is a big deal these days: In interviews with Briefings on Hospital Safety, recently surveyed hospital safety managers nationwide say that Joint Commission representatives requested to see generator test-ing records. That s not a surprise to David Stymiest, PE, CHFM, FASHE, a senior consultant for Smith Seckman Reid, Inc., based in says he has heard that sur-veyors have zero leeway on that count, as they ve been instructed to check generator testing wherever they go. I n S I D E Vol. 15 no. 9 September 2007 Imagine how disconcerting it would be to find a half-finished pipe bomb abandoned on your hospital s loading dock. Now sup-pose that a couple of weeks later, police suddenly cordon off the streets around the facility because they ve found two more devic-es this time, wired and ready to blow around the perimeter of the building.

2 You might wonder how your staff members would react and whether your emergency response plan would rise to the talkRead more details about generator load banks and the 30% nameplate requirement. See p. of ConditionsUpcoming Joint Commission changes led the discussions at several sessions of the American Society for Healthcare Engineering s conference. See p. of the monthTake stock in the Centers for Disease Control and Prevention s reiteration of flu-shot advice for healthcare workers. See p. Healthcare Security Alert, we examine 10 security pitfalls that increase a hospital s risk of a Joint Commission clarifies its generator testing requirementsTests may be combined in certain situationsTwo bomb scares offer this hospital a chance to upgrade its planningFor permission to reproduce part or all oF this newsletter For external distribution or use in educational packets, please contact the copyright clearance center at or 978/750-8400.> p. 2 San Francisco General Hospital (SFGH) learned firsthand how its disaster plan would stack up, as the above-mentioned scenarios unfolded May 22 and June 6 at an outpatient clinic on its sprawling urban campus.

3 Eventually, police explosives experts rendered the second round of devices inert, and everyone went home incidents reshape your planTaking the initiative, emergency planners at SFGH integrated the lessons they learned into their response plan. Your subscription now includes access to the Hospital Safety Center go to for more details.> p. 6 Page 007 HCPro, Inc. Briefings on Hospital Safety September permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at or 978/750-8400. So a surveyed facility can be pretty sure [it] will have to produce generator test records, says Stymiest, who is chairperson of NFPA 110 s Technical Committee on Emergency Power hospitals that Stymiest talks to satisfy the test requirement via a load bank (see Tech talk: Details about load banks and 30% nameplate on p. 4 for more). However, some hospitals have used what is called a dynamic load switching the emergency loads over to a generator and performing a test to verify that the system does indeed power its emergency tests meet which requirements?

4 Besides the four-hour test, also requires the following: Generator tests 12 times per year for 30 minutes that draw at least 30% nameplate, or energy capac-ity, of the equipment (if a generator doesn t hit 30%, the hospital may substitute a supplemental test at various nameplate ratings totaling two hours, as outlined in ) Automatic transfer switch tests 12 times per yearThe question that hospitals had after going through the four-hour test: Does that generator run also satisfy the requirement for monthly 30-minute tests, as well as the potential annual, two-hour generator tests? Before 2007, the answer was no. After The Joint Commission published a clarification in its July Environment of Care News, the answer is yes, provid-ed that for the duration of the four-hour test, it draws at least 30% option applies only if you re running diesel engines; other types of generators have no 30% incidents can count as testsFurther, if an actual power outage occurs that lasts for at least four hours (and draws at least 30% nameplate for diesel generators), that counts for the required four-hour test and for whatever shorter tests that might be eligible, The Joint Commission example, if it s been more than 20 days since your last half-hour test, an outage lasting five hours that draws enough power would satisfy requirements for monthly, annual, and triennial tests.

5 But if you re doing a four-hour load bank that draws enough power, it satisfies only the two- and four-hour requirements, because the monthly testing require-ments also include transferring the facility s power over to generators to confirm that the transfer switches still events can substitute as tests, too, The Joint Commission says in its clarification. Hospitals run-ning their emergency power supply systems for four hours as part of a peak-shaving agreement with a local utility may also satisfy the triennial test require-ment, provided they meet all of the other provisions of ask for clarificationIf all this sounds confusing, you re not alone, says Generator testing< p. 1 Elements of emergency power testing programsThe new provisions of should prompt hospitals to review and reevaluate their current emergency power plans. The following are three elements important to every emergency power sys-tem management plan:1. Emergency power gap analysis Figure out where you need power most critically during outages of several different severities and how to get that power to those critical areas 2.

6 Emergency power vulnerability analysis Determine the weak spots of your generators3. Risk management plan Take those identified vulnerabilities and come up with solutions or mitigations for themSource: David Stymiest, PE, CHFM, FASHE, senior consultant for Smith Seckman Reid, Inc., based in on Hospital Safety September 2007 007 HCPro, Inc. Page For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at or 978 Chisholm, emergency power supply systems consultant for the Motor and Generator Institute of Winter Park, FL. Chisholm is also a member of the NFPA 110 Technical Joint Commission initially required separate two- and four-hour tests. After hospitals expressed their discontent, The Joint Com-mission and American Society for Healthcare Engineering (ASHE) polled the NFPA Technical commit-tee about a formal interpretation of NFPA 110. Combining tests is fine with committee members, as long as the requirements for each are similar.

7 Overwhelmingly, we voted to tell [The Joint Commission ] that one test would be suf-ficient, Chisholm says. Because of the way that ASHE and The Joint Com-mission worded the question, the NFPA could not issue a formal interpretation of the standard, he explains. However, the Technical committee s stance was clear enough to The Joint Commission that it issued the clarification, with the caveat that future NFPA action could alter the NFPA Technical committee is expected to stream-line the next edition of the standard, scheduled for 2009 release, says Chisholm. He hopes that The Joint Commission and the Centers for Medicare & Medicaid Services will follow the new standard as written, with-out additional rulemaking. We hope to simplify it so that it will be easy for any-one to understand and won t be so dadgum convo-luted, Chisholm records need to be in orderSurveyors look for a few basic items in your generator testing documentation: That the hospital conducted the testing That testing lasted for the prescribed interval That the load bank or actual loads from the facil-ity drew enough to satisfy the 30% requirement for diesel generators That the hospital operated transfer switches properlyHowever, there are more actions that a hospital can take to move beyond the basics and show The Joint Commission that the facility has developed a sound emergency power manage-ment September, 2006, The Joint Commission issued a Sentinel Event Alert that outlined preventive steps to help avoid problems caused by power Alert discussed a number of testing measures that The Joint Commission recommends hospitals carry out, and offered examples of clinical contingency plans that hospitals could put into place during a power loss.

8 Examples included: Accessing drugs marooned in automated dispens-ing machines Using two-way radios in a facility as communica-tion backup Maintaining communications with hospital leaders who are off-siteSafety managers who read that Alert might find clues to what surveyors look for, Stymiest says. The big points are to address any problems that generator test-ing reveals and put detailed thought into handling real-istic power outage scenarios including those caused internally by equipment failures and externally, such as by weather conditions. It s asking the organization to go a little bit further and look beyond just the numbers, Stymiest says of the Alert. Make sure the lessons learned from what-ever happened during the testing are investigated and followed through .. to improve the reliability of the overall power system. We hope to simplify [NFPA 110] so that it will be easy for anyone to understand and won t be so dadgum convoluted. Dan Chisholm> p.

9 4 Page 4 007 HCPro, Inc. Briefings on Hospital Safety September permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at or 978 his ASHE monograph, Managing Hospital Emer gency Power Systems: Testing, Operation and Main tenance, Stymiest points out that during monthly testing, emergency power systems can fail and transfer Generator testing< p. 3 Tech talk: Details about load banks and 0% nameplate Hospital safety managers and facility directors might wonder why The Joint Commission is keen on running generators at a minimum of 30% capacity during load bank or real-world testing. That mantra actually comes from generator manufac-turers, who know diesel engines and the way they run, says Dan Chisholm, emergency power sup-ply systems consultant for the Motor and Generator Institute of Winter Park, FL. If you can t run your diesel engines at least 30%, you re going to cause engine damage, Chisholm says.

10 That s because at lower levels of output, unburned fuel accumulates in the engine, a condition called wet stacking. At 30% capacity or higher, the inside of the engine gets hot enough to burn all the fuel piped through 30% rule also relates to another concept that might confuse hospital safety managers new to the Technical side of emergency power: using a load bank versus the actual hospital power load for gen-erator people might assume that a hospital would bring in a load bank basically, a power-eating device on a trailer in the parking lot because it s easier than arguing with clinicians and administra-tors about what would be the best time to test the s not true, though, Chisholm says. The rea-son most facilities use a load bank is that regular power loads at a hospital won t necessarily tax the emergency system enough to satisfy the 30% rule. There are ways to complete the test without a load bank, says Dave Stymiest, PE, CHFM, FASHE, a senior consultant for Smith Seckman Reid, Inc.