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Self Assessment Tool

Joint Commission Life Safety Specialist Areas of Emphasis

This tool is a checklist which can be used to help evaluate your facility's compliance with certain elements of the 2010 Joint Commission Environment of Care and Life Safety Standards that might be reviewed by a Life Safety Specialist Surveyor.

This chart is not all inclusive. It does not include all items that are subject to survey. This checklist is not a substitute for reading and understanding the Joint Commission Environment of Care and Life Safety Standards. It is a tool that can be used to assess your facility’s compliance with the items that are listed on the chart. Possible uses for this tool are:

  • Use the tool for training your staff about compliance issues.
  • Review of your documentation. For items that have a specific testing frequency, verify that your documentation clearly demonstrates that you are in compliance. If you have difficulty understanding or explaining your documentation, an Authority Having Jurisdiction will very likely have difficulty understanding it also.
  • If you have maintenance and testing performed by a vendor, verify that their documentation is complete, Verify that tests have been performed within the prescribed time frames and that the documentation clearly identifies what was tested, and how the testing was performed.
  • Use this chart as a periodic review and submit it to your Safety or Environment of Care Committee as part of the review of your program.
  • Have someone within your organization who is not as familiar with your documentation or as close to the process use the chart to evaluate your documentation as a double check to be sure it understandable and complete.
The American Society for Healthcare Engineering of the American Hospital Association
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