Deferring ITM: Safety or sacrifice?

As a safety manager, I’ve spent my career prioritizing safety basics and empowering my team to maintain them despite our often hectic day-to-day operations. Even though it isn’t always easy, we always found ways to get it done. During the COVID-19 pandemic, the basics of safety remain just as important as we work to operate safe healing environments for our communities. 

Compliance should never be a catalyst for danger. Effective emergency management depends on providing well-practiced safety and protection measures, but with a flexible response to requirements if conducting “business as usual” could harm the health and safety of patients and staff. For example, meeting the requirement for testing fire and smoke dampers is critical to limiting the spread of fire and smoke. Yet with a virus present, bringing people from testing organizations into the hospital to perform this testing could potentially expose staff and patients to the virus and vice versa. 

Thankfully, during the crisis, the Centers for Medicare & Medicaid Services provided health care facilities with the option to defer inspection, testing and maintenance (ITM) requirements with 1,135 waivers. The American Society for Health Care Engineering (ASHE) advocated for these deferrals, along with a specified window of time for completing ITM requirements when it is safe to do so. 

Deferring ITM requirements was not a sacrifice in safety, but a crucial exercise in flexibility and innovative thinking to defend our patients and staff. The reprioritization of ITM potentially saved lives and prevented the risk of exposing thousands of individuals to the SARS-CoV-2 virus. Waiving fire alarm testing alone reduced risk to patients and protected third-party contractors from exposure to the virus in health care facilities. It is vital to understand the purpose and effectiveness of these actions and recognize how they contribute to emergency management. 

ASHE will continue to support you through these unprecedented times. The tools and best practices we cultivate today will become invaluable guides should we encounter a global crisis like this in the future. And another reminder: Documentation is always a key to success. Remember the saying, “If it isn’t documented, then it isn’t done.” 

Thank you for your resilience and courage, and please be safe.