It’s important for hospitals to demonstrate their dedication to safe, effective, and comprehensive patient care. While they can display this in their day-to-day operations, most choose to take things a step further by earning accreditation from Det Norske Veritas, Inc. (DNV); The Joint Commission (JC); Healthcare Facilities Accreditation Program (HFAP), which is now a part of Accreditation Commission for Health Care (ACHC); or a combination of these. 

All of the accrediting organizations listed above have applied for and received “deeming authority” from the Centers for Medicaid and Medicare Services (CMS), meaning they can determine which healthcare facilities meet Medicare and Medicaid certification requirements. However, each of them goes about determining that in their own way, with a different set of standards. 

In this article, we’ll be focusing on The Joint Commission and the standards it uses to determine fire safety in hospitals — including some small, but important modifications to be aware of. 

What Is the Joint Commission?

The Joint Commission is an accreditation body that focuses on quality care for the American public through a voluntary and independent evaluation process. In the United States, around 5,000 hospitals and 10,000 other healthcare facilities are accredited or certified by the Joint Commission. 

The Joint Commission is governed primarily by a group of physicians, nurses, healthcare leaders, and public representatives. All of these people work together to influence national healthcare policy, funding priorities, performance measurement, and future legislation — while also establishing standards for safe, effective, and comprehensive patient care. 

What Are The Joint Commission Standards? 

So what are these standards? Well, they’re what is used as the baseline for all of The Joint Commission’s surveys. The Joint Commission performs on-site surveys once every three years, but hospitals must also perform annual self-assessments on the years in between. 

Therefore, these standards are all focused on setting hospital performance expectations that are reasonable, achievable, and surveyable — and that are all aimed at holding healthcare facilities responsible for high-quality care.

Over the years, the Joint Commission has established hundreds of standards, with categories, or chapters, ranging from Document and Process Control (DC), to Infection Prevention and Control (IC), to Medication Management (MM), and many more. But when it comes to fire safety in hospitals, those standards are found in The Joint Commission’s Life Safety (LS) Chapter. 

Updates to The Joint Commission’s Life Safety Standards

The Joint Commission’s LS Chapter provides standards for fire prevention, detection, and response in healthcare settings. Many of these standards are based on guidelines and requirements from the National Fire Protection Association (NFPA)

Recently, The Joint Commission made a few updates to one of its LS standards: LS.02.01.35. This standard is heavily based on the NFPA 13-2010: standard. It states that hospitals must provide and maintain systems for extinguishing fires, then lists a couple of required elements of performance. Changes were made to clarify some of the previous language used in performance requirement #7, in order to align it more closely with NFPA standards. 

Below, we’ll provide a side-by-side view of the previous version of LS.02.01.35 #7 and the updated version, so you can get a better understanding of what changes were made. 

Previous version of LS.02.01.35: 

  1. At least six spare sprinkler heads of each type and temperature rating installed in the facility are readily available, with the associated wrench or tool to replace the sprinkler head. The spare sprinkler heads and wrench or tool are stored in a cabinet that does not exceed 100°F. (For full text, refer to NFPA 101-2012:;;; NFPA 25-2011:;; NFPA 13-2010: 6.2.9;;;

Updated version of LS.02.01.35:

  1. At least six spare sprinkler heads that correspond to the types and temperature rating of the hospital’s sprinkler heads, with associated wrenches, are kept in a cabinet that will not exceed 100°F. (For full text, refer to NFPA 101-2012:;;; NFPA 25-2011:;; NFPA 13-2010: 6.2.9;;; Note: If the hospital has more than 300 sprinklers, the minimum spare sprinkler head requirement incrementally increases. (For full text, refer to NFPA 13-2010:

If you work in a hospital or healthcare setting that’s accredited by The Joint Commission, it’s important to know what these standard updates mean for your facility. In order to pass your annual self-assessment or triennial survey from The Joint Commission, you need to ensure full compliance with the new protocol. 

The Joint Commission helps hospitals become reliable organizations for delivering safe and effective care — and a large component of that is adhering to their standards on effective fire protection. At Vanguard Fire & Security Systems, we’re experts on The Joint Commission’s standards, and we can help you ensure you’re always in compliance. Contact us to learn more.

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