Running a hospital isn’t just about keeping the lights on and the HVAC system humming. It’s about ensuring that every square foot of the environment supports the mission of patient safety. Few things emphasize this responsibility more than Interim Life Safety Measures (ILSMs).

ILSMs may sound like yet another compliance checkbox, but to those who manage the day-to-day operations of hospitals, they’re much more. They are the bridge between necessary construction, repairs, or deficiencies and the continued protection of patients, visitors, and staff. Put simply: ILSMs are what keep a facility both compliant and safe when the normal fire and life safety features are compromised.

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Understanding ILSMs in Context

ILSMs are a set of temporary, compensatory actions we implement whenever fire protection or life safety systems are impaired. That could mean a fire alarm system being offline, a smoke barrier temporarily breached during construction, or sprinklers shut down while piping is replaced.

In healthcare, the stakes are incredibly high. Patients may be immobile, disoriented, or dependent on staff for evacuation. That reality means even short periods of system impairment present unacceptable risk. Accrediting bodies such as The Joint Commission, DNV, CIHQ, and ACHC, along with the Centers for Medicare & Medicaid Services (CMS), recognize this and require facilities to have ILSM policies and practices in place.

Compliance isn’t just about avoiding citations. It’s about ensuring that, no matter what work is underway, the facility never loses its ability to safeguard human life.

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Why ILSMs Matter for Compliance

1. Accreditation Survival

Surveyors expect to see documented, well-executed ILSM programs. They’ll ask:

• How do you assess when an ILSM is required?
  
  
• Who makes that decision?
  
  
• Where are your records?
  
  

Without a structured program, you risk findings that can jeopardize your accreditation status. For an organization, that’s not just bad press—it can affect reimbursements and the ability to serve patients.

2. CMS Conditions of Participation

CMS requires compliance with NFPA 101 (Life Safety Code) and NFPA 99 (Health Care Facilities Code). When normal life safety features are compromised, compensatory measures are not optional. Documented ILSMs demonstrate compliance with these federal regulations.

3. Risk Management Alignment

ILSMs align directly with a facility’s broader risk management strategy. They show that leadership is taking proactive steps to mitigate hazards. In today’s environment, where liability and legal exposure are real concerns, that documentation can be a shield.

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Why ILSMs Matter for Facility Operations

Beyond compliance, ILSMs are essential for smooth, safe operations.

1. Continuity of Care During Construction

Hospitals never close. When a patient wing gets renovated, fire alarm panels get replaced, or sprinklers upgraded, we can’t simply shut down operations. ILSMs allow us to keep care delivery uninterrupted while still protecting everyone inside the building.

2. Protecting Staff and Patients

During a fire alarm panel replacement at a facility, the system was offline for 12 hours. The fire watch was activated, extra extinguishers deployed, and staff made sure everyone knew exactly what to do if a fire broke out. That wasn’t “nice to have”—it was the only responsible way to operate.

3. Strengthening Staff Awareness

ILSMs often involve additional drills, inspections, and staff education. These reinforce safety culture across the organization. Every nurse, tech, and support staff member becomes more aware of their role in fire safety when ILSMs are in place.

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The Core Components of ILSMs

A robust ILSM program includes a variety of actions, depending on the impairment. The most common include:

• Fire Watch: Assigning trained personnel to continuously patrol affected areas when detection or suppression systems are impaired.
  
  
• Posting Fire Watch Notices: Placing signage that alerts occupants and staff to heightened fire risks and outlines emergency procedures.
  
  
• Increased Surveillance: More frequent testing of fire doors, exit routes, and construction barriers.
  
  
• Enhanced Staff Training: Briefings for staff in impacted areas about emergency procedures and reporting.
  
  
• Additional Fire Extinguishers: Strategically placing portable extinguishers where automatic suppression is out of service.
  
  
• Compensatory Egress Measures: Ensuring alternate exits are marked and accessible when construction blocks normal egress paths.
  
  
• Hot Work Precautions: Reinforcing hot work permitting and supervision when construction introduces ignition risks.
  
  

The key is documentation. Every step must be recorded, tracked, and available for review. Software is the easiest way to assign, track, and close out ILSM activities—no more clipboards lost in the shuffle. Soleran has an ILSM solution specifically designed for hospitals that integrates with any other tools you may be using. 

Challenges in Implementing ILSMs

Even with the best intentions, managing ILSMs comes with hurdles.

• Resource Allocation: Fire watch requires trained staff. Pulling employees from other duties or hiring temporary help strains budgets.
  
  
• Communication Gaps: If construction crews aren’t fully briefed, they may create hazards without realizing the downstream safety implications.
  
  
• Consistency Across Projects: Different project managers may interpret ILSM requirements differently. Without a centralized process, gaps emerge.
  
  
• Survey Pressure: During surveys, surveyors will dig deep. If your ILSM documentation isn’t airtight, it can lead to findings even if the field work was strong.

These challenges are real, but not insurmountable. They reinforce why having a standardized process is critical.

Best Practices for Effective ILSM Programs

1. Embed ILSMs in the Work Order Process
   Whenever a system impairment is scheduled, a computerized maintenance management system (CMMS) should automatically trigger an ILSM assessment. Soleran’s Work Orders Suite and ILSM applications work seamlessly in this process. This ensures nothing slips through the cracks.
   
   
2. Train Staff Continuously
   Don’t wait until an impairment occurs to educate staff. Include ILSM awareness in orientation and annual training. That way, when you call for a fire watch, staff know what to expect.
   
   
3. Partner with Contractors
   Make ILSMs part of every construction pre-con meeting. Contractors must understand that safety isn’t negotiable, and their buy-in is essential.
   
   
4. Audit Frequently
   Assign leadership to spot-check ILSM compliance. A second set of eyes can catch things a busy frontline team may miss.
   
   
5. Leverage Technology
   Digital rounding tools, checklists, and automated reporting save time and create defensible documentation. They also give leadership real-time visibility into risk status. Check out Soleran’s full healthcare suite of tools from ILSM to Rounding to Work Orders and beyond.
   
   

The Bottom Line

ILSMs are often seen as a burden—a regulatory hoop we have to jump through. But in reality, they’re a cornerstone of responsible facility management. They protect lives, ensure compliance, and allow us to maintain operations without compromising safety.

The truth is, hospitals are living, breathing systems that are always evolving. Construction, repairs, and upgrades will never stop. That means impairments to life safety systems will always occur. The question isn’t whether we’ll need ILSMs—it’s how well we’ll execute them.

When we treat ILSMs not as a box to check but as a serious safety tool, we send a message to patients, staff, and regulators alike: safety is non-negotiable here.