The Joint Commission Requires BBI (Again)

Since 1995, the Joint Commission required hospitals to maintain their Basic Building Information (BBI) and Plan for Improvement (PFI) as part of their Statement of Conditions (SOC). The BBI summarized various life safety-related features associated with the facility, while the PFI allowed hospitals to manage self-identified deficiencies which could not be immediately corrected related to NFPA 101, Life Safety Code and construction projects. The PFI was particularly a useful tool, as it prevented surveyors from citing deficiencies which were already sufficiently identified and managed by the hospital in accordance with their interim life safety measurement (ILSM) policy. In August 2016, the Joint Commission changed their survey approach and stated that all deficiencies identified would now be cited during a survey, without any special consideration given to those listed already on the PFI. The PFI list continued to remain as a tool for hospitals to manage their NFPA 101 deficiencies, however most facilities chose to no longer use this process part of the SOC, instead relying on their own internal work order or tracking system. The BBI also remained as an optional tool, however was no longer being reviewed as part of the survey process.

As of January 1, 2020, the Joint Commission has added the BBI back as a requirement and it will now have its own Element of Performance (EP). LS.01.01.01, EP 7 will require that “the hospital maintains current basic building information (BBI) within the Statement of Conditions (SOC)”. In addition to the past information required, the BBI will also now be required to include specific square footages of the hospital’s building(s). The intent behind the accurate square footages is to assist the Joint Commission in more accurately determining the number of days required for the organization’s building tour.

It is important that hospitals dust off and update their existing BBI, especially if it has not been re-visited since 2016. This should include making sure that the construction types and occupancy classifications align with that identified on the life safety plans so all information is accurate and consistent. Accurate square footages should also be added to ensure that all facility information is complete and up-to-date. Not sure if your BBI is accurate? Please don’t hesitate to contact us if you need someone to review this information prior to your next unannounced survey.


Application of any information provided, for any use, is at the reader’s risk and without liability to Code Red Consultants. Code Red Consultants does not warrant the accuracy of any information contained in this blog as applicable codes and standards change over time. The application, enforcement and interpretation of codes and standards may vary between Authorities Having Jurisdiction and for this reason, registered design professionals should be consulted to determine the appropriate application of codes and standards to a specific scope of work.