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Follow these steps to make facility inspections easier, safer


January 12, 2020

By John Palmer

Most hospital safety engineers spend their careers in the back of the house, preparing for the inevitable visit their facility gets every 18–36 months from The Joint Commission’s surveyors.

They are making sure that the hospital is abiding by the rules that regulators set forth, and those rules can be the fuel of nightmares: complex, hard to understand, and sometimes vague.

The good news is that you can prepare for upcoming surveys, and the most successful safety professionals know to make facility tours a regular part of their work week, if not their daily tasks, in order to maintain the status of their facility.

Study, and know the standards

Just because you’re not the hospital’s administrator or safety officer doesn’t mean you shouldn’t know what’s behind the standards. As a hospital engineer, you should also know what a surveyor is looking for so you’ll know what to keep an eye on when you do your own surveys.

“It is very surprising to me to find out how many facility managers do not take the time to actually read the accreditation organization standards,” says Brad Keyes, CHSP, owner and senior consultant for Keyes Life Safety Compliance. “Surveyors are prepared to find as many deficiencies as they can. You need to be aware of what is expected of you to meet that challenge.”

Many standards that The Joint Commission follows are connected closely to NFPA fire safety standards and emergency preparation standards set forth by government regulators such as OSHA and the Centers for Medicare and Medicaid Services (CMS). Your job as an engineer is to know how the systems that you install and maintain help to meet these standards, which in many cases require the hospital to remain operational in the event of a disaster.

If you don’t know where to start, go to www.jointcommission.org and register your organization; then download a copy of the TJC standards to review. It’s a long list and many of the standards are vague, but knowing them will give you a guideline of the specific things a surveyor will look for. If you frame your survey preparation around the standards themselves, you’ll give yourself a head start at succeeding on survey day.
Don’t be afraid to ask for help, Keyes says—from a consultant, a neighboring healthcare facility, ASHE, or even the accreditors themselves.

Make equipment inspections remote

Multiple inspections of equipment and required tests to comply with life safety, fire, environment of care, and worker safety standards can get very complicated—and very costly.

“One large organization documented that it had more than 334,000 inspections and tests required to comply,” wrote William E. Koffel, PE, FSFPE, SASHE, president of Koffel Associates, Inc. in Columbia, Maryland, in a September issue of Health Facilities Management magazine.

“This is burdensome to the facility not only because of the tasks that need to be performed, but the interruption to the operation of the facility, potential infection control risks, additional sources of noise and conservation of natural resources (such as water that is discharged while testing fire protection systems).”
There are many inspections that are required to be done manually such as monthly inspections to make sure indicator lights are glowing, or that water flowing through a water flow switch actually closes the valve properly.

Still, many advances in technology are making it possible to conduct more inspections and tests remotely, and as the NFPA prepares updated inspection codes for 2020, expect to see some of those standards change.

Koffel writes that fire extinguishers, fire and smoke dampers, and addressable alarm notification appliances are all systems now being designed with automatic test capabilities.

Train your staff to tattle

Surveyors will almost definitely spend time with your staff members during their visit and ask them lots of questions. If they trip up on their knowledge—say, of your fire evacuation procedures or inspection schedules—there’s a good likelihood you’ll get written up for it.

If you haven’t already, it’s time to establish a staff training regimen. From a life safety perspective, you’re going to need to get your staff up to speed on fire safety and fire evacuation procedures, because not only do they need to know these in the event of an actual fire, they will be quizzed about them when faced with inspectors. The more trained they are, the more knowledgeable they will be when survey day comes.

Conduct routine safety inspections and walkthroughs with staff of different departments. The purpose here is to let them know what a surveyor will be looking for so they can look for potential violations on their own.
For instance, it’s important to train staff on the importance of a properly working fire door. If they don’t know what they are looking for, a broken door could turn into a major violation, so they need to know when it’s necessary to call a work order into the facilities department.

See things through the eyes of a surveyor

Veteran facility managers develop an eagle eye for the little things that may escape someone else’s notice—things that may prevent a life safety or facility safety violation.

As you do your daily and weekly tours of the building, remember that a surveyor will be looking for the smallest signs that your facility’s safety program is lacking, so you should do the same.

For instance, you may be the only one who notices during your rounds that boxes in the patient ward are stacked a little too high, blocking the path of sprinklers. In the course of a busy day, perhaps no one notices the stairwell door propped open (a patient elopement hazard), the spray paint can left in the hot environment of the generator room (an explosion hazard), or the contractor working in the infant ward without a name badge from security (an abduction hazard).

Look for the fire extinguishers that have an outdated inspection schedule, carry a tape measure so you can be sure gaps under fire doors aren’t too large, and have a look on the roof. Some of the best facility managers know that surveyors will look at something as simple as whether bird droppings have accumulated in HVAC intake ports—a major infection control violation.

Pass ownership

It’s OK to let someone else be responsible for damage and the need to repair it. If environmental services keeps hitting the doors with carts, for example, breaking them repeatedly, take the repair money out of their budget, and suddenly the doors will work better.

This, of course, doesn’t take the broken doors off your plate as the safety professional, but you should always be inventorying your problems.

You should be utilizing some sort of system to keep track of persistent problems. Some experts suggest using a computerized maintenance management system to help you schedule inspections, develop checklists, write work orders, and keep track of any problems.

Enter the portal

The Joint Commission and the American Society of Healthcare Engineers (ASHE) developed a web portal to help hospital safety, engineering, and maintenance personnel review Life Safety (LS) and Environment of Care (EC) standards, including fire safety, means of egress, utility systems, and life safety systems such as automatic fire suppression systems.

The portal can be accessed at http://www.jointcommission.org/topics/the_physical_environment.aspx and contains online resources and tools to help hospitals with compliance of those standards.

The following list includes a few of the module subjects you can find on the portal:

  • Utility Systems—EC.02.05.01
  • Means of Egress—LS.02.01.20
  • Built Environment—EC.02.06.01
  • Fire Protection—EC.02.03.05
  • General Requirements—LS.02.01.10
  • Protection—LS.02.01.30
  • Automated Suppression Systems—LS.02.01.35
  • Haz Mat/Waste Management—EC.02.02.01

The modules are easy to use and contain flowcharts and lots of explanations about the standards, as well as advice and links to other information. Use this portal to help guide your training efforts with your staff.


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