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Top 5 Areas of Compliance for Healthcare Facilities Assessment

Written by Intellis | 10/18/18 8:45 PM

Compliance is a critical concern in every aspect of the healthcare industry, particularly in the maintenance of facilities. When accrediting organizations, like The Joint Commission, arrive onsite for surveys, they examine everything and anything that impacts patient care, and that includes facilities-related elements such as cleanliness, clearly marked and accessible exits, the facility's ability to minimize the effects of smoke and heat, safety equipment maintenance and so much more.

Top 5 Areas of Compliance to Watch for Healthcare Facilities Assessment

Healthcare Facilities Management teams must be proactive about these compliance concerns every day of the year. Once an inspection or survey is underway, addressing facilities-related deficiencies is too late.

 

 

How can you always remain prepared for prickly inspectors from the Joint Commission while also completing your daily tasks? Here, we discuss the top 5 areas of compliance to watch to stay compliant with the shifting priorities and regulations in the healthcare facilities management sector.

 

 

1. Be Prepared for an Emergency

With the increase in events such as natural disasters due to climate change, emergency preparedness procedures have become a top compliance concern—so much so that the Joint Commission recently rewrote its Emergency Management chapter.

How Changes in Healthcare Impact Facilities Management.

Now more than ever, it is imperative that healthcare organizations take stronger steps to provide a safe and resilient space not only for patients but also for staff and visitors. Rather than waiting for an extreme weather event to occur, it is better to draft a climate resilience plan now so that your health facility keeps its lights on regardless of the conditions outside.

Learn more about how we can help you to become a climate-resilient healthcare facility.

What to Watch:

Being prepared for any emergency is the key to equipping your staff with the knowledge and skills necessary to act quickly and efficiently when needed.

Benefits of FM Software on Emergency Preparedness:

  • Digitize and store emergency plans and procedures so your team can quickly access this information. This eliminates the need to look for a binder or try to remember procedures at the last minute.
  • Know what to test and when with automated preventive maintenance tasks and emergency-related work orders.

Instead of hoping that an emergency situation will not occur, be proactive and develop a plan. Having a plan in place ensures that others on your facilities team are confident in their role in the event of an emergency. Instead of relying on stacks of binders and papers, use mobile technology to make your compliance-required emergency protocols accessible and actionable.

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2. Infection Control

Your entire maintenance and operations team plays a role in infection control and disease prevention. According to an article in Health Facilities Management Magazine, “the health facility manager’s role in infection prevention and patient care has become increasingly more important as healthcare-associated infections (HAIs) have become a growing concern.”

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Effectively controlling the spread of infection in healthcare facilities requires optimal vigilance, even when dealing with the smallest tasks. It is essential to ensure that you have the right protocols documented and a methodology in place to demonstrate that you are putting them into action. Start by making sure that everyone on your team has access to the tools and training they need to track and manage compliance work so that you can mitigate risks.

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An article in Health Facilities Management magazine identified the top four most common facility-related infection control risks. These risks are critical because they present the highest risk to patients and have received increased focus from regulatory agencies.

  1. Improper pressurization and ventilation of sensitive patient areas
  2. Dust and contaminants from construction sites
  3. Legionella growth in utility and potable water systems
  4. Contamination of sterile compounds in hospital pharmacies

 

What to Watch:

  • Housekeeping
    • Train your housekeeping staff on current infection control standards
  • Legionnaire's
    • Develop a water management plan with processes in place to protect it 
  • Hand hygiene
    • Promote good hand hygiene on your team and throughout your organization 

Benefits of FM Software on Infection Control:

  • Identify high-risk patient areas with mapping technology and set parameters within your facility management system that require completing an infection control risk assessment (ICRA) before work orders are assigned.
  • Using FM software that incorporates mobile technology allows your team to snap photos of any areas of concern and attach images directly to work orders.
  • Program your platform to prioritize Life-safety-related concerns.
  • Set your FM system to schedule daily inspections in high-priority areas.

Ultimately, compliance regarding infection control is primarily about fulfilling your healthcare facility's mission to promote health and save lives. There is a clear correlation between facility management practices and patient health, so it is crucial to set standards and ensure that your team has the right tools in place for maintaining detailed documentation.

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Implementing an efficient infection control strategy backed by facility management software will empower your team with the necessary tools to ensure a safe and healthy environment so that you are prepared for every compliance inspection.

3. Fire and Life Safety

Fire and life safety compliance is mandatory for the Centers for Medicare and Medicaid Services (CMS). According to a recent article by Facilities Maintenance Decisions, "more than 100,000 fires occur in non-residential buildings every year... costing organizations billions of dollars in damages." Violations in this area, and all areas of compliance, can result in fines, lack of reimbursements, and even facility shutdown in extreme cases.

Find out how facilities management software streamlines HVAC and utility system maintenance, testing, and facilities inspections.

Further, the Joint Commission, CMS, and OSHA constantly update new standards and regulations, and it can be challenging to remain up-to-date. Therefore, this area is a top priority for protecting patients and staff. Following compliance codes and integrating them into your daily work orders and preventive maintenance plan will make inspections easier and prepare you for any issues.

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Fire and life safety directly impact the protection of patient health and safety and the health and safety of staff. Technology can help you stay in control of growing demands.

What to Watch:

  • CMS K-Tag violations
  • Interim Life Safety Measures (ILSM)
    • Ensure you have ILSMs and make improvements to stay current with evolving codes. 
  • NFPA codes and standards
    • Stay up-to-date on changes in NFPA codes, and ensure you pass these on to your team.

Benefits of FM Software on Fire and Life Safety

  • Quickly generate reports on all activities related to life or fire safety assets on demand for key stakeholders, including CMS, AO, and hospital administration.
  • Test and track life and safety protocols during mock compliance surveys.
  • A facility management system incorporating mobile technology, like FOUNDATION, allows your team to track inspections quickly and efficiently, take photos, and start maintenance work immediately.

4. Medical Gas and Vacuum Systems

Your medical gas and vacuum systems need constant supervision to ensure they function correctly and do not endanger anyone. The ongoing operation and maintenance of these systems for health facilities ensures they remain safe and dependable for patients who rely on them for survival. Training all staff members to be aware of compliance with these volatile systems will result in improved compliance and better patient care and safety.

What to Watch:

  • CMS standards
    • Familiarize your team with current information on the storage, temperature, disposal, and management of medical gas.
  • Staff Training
    • Keep your staff trained and up-to-date on new and evolving compliance codes around medical gas and vacuum systems.

Benefits of FM Software on Medical Gas and Vacuum Systems

  • Simplify tracking, management, and inventory of medical gas and vacuum systems with recurring tasks, automated PM work orders, and digital record-keeping.
  • Implement a mobile work management system to connect compliance codes with specific work orders.
  • Easily track mock compliance audits for equipment and processes for medical gas systems.

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These systems can mean life or death for patients who rely on them. The ongoing monitoring and regular maintenance of these systems greatly depend on healthcare operations. Implementing innovative technology like facility management software will make maintaining compliance more straightforward, efficient, and streamlined.

5. HVAC and Utilities Maintenance

Managing your HVAC systems is critical to your operations and compliance. When you can better manage the condition of your heating and cooling systems and make data-driven decisions about maximizing their performance, you'll be better prepared for compliance inspections.

What to Watch:

  • HVAC Maintenance
    • Track the maintenance of your HVAC systems
    • Manage air handling
    • Make decisions around repairing vs. replacing equipment components
  • Utility Systems Codes

Ensuring your HVAC systems are more compliant and efficient will reduce costs, calls, and complaints. Using technology solutions gives you the power to increase your efforts regarding HVAC and utility systems maintenance, making the work and reporting more manageable and more thorough.

Benefits of FM Software on HVAC Maintenance:

  • Track and document maintenance for better decision-making.
  • Use facilities management software, such as FOUNDATION, to monitor all maintenance, testing, and inspections for your HVAC systems.
  • Monitor Project Management tasks.
  • Generate reports on the health of your systems and share them with key stakeholders.
  • Make decisions backed by data about repairing versus replacing equipment.

The maintenance, testing, and inspection of your HVAC and utility systems is critical, and there is no room for error in meeting current health compliance codes and standards.

The Role of Technology in Healthcare Facilities Management

Technology and software solutions such as facilities management systems offer healthcare facility managers many opportunities to improve equipment uptime and increase operational readiness. With tools like FOUNDATION, a facility management and capital planning system, you can let technology do the busy work and long-range planning for you, such as monitoring compliance codes, documenting compliance-related tasks, developing renewal and replacement plans, and implementing mobile communication to increase efficiency across the board.

Mobile-enabled solutions, like FOUNDATION, are transforming healthcare facilities management. Traditionally, when a facility issue occurred and was reported, the facilities manager was required to make a trip to the site where the issue occurred, review the problem, and schedule the maintenance work to resolve it.

Today, mobile technologies, like tablets and smartphones, make it easy to simply take a photo of a problem, such as a cracked ceiling tile. This technology saves time for the facilities team because personnel can quickly view an image of the issue within their facilities management system and quickly evaluate the problem's urgency without taking extra time to visit the physical site.

The Intellis FOUNDATION Solution is an innovative platform that employs cutting-edge data collection, analysis, evaluation, and planning to equip your team with the correct data and insights. It empowers you to ensure compliance with shifting healthcare facility regulations and gives you the right insights to improve your organization's patient safety score.