(7/2/2019)
All hospitals strive to establish and maintain a safe, functional environment, but 100% compliance is not as easy as it seems. Having an environment that provides the best possible care to patients is a common goal for caregivers and executives alike. However, many hospitals surveyed by the Joint Commission in 2018 were non-compliant with this requirement.
The surveys found the following top five requirements as “not compliant” for hospital accreditation:
- The hospital provides and maintains systems for extinguishing fires: 89% non-compliant
- The hospital manages risks associated with its utility systems: 79% non-compliant
- The hospital established and maintains a safe, functional environment: 74% non-compliant
- The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke: 73% non-compliant
- The hospital reduces the risk of infections associated with medical equipment, devices and supplies: 71% non-compliant
Don’t worry: This doesn’t mean these hospitals are unsafe or fire hazards. It means they are not reaching the Joint Commission’s requirements and benchmarks to strive toward.
The common theme here? Systems. Whether for fire safety or medical equipment, the systems that maintain and monitor them can require extensive testing and oversight. Hospitals sometimes turn to third-party vendors to manage these systems, but this is where inconsistencies can arise and lead to non-compliance. However, these snags can be mitigated to help hospitals reach compliance.
Efficient Reporting
Maintaining systems for extinguishing fires was the biggest compliance headache for hospitals in 2017. Maintaining building features that protect against fire and smoke hazards were also high on the list. Is a third-party vendor testing these systems in your facility? Although the ideal approach to all third-party-reliant procedures is to bring those in-house, it’s not often budget-friendly to do so just for fire alarm testing. So, what is the biggest problem with those third-parties? Reporting.
No matter the size of the hospital or system, it can take large amounts of time to receive testing reports – 30 to 60 days in some instances. However, any identified issues need to be addressed
immediately. When working with a third-party vendor for sprinkler or fire alarm testing, put a non-negotiable timeline in place for vendors to complete and share their reports as soon as possible. At the very least, have the vendor make management aware of any failures as soon as they are discovered or provide a daily field report so the appropriate interim life safety measures (ILSMs) can be executed at once to protect patients, staff and visitors before the full report.
Establish Consistency
It can be difficult to obtain consistent reporting from third-party vendors even in large companies with standardized protocols. Even simple pass/fail or response time measurements can be reported inconsistently from one location to another. It’s even more complicated when multiple facilities employ individual vendors separate from facilities in a different region.
Lack in consistency can lead to oversights, and hospitals should never go into a survey with a report that doesn't provide the appropriate or adequate information. For fire alarm, sprinkler and even med gas testing, work with vendors to provide consistent information across reports and locations. This may mean cultivating a stronger relationship with vendors to file reports in a new way, but it’s an investment of time that will pay dividends, especially when it comes to the next survey.
Find the Best Partner
Not every vendor is the best fit for every facility. It’s not wrong to recognize that fact and search for a new partner if necessary. Are consistency and reporting an issue? Look at how several vendors structure reports. Does the facility utilize four or five vendors across different reporting functions? Consider reducing the number of vendors. With a heavy reliance on reports, don’t forget to take the ability of a vendor’s technicians and the quality of their work into consideration – the report is only as good as their ability to fix what’s wrong. Again, budgeting could play a role here, but it is worth it to crunch the numbers to see which vendors perform the best with the best reporting for the best price.
It’s unlikely that every system in a hospital can be run in-house, but for the safety of patients and employees, the above elements should remain non-negotiable.