Code compliance is changing, placing greater responsibility for the physical environment squarely on the shoulders of hospital administrators. 

Gone are the days when you could delegate facilities management entirely, without monitoring its current state and progress toward compliance and safety. Should a violation or accident occur, the fallout and financial hit that follows are ultimately your responsibility as a hospital executive.
In this issue, we share three essential tactics for ensuring your facilities team is survey-ready, identifies issues early, and avoids costly lapses.
What’s changed
With the adoption of the 2012 Life Safety Code ©, you can expect surveyors to take a much harder look at your hospital’s infrastructure and physical environment, as opposed to the nursing or clinical focus that was common in the past. Already, The Joint Commission is employing life safety engineers to perform the life safety portion of the survey.
On top of having trained life safety engineers going through your facility with a fine toothcomb, the environment of care also tends to be one of the most heavily cited parts of The Joint Commission code, simply because it’s easier for a surveyor to point out something that’s wrong with a building, rather than a person. Should a violation come to light, let us remember The Joint Commission has compressed the remediation timeline to just 60 days.

Your challenge
Perhaps your greatest challenge is that, outside of the facility director and some technicians, not many people truly understand how the physical environment impacts the code (and vice versa), how it all fits together, and what dollars and skills sets are needed to maintain it properly.


What you must do
1. Centralize & standardize your facilities documentation. 
When surveyors see reports that are disparate and uncoordinated, they interpret that as a sign of dysfunction. And it usually is. This is common in facilities managed by multiple entities.
Not only do disparate reports and processes make it difficult for you to get a clear picture of your physical environment, they also make it hard to pinpoint what’s falling through the cracks.
To counter those problems, direct your facilities team to use simple matrixes to track progress, in alignment with regulatory requirements. Also, ensure they review vendor reports on a consistent and timely manner. Often, vendor reports are missing signatures, codes or vital information that could jeopardize a regulatory survey. Other times, vendor reports identify a life safety issue that goes unread and ends up falling behind the remediation timeline.
Just as important, get familiar with that documentation.
2. Watch for industry survey trends. 
Identifying industry survey trends – common deficiencies and the focus areas for TJC – is a relatively simple way to avoid the same high-potential hits when a surveyor steps into your facility. It’s wise to leverage that intel to preemptively address common hits before surveyors show up at your facility.
Although, while looking at industry trends can provide a good indication of your survey success, it should not be used as a replacement for a thorough compliance review within your facility prior to any survey. 
3. Spread—don’t defer—maintenance. 
Historically, hospitals have nurtured a habit of waiting to address facilities deficiencies until 12–18 months before a survey. At that point, they’d throw money at problems in a mad dash against time to get everything ready for surveyors. And if surveyors identified an issue, facilities still had a generous grace period to fix it.
Now, with the shrunken remediation timeline, you’d have to throw a lot more money to fix problems within 60 days, if that’s even possible.
You have roughly three years between surveys. Use them. Spread out investments and improvement plans over that time, and avoid paying far more in violations and rush service fees down the road.


Keeping your facilities safe and compliant is a big job, and so are the consequences (financial and otherwise) of lapses and blind spots. No one expects you to become a facilities expert. But what is expected of you is leadership that’s involved and familiar with what’s happening in your physical environment.
If nothing else, ensure your organization is survey-ready by doing what needs to be done between surveys, so you don’t go into crisis mode when The Joint Commission comes your way.  For more information on how to prepare your healthcare facility for the next compliance survey, download our free whitepaper Pre-Audit Adaption: Ensuring Daily Joint Commission Compliance.