Methodist Charlton Medical Center meets fire safety requirements with help from an outside vendor.

Before he found a better way to do it, preparing for the Joint Commission’s accreditation survey could be a test of will for Mike Lowe, director of engineering, Methodist Charlton Medical Center, a general acute care community hospital in Dallas.

A visit from the Joint Commission required that Lowe pull together reports on testing and maintenance of fire and life safety systems and equipment made by different vendors and turn them into one understandable, comprehensive report.

It was a time-consuming and cumbersome process that, to compound matters, took a few hours to review with surveyors because it lacked precision.

“We had a company that would test the fire pump and sprinkler system, another would test the fire alarms, somebody else would test the kitchen hoods,” Lowe says. The result was a disorganized, imprecise reporting system.

Lowe knew there had to be a better way. He turned to Siemens, which had been providing the medical center with fire alarm system testing and maintenance for more than 10 years.

He worked with Tracey Narveson, Siemens sales account representative, to create a customized building solution that includes an all-encompassing life safety management program and a health care accreditation program to meet Joint Commission requirements.

The program designed for Methodist Charlton ensures that testing, inspections, and preventive maintenance are performed on schedule and provides coverage when equipment failures occur.

The Fire Services for Healthcare Accreditation Program helps Methodist Charlton to organize, manage and track reporting requirements for accreditation. It includes a comprehensive documentation management system to ensure that all fire and life safety documentation is properly completed, organized and accessible.

Siemens helped to ensure that all of the necessary reporting requirements, including National Fire Protection Association (NFPA) standards, local fire codes, and state and federal health care accreditation standards for the Centers for Medicare & Medicaid Services, were documented and organized properly.

The company developed a binder with reports containing fire and life safety systems test reports that are standardized and customized to meet the Joint Commission’s documentation requirement of EC.02.03.05-EP25.

Lowe says the documentation is so good that it has become the industry standard, and any hospital that doesn’t produce it can invite closer scrutiny of life safety systems and equipment.

“The surveyors love it when the documentation is presented to them in a standardized fashion that makes sense and hits every one of the key points for accreditation,” he says. “They’re not looking for a needle in a stack of needles.”

When the Joint Commission comes in for a survey now, it takes minutes instead of hours to review reports, Lowe says. “We make it easy for the surveyor to ascertain within the first 10 minutes that we are on top of our testing and maintenance with a well-organized and thorough binder [containing documentation]. This sets a great tempo for the day,” he says.

Siemens works with the Joint Commission on how to improve the reporting process for future surveyor visits. The documentation and testing process also helps Methodist Charlton to meet requirements for the NFPA, state health department, local fire department or any other regulatory agency, he says.

Having one vendor perform the testing and maintenance, as well as organize the documentation, has proven invaluable for Lowe and his staff, he says. “It frees up hundreds of manhours [by] having someone else do the service work for us,” he adds.


HOSPITAL // Methodist Charlton Medical Center

NEED // Meeting Joint Commission fire and life safety requirements

SOLUTION // Siemens Fire Services for Healthcare Accreditation program