Holy Name Medical Center’s facility management team uses the CRx software system to ensure compliance with Joint Commission Elements of Performance.

Photo courtesy of Healthcare Facility Compliance Corp.

Holy Name Medical Center (HNMC) in Teaneck, N.J., is a comprehensive, 361-bed acute care facility providing technologically advanced and leading-edge care across a continuum that encompasses education, prevention, diagnosis, treatment, rehabilitation and wellness maintenance.

Nearly 1,000 physicians representing dozens of medical specialties provide personal attention in a culturally sensitive environment to help create an exceptional health care experience for every patient. HNMC has received a number of awards and accreditations recognizing its high-quality patient care, innovative treatments and revolutionary technology. However, like many other large health care organizations, HNMC also faced the ongoing problem of compliance preparedness.

The medical center sought a health care facility compliance software solution that could help to ensure that all Joint Commission Elements of Performance (EPs) were satisfied on time and that documentation was recorded and accessible.

HNMC chose HealthCare Facility Compliance Corp. (HCFCompliance) and its CRx solution to address all compliance requirements associated with the Joint Commission EPs related to Environment of Care (EC), Life Safety (LS) and Emergency Management (EM) standards. The medical center now can track hundreds of EP documentations, notifications, inspections, fire drills, rounds and interim life safety measures (ILSM) with a complete audit trail through one single program.

The goal of HNMC was to have an all-in-one compliance solution, yet not duplicate existing data. The CRx solution interfaces with Holy Name’s work order system, avoiding duplication of data. In addition, CRx incorporates a risk-analysis module based on the Joint Commission ILSM requirements, which in turn are based on the hospital’s specific policy.

Its dashboard shows and tracks deficiencies for every EP, due or past due. “The HCFCompliance CRx patent-pending software streamlined our daily rounds by eliminating our previous two-step manual system whereby we no longer capture the event and document it later,” explains Steve Mosser, Holy Name Medical Center’s vice president of facility management. “The CRx system allows us to accomplish all our daily tasks relating to EC, LS and EM more efficiently.”

HNMC says it can keep current by documenting the information at the time of inspection or at the time activities are performed. The medical center’s work orders are automatically created, with pictures and notes captured at the time of inspection. It then notifies staff if risk analysis is required and, if so, suggests ILSM-needed activities based on the risk-analysis results. When work orders are closed, inspection status is automatically updated and stops the ILSM. The dashboard reminds staff of required tasks, shows when tasks are completed, updates work orders and preventive maintenance data, and files and inserts information into the appropriate e-binders.

“As a newcomer to Holy Name Medical Center, I was amazed by the ease and extensiveness of the CRx solution,” says Scott Gorman, the medical center’s manager of safety emergency preparedness. “Having an interactive matrix, alerts, powerful reports, ongoing EP monitoring tools and complete inspection points for every asset is extremely beneficial. Now, having integrated risk scores that are applied to our specific risk-assessment policy, suggesting ILSM explicit actions, determining impact and providing full process documentation with a complete detailed drill-down capability to review inspections’ status, makes it an amazing, complete in-depth solution covering all compliance requirements.”

Stephen Bennett, director of plant maintenance, says the system is not only easy to use, but also was simple to implement.

“I was working with HCFCompliance from Day 1 on the implementation on the CRx solution at our facility and was stunned by the speed of the implementation and the adaptation of our team to the CRx solution,” he says. “Having the added ILSM modules makes it a straightforward full health care facility compliance solution. I have no doubt many health care facilities will soon enjoy the solution, while at the same time, benefit from the cost savings.”