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A facility professional new to a hospital has just been told by the CEO that the facility has been in its “Joint Commission window” of 18 months from the previous survey for the past year.

Although familiar with The Joint Commission survey process, the facility manager has no idea whether the hospital is ready. What could be done in a short time  to prepare, knowing that the surveyors could be on-site next week? What should be the priority?

A well-designed survey-compliance program will enable this facility manager to be prepared well ahead of survey time.

Tracking compliance

Whether managing a critical access hospital or a multifacility system, compliance must be tracked. The Joint Commission has published a documentation checklist, but it is much better to build an annual plan with dates to add to the hospital’s computerized maintenance-management system (CMMS) or a calendar to be viewed and used often.

This ensures that the date time frames required for various environment of care (EC) testing intervals aren’t missed.

These date time frames can be found at the beginning of the EC chapter in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals (CAMH):

  • Every six years = 72 months from the last event, +/- 45 days.
  • Every five years = 60 months from the last event, +/- 45 days.
  • Every 36 months/three years = 36 months from the last event, +/- 45 days.
  • Annually/every 12 months/once per year/every year = one year from the last event, +/- 30 days.
  • Every six months/semiannually = six months from the last event, +/- 20 days.
  • Quarterly = three months from last event, +/- 10 days.
  • Monthly = 12 times per year, once per calendar month.
  • Every week = once per calendar week.

Health facility professionals should keep an eye out for The Joint Commission’s updates to the CAMH. The manual is available on The Joint Commission Connect website and e-edition.

When tracking this information for the first time, facility professionals should build a simple spreadsheet.

Across the top, and in columns, they should enter the calendar year’s timeline and include the intervals, excluding weeks. For each row, the elements of performance (EP) that require documentation should be listed. In each intercepting cell, the next EP compliance date should be entered. The last documented date should be referenced to build this tracking spreadsheet.

Facility professionals should put in the future date in line with the time frame for quick reference on the additional +/- days. They should think about items that would reduce cost. For example, during one of the semiannual kitchen hood tests, the fire alarm-testing company can be called out to prevent multiple trips. Also, facility professionals should have the hospital’s fire alarm-testing company document smoke damper functionality when testing the relays that activate the dampers (this only must be performed once every six years after the initial one-year test).

Once the plan is built, facility professionals should save and print a blank copy (or use a blank electronic version) to insert the actual date completed. They also should enter the planned dates into their CMMS or calendar. For subsequent years, facility professionals should obtain the latest CAMH in the fourth quarter of the calendar year and add, remove or relocate EPs as needed based on the changes. The tracking spreadsheet/tool should be considered a living document and must be maintained as such. 

When working with a multifacility system with centralized Joint Commission teams, facility professionals should add additional rows in various colors to give a comprehensive snapshot of the system. This tool is also beneficial for multifacility systems that use the same vendor across several campuses. Professionals can communicate the scheduling plan with the hospital’s vendors by hosting a joint meeting well in advance of the required testing timeline. Vendors should be asked to schedule the planned testing dates for the next year and beyond in their scheduling system. When the facility manager and supporting team are engaged proactively, the hospital is in a better position to mitigate risk. 

This planning process also works well for fire drills using The Joint Commission’s Fire Drill Matrix Form, which can be accessed by ASHE members. Facility professionals should build out where and when fire drills will be performed for the year and offer windows of time for these drills in case the team is working on a higher priority at the time of the planned drill. They should be sure to make the plan reasonable and account for some flexibility.

Timeliness and planning are critical to a successful survey. EPs are assigned a required time frame and, once out of compliance, the hospital will be cited by The Joint Commission.

Testing and inspection

One of the most difficult areas of compliance is testing and inspection, especially of fire alarm systems. It’s crucial for facility professionals to have processes in place. For a start, they must inventory, inventory, inventory! If the hospital’s systems aren’t already inventoried, it’s difficult to “test the inventory.” When inventorying assets, facility professionals should use bar codes, QR codes or asset labels on all components required for testing.

Some components, like generators, are easy to inventory. Others, such as fire doors, dampers and fire alarm devices, are more difficult. Every smoke detector and maglock should be included. This involves thousands to tens of thousands of devices for most hospitals, but knowing which components the hospital has will save valuable time in the future. Also, an established baseline is necessary when explaining to the surveyor why the inventory numbers are changing.  

Facility professionals should remember to leverage the hospital’s systems. They or the hospital’s fire alarm vendor should download the fire alarm program to obtain a definitive inventory of devices. This also applies to building automation systems (BASs) that utilize direct digital control (DDC) technology. DDC simply means that the BAS is digital. Using this platform, for example, facility professionals can query and separate their smoke dampers. This won’t help with fire dampers as they are strictly mechanical, but it eliminates some of the labor. 

The hospital’s life-safety plans also should be reviewed. Have any walls been derated? Are all the doors and dampers still required? If not, they should not be included in the testing and maintenance inventory. 

There is a big debate over whether fire and smoke doors are considered “obvious to the public.” Fire-safety components obvious to the public that are no longer functioning as life-safety components must be decommissioned. This means removing UL labels from fire and smoke doors. If cited, facility professionals should consider asking the surveyor to point within the code where “obvious to the public” is defined. If the surveyor cites the hospital, a Standards Interpretations Group review and interpretation should be requested. 

This process is just the beginning of inventorying and doesn’t account for classifying high-risk utility inventory or developing alternative equipment maintenance (AEM) strategies as described by David L. Stymiest PE, CHFM, CHSP, FASHE, in an article titled “Risk and reward: Conducting alternate equipment maintenance assessments” in the July 2018 issue of Health Facilities Management magazine.

Facility professionals should build a process for tracking failed devices. Assuming testing, inspection and maintenance of the fire alarm is outsourced, for instance, they should have the hospital’s fire alarm vendor provide a list of failed devices at the end of every testing day. Facility professionals can reference the hospital’s Interim Life Safety Measures (ILSM) policy on how to address the devices that cannot be immediately repaired. They should find a way to link everything together. For example, below is the process for reconciling a failed smoke detector:

  • Create a work order in the CMMS and link it to the failed smoke detector asset number. Most CMMSs will auto-generate work orders for failed devices. However, if a facility’s CMMS won’t do that, the facility professional can simply reference the smoke detector asset number.
  • Create the ILSM assessment that is tied back to the work order number and the date of the ILSM assessment.
  • Issue the work order to the fire alarm vendor. When the fire alarm vendor creates the quote, he or she should reference the work order number and/or the asset number in the scope of work.
  • Once the repair is complete and the retest successfully passed, the fire alarm vendor should reference the quote number, work order number and/or the asset number on the invoice.
  • Depending on the hospital’s CMMS and its storage capabilities, all relevant documents should be attached to the asset and/or work order.

This process creates a timeline from failure identification to a successful retest. When multiple failures are encountered, facility professionals should follow the same process for each failure. If the hospital doesn’t have a CMMS or someone proficient enough to manage it, this process can still be accomplished through a basic spreadsheet. Facility professionals should find a way to track failures and then train the hospital’s facilities staff and vendors on expectations.

Facility professionals should document when devices are added to or removed from the inventory. Whether using a CMMS or a spreadsheet, they should include the asset number, device description, device location and the date when the device was entered into inventory or when it was decommissioned.

For larger facilities or multifacility systems with a CMMS team, new asset request forms can be created that include all necessary inventory data, date in service, model number, serial number and other information. Facility professionals also should create asset disposition forms to track when assets are taken out of commission. This way, a trackable document is maintained as inventories inevitably change from year to year. 

‘Cleanup’ policies

Facility professionals should verify that the hospital’s ILSM policy clearly outlines such definitions as “immediate,” “out of service” and others. The Joint Commission’s Life Safety chapter (LS.01.02.01) requires that Life Safety Code deficiencies are evaluated according to the hospital’s ILSM policy if they cannot be immediately corrected. By defining “immediate,” an established timeline for immediate repair is created.

Facility professionals should remember that various codes and conditions define “immediate” differently. For example, does a repair for which the technician needs to run to his truck for a tool mean that the repair is no longer immediate? The intent of the code should be evaluated. Does the deficiency create an imminent danger to occupants and how is “imminent danger” defined? When should multiple and similar assets be grouped into one ILSM assessment? What does “out of service” mean? Again, the intent should be evaluated.

Sometimes, code intent is clarified in newer editions of the code. For example, the National Fire Protection Association’s NFPA 72 2010: 10.19 discusses “system impairments” and “out of service,” but it isn’t until the 2013 edition that the committee clarifies in Annex A that, “Out of service is meant to be the entire system or a substantial portion thereof” (NFPA 72 2013: A.10.21.4). Facility professionals also should review the corresponding handbooks. The NFPA handbooks are invaluable when it comes to understanding the intent.

The Joint Commission’s Life Safety surveyor may disagree with the hospital’s interpretation of code and how the policy is written but, if the team is following the hospital’s policy, the surveyor likely won’t cite the hospital. Instead, the surveyor may provide verbal recommendations, which should be accepted willingly. These surveyors have extensive training and years of experience, and most are willing to help.

Finally, health facility professionals should build binders or electronic files that follow The Joint Commission’s documentation checklist. Life Safety surveyors are now required to review documents for 90 minutes. They have one intent — find issues with documentation.

Facility professionals should provide all the documentation needed to quickly go through the checklist and ask questions. The surveyor will allow for IOUs but, if the documents aren’t organized and ready for the surveyor, several people will have to be redirected because IOUs must be furnished before the surveyor completes document review (not all surveyors will accept next-day delivery). 

Plan well ahead

These tips offer a partial listing of how health facility professionals can prepare for a Joint Commission visit. The key is to look at each EP, the corresponding survey process and plan it out well ahead of survey time.

Joshua Brackett, PE, CHFM, is special projects manager for facilities management for Baptist Health in Little Rock, Ark. He can be reached at