Pre-construction risk management should center patients while still considering the impact to all stakeholders.
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Hospitals accredited by The Joint Commission are required to comply with Environment of Care Standard EC.02.06.05, which says an organization must have a process for assessing and mitigating risks before planned maintenance or construction work is performed. The standard also requires that the process can be followed when unplanned construction or maintenance activities would pose risk to patients, visitors and staff.
This process is referred to as a pre-construction risk assessment, or PCRA. The PCRA must include evaluation of activities that could pose a risk to building occupants, such as falling debris, vibration, air quality, utility interruptions, noise, infection control or interruptions of life safety features. However, the standard is not prescriptive and the look and feel of PCRA programs may vary from one health care organization to another. What is critical is that an organization’s program is effective, transparent and continuously improving.
Establishing an effective PCRA program
Whether a PCRA program is just being assembled or an organization is looking to fine-tune an existing process, there are key elements and stakeholder participation that are necessary. The term “multidisciplinary” is often used when describing PCRA team membership. In health care, a multidisciplinary approach works well in most cases and is often the norm for committee and task force work. Departments are interconnected directly and indirectly so the effects of disruptive work can have impacts where they were not intended. Suggested department representation or subject matter experts to comprise a PCRA team include: facilities, construction, infection prevention, security, public affairs, biomedical, nursing, environmental services and safety.
Certainly, others can be included as appropriate, and it is understood that not all health care organizations have individuals who fill each specific role. The point is that a successful PCRA program will have representatives that bring different perspectives and offer department-specific knowledge to ensure safe and uninterrupted patient care.
There are many environmental elements that fall under the PCRA umbrella based on the work being planned or needed to address an issue. A great way to ensure as many elements as possible are considered is to create a policy and checklist tools. A policy will help guide an organization on when the PCRA process will be used, how it will be managed, who will be responsible and how it will be enforced. Tools are required for just about any task in health care, and a PCRA process is no different.
Again, requirements for a PCRA program are not prescriptive in terms of implementation or assessment, but solid checklist tools are essential. A PCRA checklist should focus on patients because they are likely to be at the greatest risk of impact due to critical utility interruptions, noise, vibration or degraded life safety features. However, all building occupants must be included when assessing risk.
The PCRA tool should trigger other risk mitigation strategies when identified. For example, if planned work will require a temporary electrical shutdown affecting patients, a utility interruption plan will need to be implemented if viable strategies to avoid it are not possible. If a fire sprinkler system or means of egress are affected, an interim life safety measure (ILSM) plan must be put in place.
Arguably, the most key component of the PCRA is an infection control risk assessment (ICRA). The ICRA must establish the risk levels to patients, visitors and staff based on level of acuity or criticality; the types of space adjacent to the work being done; the type of work being done; systems that will be affected; and strategies to eliminate risks based on the assessment.
The American Society for Health Care Engineering (ASHE) has developed an ICRA program and has continued to improve the program and checklist tool based on evolving needs and lessons learned in the field. In fact, the ASHE ICRA 2.0™ has been released along with opportunities for training on its content and implementation.
An evolving concept to be considered in a PCRA is a project’s impact on domestic water systems. Hospitals are required to have a water management program that has its own set of conditions, including a multidisciplinary team dedicated to the program’s oversight. To support an organization’s water management program and its PCRA, a water infection control risk assessment (WICRA) might be considered. The WICRA looks at types of domestic water interruptions and designates strategies to mitigate the release of waterborne pathogens when breaches of the system occur, either planned or unplanned.
Continuous improvement of an effective PCRA program
As mentioned, ASHE has tremendous tools and resources that can be referenced, but refinement may be needed to accurately capture elements of a particular health care organization. Checklist tools should be flexible by design to allow continuous improvement.
A diverse and multidisciplinary team of subject matter experts along with customizable tools are a very good start to managing a PCRA program. However, a truly effective PCRA process requires an engaged team that is not afraid to ask questions or respectfully challenge proposed risk mitigation strategies. In other words, a multidisciplinary team that does not have input on the plan or opportunities to be involved in pre-construction risk planning suboptimizes its value and the value of the program. Therefore, it is imperative that PCRA team members understand their role with expectations that they are prepared and empowered to have a questioning attitude.
Construction professionals must be comfortable having assessments challenged and should feel equally as comfortable soliciting recommendations from the PCRA team. Team members can also suggest alternatives that support the work but may reduce unnecessary burden. For example, a project manager may propose an ILSM for reduced corridor width in a suite where it is not required nor does it improve safety. This is the type of proposal that a multidisciplinary team can discuss from all its various angles.
Routine and well-run meetings to review PCRA plans can be very effective in sustaining engagement, reviewing policy language and ensuring checklist tools are still valid, but they should never become unnecessarily burdensome. So, in those cases when there are no new agenda items for an upcoming meeting, cancel it. Who doesn’t love that once in a while?
Gordon Howie, MSPM, CHFM, CHC, is regional director of facilities and construction services at Mayo Clinic Health System in Eau Claire, Wis., and 2023 ASHE president.