Established, formalized processes that ensure everyone is on the same page will help organizations realize continual improvement.

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Health care facilities management has evolved over the past several years due to the introduction and implementation of the International Organization for Standardization (ISO) 9001 quality management system principles and how they have been integrated into the everyday activities of facilities professionals.

As a result, hospitals are moving away from an immediate one-time correction or Band-Aid approach of a physical environment nonconformity (i.e., finding) to developing, maintaining and continually improving sustainable processes by identifying, educating and involving all interested parties into their own quality management systems.

When utilizing the ISO 9001:2015 risk-based methodologies of reviewing the results of internal audits, monitoring the status of preventive and corrective actions, and evaluating the effectiveness of actions taken, continual improvement becomes ingrained into the culture of the organization and often becomes the mission, vision and values statement.

Top 10 findings

Most health care facilities consider as part of their quality management systems physical environment nonconformities identified by accrediting organizations that report survey results to the Centers for Medicare & Medicaid Services (CMS). The following 10 nonconformities were identified by DNV Healthcare USA Inc.-accredited organizations for 2022 and arranged from most to least common.

1. Items being supported by sprinkler lines (National Fire Protection Association’s NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition). Health care facilities are sometimes referred to as living ecosystems that evolve and change over time. Emphasis tends to be given to areas that are visible to the public and, unfortunately, areas not readily or continually visible to the public are often overlooked. Sprinkler piping tends to fall victim to this out-of-sight/out-of-mind approach. As a result, mechanical and support systems tend to be supported by sprinkler lines above the drop ceiling.

NFPA 13-2010,, states: “Sprinkler piping or hangers shall not be used to support non-system components.” What does this mean? Anything that is not a component of the piped sprinkler system cannot be supported by the piping, as it adds additional weight and can potentially cause the piping infrastructure to collapse, rendering it out of service.

When performing above-the-ceiling reviews during a survey, DNV surveyors will not cite inadvertent contact with piping. However, if electrical fixtures are attached to piping, HVAC ducting is pressing and bending a pipe, or low-voltage cables are zip-tied to a sprinkler line, they will be cited as a nonconformity during the survey and thus require a corrective action.

Why is this the most cited nonconformity? Typically, this requirement is consistently overlooked or not included during firewall inspections conducted by the individual organization.

2. No annual operating room training of fire and other hazards (NFPA 99, Health Care Facilities Code, 2012 edition). Health care facilities are high-risk environments. There are areas within health care facilities that are even higher risk, such as emergency rooms, labor/delivery, behavioral health units and the operating arena. These areas require a different level of planning, risk assessments and oversight than other areas of a hospital. In addition, emergencies never happen at convenient times or places and tend to occur at the most unexpected and inopportune times imaginable. 

NFPA 99-2012,, outlines the expectations and requirements for the orientation and ongoing fire safety and general safety protocols for this high-risk area in the hospital. When this nonconformity is identified, most often health care facilities managers are unaware of these very important requirements.

Although nonmedical emergencies in operating suites are unlikely, they are still possible, and with proper orientation and training, adverse and/or patient sentinel events will be kept to a minimum.

3. Compressed gas cylinders not individually secured (DNV National Integrated Accreditation for Healthcare Organizations (NIAHO®) accreditation standards). Formally a specific requirement in both NFPA 99 and the DNV NIAHO accreditation standards, this requirement has since been revised. NFPA 99-2012,, now states: “… cylinders shall be protected from abnormal mechanical shock ….”, whereas NIAHO PE.5, SR.5, states: “All compressed gas cylinders in service and in storage shall be individually secured …”

Given this difference in the standard requirement, health care facilities managers and staff are unsure which requirement should be followed. Whenever codes or standards appear to conflict with each other, the more stringent applies. In this case, the DNV NIAHO accreditation standard takes precedence, given that it is more stringent with the specific requirement to “individually secure” the compressed gas cylinders versus the NFPA 99 requirement to simply be protected from abnormal mechanical shock.

All too often, surveyors observe multiple compressed gas cylinders secured by a single rope or chain, commonly referred to as “group-chained.”

4. No monthly owner’s inspection of kitchen suppression (NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition). It is the responsibility of the owner of any fire-suppression system to ensure the equipment, devices and overall system are being properly maintained by qualified and/or licensed personnel. Most health care facilities are consistently compliant with the semiannual testing and inspection of the Ansul fire protection system from Johnson Controls’ Tyco products. However, a good percentage are overlooking the monthly owner’s visual inspection as required by NFPA 17A. This finding is typically a result of a lack of code compliance knowledge of the owner of the system.

5. Physical environment ligature risks (DNV NIAHO accreditation standards, ISO 9001:2015 and CMS Conditions of Participation). Behavioral health services are being provided at increased volumes that require an interdisciplinary approach and additional awareness of the unintended consequence of self-inflicted patient harm. Patients and families expect the health care services provided to be delivered in a safe environment to ensure that patients leave better off and healthier than when they initially presented themselves at the hospital. To ensure optimal success, health care facilities are focusing more on the physical space where behavioral health services are provided. This includes spaces that are free from the risk of “self-ligature” from a behavioral health patient.

How does this equate to a common nonconformity, including an immediate-jeopardy determination, condition-level finding or perhaps a different type of a process breakdown? In short, patients are put at immediate risk of serious injury or death if the patient is determined to have homicidal/suicidal ideations, placed in a room with opportunities to conduct self-harm through ligature and are not properly monitored by hospital staff.

As noted, this patient population requires an interdisciplinary approach that includes medical staff, nursing staff, social services, administration and engineering controls. From a physical environment standpoint, health care facilities managers are tasked with ensuring the actual physical environment is free of the opportunity to commit ligature. Examples include, but are not limited to, eliminating coat hangers, door handles, grab bars in restrooms or any other physical fixture that could support the weight of the patient.

All too often, this common finding results from any combination of improper patient assessments, incomplete or ineffective monitoring and physical fixtures present that create an opportunity for an adverse or sentinel event.

6. Fire/smoke barrier penetrations (NFPA 101®, Life Safety Code®, 2012 edition). All health care facilities are required to maintain effective smoke and fire barriers to prevent or limit the spread of smoke and fire. If a fire emergency occurs, the barrier management system is designed to allow the maximum amount of time possible for occupants to exit from a structure.

Facilities managers have referred to barrier penetrations as a never-ending game of whack-a-mole because, when penetrations are filled in and corrected, more pop up in a different area of the hospital. Why are these corrections not sustainable? The reason for this nonconformance is because an effective barrier management program is not in place, meaning a formalized process that approves, oversees, validates and follows through on penetrations in barriers before, during and after they occur. This is an example of preventive action versus a quick-fix triggered by the surveyor. Effective barrier management plans outline who is responsible for what, where it applies, when to follow up, how to verify closeout and other actions.

7. Loaded sprinkler heads (NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition). Sprinkler heads of water-based fire protection systems are required to be properly maintained as installed and designed to ensure they will operate as intended in the event of a fire. What does that mean?

NFPA 25-2011, 5.2.1, outlines the requirements for the visual inspection and minimal physical condition the sprinkler heads are to be maintained for compliance. Sprinkler heads are required to be visually inspected on an annual basis, and the heads are to be replaced if any of them show signs of leakage, corrosion, physical damage, loss of fluid in the glass bulb, loading (dust or debris) or being painted other than by the manufacturer.

The most common observation are sprinkler heads that are covered in dust and debris that results from high airflow relative to the location and orientation of select sprinkler heads. Meeting the annual comprehensive floor inspection requirement will identify and eliminate most if not all of these issues.

8. Inaccurate electrical box panel schedules (NFPA 70®, National Electrical Code®, 2011 edition). Per the 2012 edition of the Life Safety Code, the corresponding applicable edition of the National Electrical Code is the 2011 edition, which is also referred to as NFPA 70. This requires that all electrical panels have a current, complete and accurate panel box schedule, specifically in Article 408.4(A).

During the survey process, surveyors will perform a sampling and open various electrical panel boxes throughout the facility to validate whether a panel schedule exists and whether it is complete and accurate. The reason panel schedules are a common nonconformity is because one or all of the requirements are not met.

The most common observation is when a spare circuit is switched on and is hot, meaning electricity is active relative to the individual circuit. This indicates an inaccurate panel schedule and potentially puts the end user at risk of injury or death if someone is working on that circuit and turns it off, believing it is only a spare when it could be controlling critical patient care systems or equipment.

9. Inaccurate air pressure relationships (ASHRAE/American Society for Health Care Engineering (ASHE) Standard 170, Ventilation of Health Care Facilities, 2008 edition). One of the highest risk factors is the management and oversight of the ventilation controls throughout the hospital. Although countless requirements are in place for fire safety, more adverse and patient sentinel events occur every year in hospitals as a direct result of the mismanagement of ventilation controls. 

Imagine the potential risk to patients if an operating suite was negative pressure and not positive pressure. What if the dirty side of sterile processing was positive pressure and not negative pressure? Health care and health care-associated infections (HAIs) have received more focus and scrutiny due to the COVID-19 pandemic, but HAIs have always been a factor in patient outcomes. Proper ventilation in a health care facility is critical.

During the survey, the accrediting organization will ask how the hospital validates pressure relationships in accordance with ASHRAE/ASHE 170 or authority having jurisdiction equivalent. Additionally, surveyors will periodically check high-risk areas during an on-site survey with a tissue or smoke test. If the result of the spot check reveals noncompliance, a finding or citation may be issued.

Typically, the reason inaccurate pressure relationships are a common finding is due to a hospital not having a process to validate whether the ASHRAE/ASHE 170 standards are being maintained per the current applicable code.

10. No semiannual battery testing of fire alarm control panel (FACP) (NFPA 72®, National Fire Alarm and Signaling Code®, 2010 edition). Following initial acceptance testing of the fire alarm system, a commonly overlooked requirement specific to the national fire alarm code is the differing requirements for periodic testing of the backup batteries for the FACP. While several devices related to the fire alarm system require annual inspections or testing, the batteries that power the control panel during a power loss have differing frequencies, depending on the type of battery that is a part of the FACP. Lead-acid and primary (dry cell) batteries require monthly testing, but nickel cadmium and sealed lead-acid batteries require semiannual testing. This is common because of the misconception that all batteries are tested and inspected the same. It is important that health care facilities managers not only have a working knowledge of the components of the FACP but also an understanding of current applicable code books and updates to the relevant codes and standards.

Formalized processes

High-performing organizations balance planning, risk assessments, monitoring, evaluations and communication to ensure consistent outputs. Without formalized processes that ensure everyone is on the same page about what they are going to do before, during and after they do it, continual improvement will never be fully realized.

The background and philosophy of DNV Healthcare accreditation

DNV Healthcare USA Inc. is part of an international accredited registrar and classification society headquartered in Oslo, Norway, with additional support offices in Katy, Texas, and Cincinnati. The company currently has about 12,000 employees and 350 offices operating in more than 100 countries, and provides services for several industries including maritime, oil and gas, renewable energy, electrification, food and beverage, and health care.

In 2008, when DNV received deeming authority from the Centers for Medicare & Medicaid Services (CMS) to accredit health care facilities in the U.S., it forever changed how health care accreditation is performed. Instead of making one-time, short-term corrections after a finding from a survey, the DNV approach allows health care organizations to develop their own processes that comply with the CMS-approved DNV NIAHO® (National Integrated Accreditation for Healthcare Organizations) accreditation standards to focus on long-term sustainable preventive action processes to mitigate and minimize adverse and sentinel patient events.

Over the past 15 years, DNV Healthcare has grown to become the second-largest hospital accreditation organization in the U.S. and currently accredits and/or certifies over 800 hospitals. Its scope of services includes the accreditation of acute care, critical access and psychiatric hospitals. It also provides certification services for four levels of stroke and several other certifications. DNV anticipates final approval from CMS to accredit ambulatory surgical centers in late 2023 or early 2024.

DNV surveys are not a pass/fail test, there are no traditional scoring systems and no tipping points. Errors happen once, twice is a coincidence and three times is a pattern. There are exceptions but, for the most part, this is how DNV Healthcare surveyors evaluate the effectiveness of the process approach.

Successful accreditation of a health care organization is not based solely on the volume and type of nonconformities (i.e., findings) identified, rather the successful implementation of sustainable corrective action processes to emphasis continual improvement and to prevent the recurrence of similar nonconformities in the future.

About this article 

This is one of a series of monthly articles submitted by members of the American Society for Health Care Engineering’s Member Tools Task Force.

Brennan P. Scott, CHOP, CHFM, is program manager for acute care/critical access hospital services, head of surveyor development and educator/trainer for DNV Healthcare USA Inc. He can be reached at