Tools and articles produced by the Member Tools Committee help assist ASHE members with issues they face while operating health care facilities.
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What makes the American Society for Health Care Engineering (ASHE) unique is the openness of its members to reach out for assistance with obstacles plaguing daily operations, combined with its members’ willingness to share tips and tricks that worked well at one facility in the hopes of aiding another.
In 2017, ASHE’s Member Tools Task Force (MTTF) was formed to produce tools and articles to educate and assist members with issues they face on the job. Since then, the group has published at least three articles and an associated tool in each issue of Health Facilities Management (HFM) magazine.
For 2024, the MTTF has been promoted from a humble task force to a full-fledged ASHE committee, now referred to as the Member Tools Committee (MTC), and its number of articles and tools will increase accordingly.
Highlighted tools
The MTTF/MTC tools have a home on ASHE’s website at ashe.org/tools, where members can click on the “Compliance Tools” filter to access them or drill further down by topic. Several tools created by the MTTF over the past few years are highlighted here. They include:
• NFPA 99-2021 Risk Assessment Tool. The NFPA 99-2012 Risk Assessment Tool, was developed to help staff comply with the risk-based, patient-focused approach required by the National Fire Protection Association’s NFPA 99, Health Care Facilities Code. The tool contains three worksheets — “Systems,” “Equipment” and “Emergency Management.”
The Systems sheet is used to record critical rooms/areas in the facility, the systems used in that room (e.g., medical gas, electrical systems, information technology, water and HVAC) and the level of risk that is posed if any of these systems were to fail. The risk categories, as outlined by NFPA 99, are failure of the system or equipment: (1) is likely to cause major injury or death to the patient or caregiver, (2) is likely to cause minor injury to the patient or caregiver, (3) is not likely to cause injury but may cause discomfort to the patient or caregiver, or (4) will have no impact on patient care.
The Equipment sheet can be used to list the patient care equipment in the facility and rate each with the appropriate risk level category. The Emergency Management sheet is used to document the building category from the NFPA 99, Table 12.3, application matrix for each building. (Users should note that the Centers for Medicare & Medicaid Services enforces the 2012 edition of NFPA 99.)
• Life Safety Risk Assessment Tool. This tool can be used in conjunction with a facility’s interim life safety measures (ILSM) policy. If a manager finds themselves asking if an ILSM is necessary in a certain situation, it is best practice to go ahead and fill out the ILSM to determine if any mitigation measures need to be followed. In ASHE’s Life Safety Risk Assessment Tool, the user can follow the matrix to identify the risk tolerance for the specific issue by plotting the “Impact of Deficiency” and the “Severity of Occurrence.” The table on the bottom page shows examples of common life safety deficiencies to use for reference. These pre-populated examples can be deleted to use the table for a new assessment.
• Front Line Staff Participating in Design Process. This tool can be used in designing clinical areas to meet the needs of the end users. Often, clinical areas are designed with inadequate input from front-line staff. This leads to items being left out of the design or provided in the wrong location.
Tabs one and two of this tool can be used during project design meetings to track all the departments that will use the new space or be responsible for maintaining it. Tabs three and four can be used to track the items that will go into the space, the utility requirements for each item and who will be responsible for securing the items.
During the design phase, it is helpful to talk through each room type on the floor plan and every item that is needed for that room to function, down to the trash cans and paper towel dispensers.
• Temperature and Humidity Control Tool. A particularly challenging issue is compliance with temperature and humidity ranges in the perioperative services setting. This tool is a draft policy to foster communication between key stakeholders affected by temperature and humidity in a sterile setting and the effects on patient safety.
It is based on the 2019 white paper, “Humidity Control Events in Perioperative Care Areas,” by ASHRAE. The paper outlines the option of creating a multidisciplinary team to determine how to approach situations when the temperature or humidity falls out of range for extended periods of time.
This policy takes the pressure off the facilities management personnel on duty to provide clear, actionable steps that have been agreed upon by all parties. The framework of this policy can also be applied to any area sensitive to environmental concerns, including compounding pharmacies.
• Environmental Rounding Tool. This tool can be used while performing environmental rounds throughout the facility. The sheet is pre-populated with common deficiencies to act as a helpful master checklist to participants while conducting tours. The spreadsheet covers a multidisciplinary range from life safety and general maintenance to infection prevention, environmental services, safety, biomedical equipment and patient rights. Columns next to the deficiency keep track of additional comments, the name of the person or department assigned to correct the finding and status updates. Then, the top of the page allows the user to document the date, location and contact for the area to easily keep an organized file for each event.
The document can be used in the provided software format, or copied and pasted into a shareable format that allows the participants to collaborate simultaneously so the completion status can be updated in real-time.
• Hazard Vulnerability Assessment (HVA) Tool. In 2022, ASHE published an upgraded version of the HVA Tool that had commonly been passed around from facility to facility. Historically, HVAs were treated by facilities mainly as a requirement from their authority having jurisdiction, being filled out and filed in a binder just to check off the survey-readiness to-do list. Finally, a group of ASHE members reviewed the tool and decided to make a more useful version that could have a greater impact.
The key difference between the “old” HVA and this “new” HVA is that the new tool, which can be accessed at puts a greater weight on the “mitigations exercised within the past [five] years” column. The goal is to use this tool to create productive changes year to year. In other words, when using this matrix, if a facility’s highest-ranked risk factor is the same risk from the assessment conducted 10 years before, the organization needs to reevaluate this line item and place a higher importance on its emergency preparedness plan.
• Job Description Tool. In today’s competitive hiring climate, health care facilities professionals require an intentional, proactive strategy to gain an edge over other fields. To avoid losing talent, facilities managers also must develop a clear, objective career path for each trade that empowers employees to grow their respective skill sets and reach career goals.
Facilities leaders should regularly review and update their department’s job descriptions, similar to their management plan review process. “By updating outdated, inconsistent job descriptions with newly defined competencies and minimum required skill sets, both new hires and existing employees clearly understand what is expected of them. This, in turn, removes the guesswork from specific assignments for each trade, leading to less division and more collaboration,” according to the HFM article that introduced this tool in 2022.
This long-awaited tool provides examples of action-driven tasks that can be used when creating relevant job descriptions for facilities management employees, broken down into the competency categories of equipment and systems, survey readiness, infection prevention and control, time management, and customer and patient satisfaction.
• Training Plan Development and General Guidelines. “Ongoing education and training strengthens employees’ existing skills, helps them improve gaps in their skills, helps to retain current employees, enhances employee satisfaction, and provides valuable knowledge and skills that support them in their daily roles and responsibilities,” according to the HFM article that introduced this tool in 2022. The template is designed to help establish training guidelines for staff at every level of the organization, from new hires to those in management and supervisory roles. The document provides steps to identify gaps in the current skill set of the department’s members and lays out a clear pathway to implement and record progress for each employee.
• Lockout/tagout (LOTO) Tools. Proper LOTO practices and procedures safeguard workers from hazardous energy releases. Keeping forms and procedure documentation significantly helps to ensure that precautions are enacted and proper steps are taken throughout maintenance and servicing activities. These tools can help facilities managers kick-start that documentation process. The energy control procedure form records detailed information on lock usage, the specific equipment or machinery involved and the energy source being controlled. A lock inventory form, when used in conjunction with an energy control procedure form, can provide oversight of lock usage and control.
• Business Occupancy Survey Simplification Tool. The first step in a successful business occupancy survey is to provide up-to-date basic building information. ASHE members can access this tool to help conduct a self-assessment to determine the building’s current level of compliance for topics such as building separations, means of egress and other miscellaneous requirements.
• Managing Water Safety for Construction Tool. This infection control risk assessment (ICRA) tool is a decision matrix that provides water management teams with a means to assess any construction project and implement appropriate risk mitigation measures. The tool leverages existing core ICRA principles to establish a framework for water safety management during health care construction and renovation projects. Users can follow the axes of the matrix (“Occupant Risk Group” and “Distribution System Age”) to plot the scope of the project and follow the mitigation steps outlined for each result.
• Energy Gap Analysis Tool. As organizations set environmental sustainability commitments, health facilities engineers are being challenged not only to meet energy management goals but also to define how to manage the organization’s environmental footprint. According to the landing page of the tool, which can be accessed at ashe.org/energy-gap-analysis-tool, facilities managers can use this tool to assess the degree to which their teams have adopted various energy conservation measures.
With this tool, users can track progress to achieving specific sustainability goals and categorize each goal by the action-abilities of prepare; schedule; control; repair; audit; replace; planning, design and construction; or general sustainability. Further resources, training and opportunities to participate can be found through ASHE’s Energy to Care® Program at ashe.org/energytocare.
• Backlog Analysis Tool. This tool can be used to assess the current condition of a facility’s asset management program and benchmark the effectiveness of the current investment strategy. The spreadsheet allows the user to list each important asset in the facility, along with information relative to each, such as the asset’s age, condition and cost to replace.
Depending on the age and the condition of the piece of equipment, the spreadsheet will calculate the amount the facility should budget for equipment within the next five years, then in five to 10 years, in 10 to 20 years and so on.
The tool is designed to assist in budget requests for funding professional facility condition assessments (FCAs) and in gaining support for funding to implement cost-effective solutions for projects uncovered by the FCA. Creating FCAs is a best-practice strategy for facilities managers and requires excellent documentation to secure funding.
• Benefits of Predictive Maintenance (PdM). The Department of Energy’s “Operations and Maintenance Best Practices, Release 3.0 — A Guide to Achieving Operational Efficiency” estimates a PdM program can provide an 8% to 12% reduction in maintenance costs over a typical preventive maintenance program. This ASHE tool lays out steps for implementing a PdM in a facilities management department.
Getting involved with the MTC
American Society for Health Care Engineering (ASHE) members who are seeking an answer to an issue that doesn’t seem to have a published solution or, better yet, are interested in sharing a solution or idea with their colleagues should consider joining ASHE’s Member Tools Committee (MTC).
Three main components of the MTC include suggesting article topics and tools, participating in the review and editorial process, and authoring an article or tool.
Each fall, the MTC will collect topics and author suggestions from the ASHE community. Then, the MTC will hold a strategic planning meeting to lay out the topics and assign appropriate authors and article lengths to each topic for the following year.
Then, in each issue, Health Facilities Management magazine will publish two MTC feature articles (2,000 words with an additional 300-word sidebar); one Member Toolbox article (350 words), often with a related tool; and one Advocacy Adviser column (350 words).
In addition to sharing knowledge with colleagues, ASHE members who author feature articles can satisfy one of the requirements of their ASHE Fellow or Senior (FASHE/SASHE) applications.
ASHE members can view a list of MTC and other volunteer opportunities at My ASHE by clicking on “Volunteer Opportunities” under the “Volunteer” dropdown menu.
Jordan Plyler, SASHE, is the special project manager at Baptist Health Medical Center in Little Rock, Ark. She can be reached at jrnorthcutt@outlook.com.
