Documentation of ITM for health care facilities

As inspection, testing and maintenance evolves, documentation remains an important representation of the health of the facility.

Image by Getty Images

Health care facilities face the challenge of continual operation, so their systems must be dependable and reliable. Whether it’s electrical service for patient spaces, air that’s conditioned through air handlers, water in the sprinkler pipes or the generator ready to power the hospital at a moment’s notice, systems throughout the facility need to be ready around the clock.

Consequently, inspection, testing and maintenance (ITM) is imperative to continued functionality of devices and early identification of problems. ITM is not just a rule or requirement but a routine that keeps the building honest. It is how the team looks for early signs of trouble and fixes problems before they grow. It is how the hospital protects people and keeps services running.

Role of documentation

Authorities having jurisdiction (AHJs) use ITM documentation to get a sense of the history of the building when on-site for a limited amount of time and gain confidence in the facilities team’s attention to detail. Good ITM documentation reflects diligence, care and appropriate response when it comes to maintaining a facility.

For facilities teams, documentation can be a heavy burden. They manage staffing, budgets, emergencies and projects while also keeping equipment reliable. Writing things down can slip behind urgent calls. When hospital administration understands the importance of documentation, they can better support the facilities team.

When leaders give time, tools and structure for documentation, they show respect for the work and the people who do it. Then, documentation becomes part of the job, not extra homework. Over time, routine documentation turns into a live picture of building health, useful for daily decisions and long-term planning.

Leadership needs to understand the time and attention required to properly document ITM and support the facilities manager in meeting those expectations. Implementing recurring, self-sustaining documentation is a more successful long-term solution than a documentation scramble when facilities need to provide ITM records to AHJs.

Facilities managers should remember that documentation is not just a hoop to jump through for AHJs. It is the pulse on the health of the facility. They must use it as a tool to keep the physical environment thriving.

Successful standardization

Standardization of equipment, materials, procedures and documentation contributes to a successful facilities team across a health care system. Standardization means choosing a smaller set of equipment and materials that the team knows well and can confidently maintain.

It means familiar forms that staff can understand, even when supporting a sister facility. It means consistent labeling and simple, shared part numbers that can be referenced across the health care system. It means consistent training for facilities team members conducting ITM or consistent outsourcing to reliable third-party contractors.

Standardization is not rigid, and every facility has unique features. It leaves room for special cases when they truly matter. Revisions in the effort of standardization should ask: Does the change foster better communication, more consistent analysis of results or improve the efficiency of the ITM? If the answers are no, the facility should reconsider the reason behind standardization.

Documentation that is frequently reinvented or edited with the goal of standardization can cause confusion, frustration or missed details. Instead, facilities managers should take time to truly evaluate the differences in documentation between facilities and identify the hardships they may face with a change. Once a method of documenting ITM is standardized, revising it should only be done with substantiated reasoning.

Significant changes in the organization of individual forms or overall documentation should be accompanied by staff training. Summary sheets that outline the device inventory totals by building, the ITM dates within the current year and the number of devices that passed or failed can unify the documentation and strengthen confidence during a document review. Managers should proceed with caution, however; surveyors will compare inventory totals from year to year, gauge inspection intervals based on the summary sheet and request follow-up documentation for any failed devices.

All ITM documentation should include revision dates, referenced codes and standards, the person performing the ITM, actions/measurable steps and results. It is up to the facility or health care system to develop how to present consistent information. Changing forms or records mid-interval requires additional staff training or the facility risks missing information.

The format of documentation is evolving, and facilities managers need to evolve with it. Paper is simple, quick and resilient during outages, but efficacy is largely dependent on the facilities team. The handwritten notes and stacks of binders of past decades are being replaced with auto-generated preventive maintenance systems and cloud-based recordkeeping. Digital systems offer reminders, dashboards and long-term storage.

A hybrid model may work best — paper where it makes sense, and digital where it adds value. The goal is not to pick a side. The goal is to capture the truth clearly and consistently. While the landscape of documentation is varied, it’s important to establish a process that works for and can be sustained by the facilities team.

Staff training

Documentation is only useful when it can be understood. Information must clearly present the action performed and the results of the ITM. Facilities team members must be able to understand the “why” behind the ITM action. When staff understand that a pressure reading affects patient safety or that a log trend shows a fan failing slowly, their attention sharpens.

New staff members should be trained on ITM procedures using videos or guides from the manufacturer. Managers should let new team members shadow experienced team members when performing ITM, utilize the American Society for Health Care Engineering’s Quick Training on-demand learning or provide access to third-party instruction.

When staff receive documents from third-party inspectors, it is imperative they ensure the results make sense. Are all components filled out? Is the recorded information within the defined acceptable ranges? It may be helpful to have staff members witness at least one ITM iteration performed by the third-party inspector to confirm all documented steps are understood. When third-party inspectors perform the ITM, the in-house team still owns the outcome.

For ITM activities performed in-house, managers should format the documentation to reduce burden on the facilities staff. Forms should be clear, with answers that are easy to mark correctly. For example, in weekly visual inspection forms, reviewers can scrutinize yes/no prompts where both “yes” and “no” are correct answers depending on the question. This creates a risk of selecting the wrong answer, misunderstanding the prompt or creating hurdles when managers review the task.

In a weekly fire pump inspection, “Are pump discharge, suction and bypass valves fully open?” has an optimal answer of “yes,” whereas “Are any leaks observed?” has an optimal answer of “no.” Instead, prompts can be phrased so all answers are either “yes” or “no.” Thus, in the previous example, the latter question could be changed to “Is piping free from leaks?” to align the correct response to “yes.”

This allows managers to quickly review documentation and follow up with items that are out of compliance. Remember, if a form changes, the change should be communicated to staff, not discovered by surprise. Forms in paper and digital formats should look and flow the same way. Every ITM record should answer five simple questions: Who did the work? What was done? When did it happen? Which standard was applied? What was the result?

Closing the loop

ITM will inevitably result in identification of failures. No facility is expected to have perfect results; in fact, ITM documentation with no failures may draw suspicion from AHJs. Good documentation will show that a failure is identified and continues to show how it is resolved.

When an item is found to be out of compliance, the organization must act promptly. Associated work orders, scheduling emails with third-party vendors and a summary of the repair can all contribute to how a facility documents a repair. And the repair is not the finish line. The team must document the retest of the system to confirm that the repair worked. They close the loop by linking the initial inspection, failure, repair work order, retest and the final result.

Other documentation outside of direct repairs may be necessary when something fails. A risk assessment should be conducted to determine whether the deficiency poses a safety concern and to identify appropriate mitigation strategies. If life safety is impacted, an alternate life safety measure must be implemented per the facility policy. These may include extra rounds, temporary equipment or added signage, and are intended to be temporary mitigation strategies rather than permanent fixes. The actions must be documented and communicated clearly with affected occupants and staff.

For quality control, another team member should periodically review documentation. Administrative staff can review forms to ensure all components are filled out before filing the paperwork. Managers can perform a competency review to ensure results make sense. It’s just as important to dig into the details as it is to step back and globally assess, “Do these results make sense?”

If questions are raised by employees in the organization, even more questions will be raised by AHJs. These reviews should be quick and engrained in the facility process rather than as another burdensome task for staff. An annual in-depth document review, either in-house or conducted by a third-party/mock surveyor, is essential. To offer unbiased feedback, the person who conducts the review should not be involved in the reports on a regular basis.

The document reviews should confirm the following:

• ITM dates occur within prescribed inspection intervals.
• Prompts/form fields are not missing information.
• Documented data is not outside of set acceptable ranges.
• Signatures/approvals are provided.
• Failures are provided with follow-up documentation/work orders.

Codes, standards, manufacturers and asset history all impact required ITM intervals. Accrediting organizations stipulate the intervals and establish acceptable grace periods. Some organizations alter the definitions beyond the code minimums. If inspection intervals are missed, facilities managers should own it, provide substantiation (if applicable) and adjust the internal process to ensure it does not happen again.

Facilities managers may consider shifting inspection timing (earlier but never later) to better align with the available facilities resources.

For instance, health care facilities staff may find it difficult to properly perform all testing if all quarterly tests are due within the same 30-day window. Instead, facilities managers should document the burden, outline which devices will be adjusted, conduct testing of such devices earlier in the quarter and provide continued documentation with the new timeline.

The facility needs to establish confidence in the testing intervals between adjustments, and such adjustments may be iterative processes over years to optimize the ITM schedule.

Facilities managers should treat the annual review like a survey document review. They should ask questions and challenge discrepancies. Managers also should prepare key staff members who perform the ITM to answer questions regarding their paperwork and show their repair process.

Digital work order systems can file reports automatically, but facilities staff need to know how to retrieve asset history during a document review. Some facilities have dedicated support staff that handle hard copy documentation filing or receive reports from third-party contractors.

Facilities managers should exercise caution if all documentation organization and literacy falls to one person. Annual reviews can highlight whether additional training is needed to ensure enough team members can access the requested documentation. Documentation navigation and communication are key to confidence during a document review.

Steady actions, honest records

A building’s history is written in steady actions and honest records. ITM documentation can identify trends that signal problems early, before they become failures. Each task may seem small on its own, but together they create a safe and steadfast patient environment.

The following small, steady habits create reliability:

• Write things down right away.
• Keep forms simple and consistent.
• Store records in shared locations.
• Review forms once a year and update accordingly.
• Pair new staff members with experienced mentors.
• Observe at least one contractor inspection.
• Standardize parts and platforms where it helps.
• Tell the truth in records and link the follow-up.

ITM documentation is not about binders, checklists and “gotcha” moments. It is a story about the people who take care of a building so it can take care of others. It ensures spaces are safe, systems stay ready and patient care can continue without disruption — 24 hours a day, seven days a week and 365 days a year. 

Related article // New construction considerations

A new building can seem like a solution to the perpetual problems of aging infrastructure. However, they come with their own challenges, and facilities teams may not be included in the design choices of development teams.

Facilities managers should advocate for facilities staff to be part of the design and construction of a new building. Building tours, witnessing commissioning or attending installations by the construction team will help ensure the team running the building starts off on the right foot for inspection, testing and maintenance.

Commissioning is a facility’s original record and may form the basis of design for the life of a device (e.g., fire pumps). Managers should ensure facilities staff can review and understand all commissioning documentation and ask questions of the design team or installation contractors before project completion. Newer features, such as self-diagnostics, can reduce the preventive maintenance burden, but managers should ensure facilities staff know how to maintain the newer devices. Some staff may be skeptical of devices or equipment they are unfamiliar with.

New construction often brings in new codes. Managers should consider all the codes that apply in a specific municipality, which often differ from the codes adopted by accreditation organizations, or whether corporate standards or insurance providers have more stringent requirements. Facilities must meet the most restrictive code, but differences should be clearly documented.

Approximately one year after occupancy, facilities teams should revisit the original design intent to confirm systems are operating as intended. A post-commissioning review identifies performance gaps, inefficiencies or drift caused by operational practices, environmental changes or equipment wear.

Comparing current performance to original commissioning benchmarks helps determine whether adjustments or retuning are required. Without this step, systems can gradually move away from design parameters, increasing energy use, reducing reliability and driving higher life-cycle costs. Proactive post-commissioning protects the original investment and ensures long-term operational value.

Back to Member to Member series

Allison Ellis, PE, PMSFPE, is director and co-owner of Koffel Compliance LLC in Columbia, Md., and Khuong Huynh, CHFM, CHC, SASHE, is assistant vice president of facilities at Penn Presbyterian Medical Center in Philadelphia. They can be reached at aellis@koffelcompliance.com and khuong.huynh@pennmedicine.upenn.edu.