When the news goes out that Joint Commission surveyors are at your hospital, do you start frantically searching for binders, folders, and any copies of recent inspections and work done that you can get your hands on in the hope that you will have what the surveyors request? Is your plan for documentation review to get a list of required documents and have all of your employees rifling through papers? Have you actually looked at your documentation recently?
When surveyors come on-site, they expect to be able to review the documentation that supports your statements that you have completed the required inspections and maintenance set for by the Standards for Accreditation. Surveyors can review either paper or electronic versions of documentation, but it must be in an organized and accessible way. This is where having a good documentation organization system is essential
As facility managers, you are responsible for over 25 different types of records that range from weekly inspection reports to yearly inventories. Keeping all these documents in order and easily accessible is no easy task. The first step to a successful documentation system is making sure that the actual work, be it inspections, preventative maintenance, or repairs, happens on time and correctly. If the work isn’t done, there can be no record of it.
Facilities can utilize information technology systems to help manage equipment and ensure that required maintenance occurs on-time. These systems, called computerized maintenance management system (more typically known as enterprise asset management or “work order” systems) help facility managers keep track of routine work that needs to be done on equipment as well as requests for repairs, improvements, or renovations that come into the facility department. By utilizing a CMMS, facility managers are taking the first step in ensuring they have adequate document management. These systems automatically create and store information on equipment, operations, and building systems that surveyors may want to review. For example, a surveyor’s request to review the last three years of inspections on fire extinguishers for a certain area can easily be output in a report format using the CMMS software. Going back to our first step, these systems can also be configured to keep an ongoing log of what equipment maintenance or inspections are due, making sure that you don’t miss a deadline.
However, these systems are not document organization systems on their own. These systems on serve to log when work was completed, with some pertinent details about that work (who it was done by, when, maybe how much it cost, etc). The second step to a successful documentation organization system is to figure out how to handle inspection reports, fuel logs, or other miscellaneous documents that are not necessarily part of a CMMS. For example, Joint Commission Standard EC.02.03.05 EP 11 states that fire pumps must be annually tested underflow. Typically this test is conducted by an outside testing agency who compiles the data created during this test and creates a graph that shows the pressure and flow results of the test. This graph is an easy visual to show the results of the testing, so it is an easy thing for a surveyor to ask for.
Since this information comes from a third party, it is not usually easy to add it to a CMMS. Therefore, the third step to a successful documentation organization system is to have some means of an electronic database to store these types of reports and information. This can be as complex as a purpose-built database software system or as simple as using Adobe Acrobat to create pdf portfolios that have all of the documents organized within folders for each Elements of Performance required. It is recommended that however you create your cache of documents, there is some kind of table of contents, or even better, a listing of bookmarks that allow for easy navigation back and forth between documents. Using the pdf portfolio method, you can also scan in other documents like work orders or invoices from contractors that show that a deficiency was corrected, so that all of your information is in one place.
By understanding the need for organization and utilizing these three steps in your documentation process, you can avoid fumbling in front of the surveyor or losing the one paper you need to avoid a finding. Being organized means being prepared, and being prepared in front of a Joint Commission surveyor is the most important step to a successful survey.
COREY JP CUNNINGHAM 