Documentation Organization

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. 

Life Safety Measures

Construction projects within a healthcare setting can create multiple impairments and danger to patient safety. From small repairs on building systems to complete renovation projects, facility managers need to ensure that their policies and procedures for managing all types of construction projects adequately protect the patients within their facilities. To do this, implementation of Interim Life Safety Measures (ILSM) needs to be assessed and utilized to prevent life safety issues. But how do you know when and where to use ILSM, and why should you? 

Interim Life Safety Measures (ILSM) are measures that are undertaken outside the normal operations of a facility to provide for the safety of the patients and staff within the building. Normal life safety measures and systems include things like fire suppression systems, fire alarm, and exiting pathways through stairwells or other means. When construction projects impede the function of those systems in such a way that could cause harm to a person in the event of an emergency, then Interim Life Safety Measures need to be taken. ILSM are incorporated into the project from start to finish and are usually the first thing done on a project and the last thing removed from a project. However, life safety issues do not only stem from construction projects; ILSM can also be used in the event of a breakdown in equipment or schedule maintenance on systems. 

When any suspected life safety concern arises, the first thing that must be done is to do an assessment of that concern. Ask questions regarding the work; will there be large amounts of debris or dust created by this work? Will any life safety barriers (walls, doors, etc.) be breached as a result of this work? Will this work impair any life safety systems, and if so for how long? Once information about the job is determined and assessed, then ILSM can be implemented per direction from your company’s policy. ILSM policy should be based on the guidelines from CMS and be easily identifiable such that when typical life safety measures are breached, what ILSM to be implemented are clear. 

CMS gives 14 standards for ILSM that should be included in company policy during work. These standards include things like no smoking during work, making sure exit routing is free from obstacles during work, and using temporary means of fire observation if fire alarm systems are impaired for more than four hours at a time. Again, use of these measures falls back to guidance by the hospital’s ILSM policy. This policy should clearly state what measures should be used and when they should be implemented. The standards from CMS should only be a baseline for measures against impairments of life safety systems, and hospitals should craft their own policies to follow during construction project. 

Once the decision to implement measures is made, these steps should be taken immediately and should be thoroughly approved before work takes place. During the work, measures should be monitored on a basis determined by the hospital’s ILSM policy. Some measures, like have a manual fire watch if a fire alarm system is down for more than four hours, should be monitored constantly by a competent person, either an employee of the hospital or a trusted contractor. Other measures can be monitored on a daily, weekly, or as-needed basis, as set out in the policy. 

As you can see, the most important aspect to correctly and safely used Interim Life Safety Measures is to have a complete and thorough policy written by the hospital that clearly states when and under what conditions ILSM must be used and implemented. Hospital engineering should work with risk management, hospital administration, and other concerned parties to make sure that this policy supports the protection of the hospital’s patients and staff when life safety systems are offline. 

Hiding in the Hot Tub

In September of 2019, thousands of people visited the North Carolina Mountain State Fair for days of fun and entertainment at one of America’s favorite pastimes. However, for over 100 people, their trips to the fair would turn sickening. According to North Carolina health officials, in the days and weeks following the fair, 124 people became sick and one person died with Legionnaire’s disease, a disease that causes pneumonia symptoms, including coughing, fever, shortness of breath, and can lead to breathing issues and death in vulnerable populations. 

What makes this outbreak so interesting is the nature of how the victims were exposed to Legionella, the bacteria that causes Legionnaire’s disease. Officials traced the outbreak back to a hot tub display set up at the fair. Legionnaire’s disease is not spread through direct contact; rather it is spread through the aerosolization of water that is infected with the Legionella bacteria. The combination of hot water, jets that create bubbles, and the open air display created the perfect environment for Legionella to thrive and infect the air around the display, which many people walked through during the fair. 

As a healthcare facility professional, what does this sound like? Water that circulates though hospitals and other healthcare facilities can create the same scenario found at the NC Mountain State Fair. Because hospitals serve populations that are at the highest risk for developing Legionnaire’s disease when in contact with Legionella, the CDC consider’s it essential that hospitals and nursing homes have water management plans in place to limit Legionella and other waterborne pathogens from growing and spreading in those facilities. 

These pathogens occur naturally in the environment, so the first line of treatment occurs at municipalities’ water treatment plants. But facility managers must also work to create policies and procedures that prevent these pathogens from entering the water distribution system. Contamination can happen during construction and renovation projects, where vibrations and water pressure changes can damage the bio film within plumbing systems, releasing existing waterborne pathogens. They can also happen in piping breaks, whether in the facility or to water main breaks that service the facility. 

Facility managers need to discuss these opportunities for contamination within their departments and create a unified water management plan on how to deal with those potential issues. Management procedures can include water sampling, ensuring adequate disinfection, maintain correct water temperature to prevent growths, and ensuring lines are flushed before, during, and after construction. By creating front line defenses against waterborne pathogens, facilities can stay ahead of contamination and reduce the risk to the patients under their care.