The Standard for Healthcare FacilityManagement Compliance

Online Webinar Series

EOC Annual Evaluation of the Management Plans

for the Physical Environment

Host:Martyn BufflerVice President, Sales and MarketingEmail: mbuffler@sitefm.comPhone: 512-480-0883 x125SiteFM

Faculty: Tom Zahorsky CHFM, CHSP-FSMVice President of Client ServicesEmail: tomz@sitefm.comPhone: 281-362-1686SiteFM

Thank you for joining us today!

Agenda• Introductions (5 minutes)• The Annual Evaluation Process (40 minutes)• Next Steps (5 minutes)• Q&A

Housekeeping• We will be in webinar mode – all lines muted• Please enter questions in the control panel • If you have technical difficulty press *0 for

operator assistance.

About SiteFM

SiteFM is Exclusive to Healthcare• Based in Austin, TX for 22 years• Over 425 facilities across the US using SiteFM• SiteFM Work Order Manager and Facility Drawing

Management• SiteFM Vision – Critical Asset Monitoring and

Equipment Location

Healthcare Facility Management Experience• Healthcare FM Experience on Staff• Partnerships with Industry Leaders• Compliance-Focused Solutions

“Technical knowledge of hospital operations, codes and regulatory standards, the IT design team, and customer support truly set SiteFM apart from other vendors. The management of a complex medical facility can be greatly enhanced by forming a partnership with the SiteFM team “

Northwest Hospital and Medical Center / UW Medicine

Jim EllisCompliance Manager and

Fire Marshal

SiteFM Customers – Over 400+ Across the US

Life Safety Drawing – Creation and HostingSiteFM will review and assist you with updating your Life Safety Drawings

Deliverables• Review of existing Life

Safety Drawings• Creation/Update to all

specified Life Safety areas• Printed Life Safety and

SOC floor plans, along with CAD files

• Free Hosting – Online web access

SiteFM Work Order Compliance

The latest mobile software technology is integrated in the NEW SiteFM program, providing unprecedented work order mobility and efficiency for all types and sizes of healthcare facilities.

SiteFM VisionEnvironmental Monitoring & Asset LocatingSiteFM Vision improves healthcare facility workflow, operational visibility and profitability by creating a healthcare based, scalable system with comprehensive asset locating and environmental monitoring.

This comprehensive system empowers hospitals to increase staff -facility efficiencies and improve documentation & reporting – while boosting customer service.

“95% of healthcare facilities utilizing RTLS have realized operational efficiency gains.”-Recent KLAS report

Value to Attendees• Please submit questions during the presentation to be read during the Q&A session at the end of the presentation• To receive a copy of the slides, fill out the post-webinar survey• SiteFM offers a free data analysis of your CMMS data•Sign up for a product introductions/demonstrations for:

-Work Order Manager-Facility Drawings-Area and Equipment Monitoring

at www.SiteFM.com.

Tom Zahorsky CHFM, CHSP-FSM

• VP of Client Services, SiteFM• 35+ Years in Healthcare Facilities Management• Former Joint Commission Life Safety Surveyor• Former OSHA Voluntary Protection Program (VPP)

STAR Worksite Coordinator

Faculty Background

Webinar Objectives

At the end of today’s program you will be able to discuss:• The purpose and value of the annual evaluation• Requirements for annual evaluations

– Objectives – Scope – Performance – Effectiveness

• The annual evaluation process• Impact on Safety and Operations

Purpose

• Determine effectiveness of program(s)• Measure progress towards goals• Organize the approach to Safety Management• Determine appropriateness of goals• Continue similar goals if appropriate• Establish new goals and measures• Provide a sense of direction

Value - Internally

• One of the most important internal Quality Improvement documents in the hospital

• Determines program effectiveness• Determines appropriate performance measures• Used to update Management Plans• Provides guidance for Safety Committee

Importance - Externally

• Insightful document for surveyor review• Indicates program effectiveness• Indicates understanding of process

Importance – TJC survey success

• From a survey success standpoint, the annual evaluation used to be required by one element of performance under one standard.

• Now, there are 4 standards and multiple elements of performance that relate to the annual evaluation process

Requirements

• Objectives• Scope• Performance• Effectiveness• Conducted in a timely manner• Put to use

How To - Objectives

• States the responsibility of the program(s) • A statement of what it is that is to be accomplished by

this plan• Comes directly from the Management Plan• Rarely changes from year to year

How To - Objectives Example

• To provide a fire safe environment for staff, patients, and visitors through a comprehensive program for the management of Fire Prevention and Life Safety systems, equipment, staff training and planned inspections, maintenance and service to related systems, equipment and building features.

How To - Objectives

• Specific actions planned to affect improvement• Objectives support program goals• Objectives should be measurable• Performance Indicators measure progress towards

specific objective• Objectives can change from year to year

Objective Examples – Fire/Life Safety Program

• Improve average staff performance on fire drills by 5%• Achieve specifically identified improvements based on

scores from the Building Maintenance Program for Life Safety.

• Monitor compliance with the Above Ceiling work permit and Hot Work Permit programs (new).

• Maintain consideration of the Statement of Conditions (SOC) at each meeting of the Environment of Care Committee by keeping it as a standing agenda item.

How To - Performance Indicators

• 100% Verification Testing-Yes or no, target 100%• Average staff score on fire drills, trended monthly• Improve fire door latching scores from 88% to at least

95% by changing frequency from semi-annually to quarterly

• Monitor number of Hot Work Permit program violations verses total number of permits issued(new).

• Provide summary reports of discovered Life Safety deficiencies and if they are work order correctable or will require PFI and or ILSM

Per

form

ance

Indi

cato

rs fo

r the

EO

C

Safety ManagementMonitor the knowledge of employees in the safety components of annual re-training. Test scores from each of the EOC Categories are at least 95% taken by random sampling.

  Safety Management  Employee Safety Management  Security Management  Emergency Management  Hazardous Materials and Waste Management  Life Safety Management  Medical Equipment Management  Utilities Management

National Patient Safety Goal Compliance RateInpatient Fall Rate (falls/1000 patient days) Employee Safety – Lost Time Injury Rate is Below State Average for SIC CodeEmployee Safety – Needle stick or other injury rate below prior year (per 100,000 worked hours)

Hazard Surveillance – percent of probes found to be in complianceProduct Recalls – percent of recalls and notices responded to by deadlinesSecurity ManagementSecurity Incidents per month by typeSecurity - % of CCTV system operational monthlySecurity – staff scores on security drillsSecurity – response time to events of different typesSecurity – number of incidents of different types compared to year priorEmergency ManagementEmergency Preparedness scored staff performance on drillsPercent of HRSA Grant Funded Supplies LocatablePercent of Emergency Contacts Valid During Random Test Calls (after hours)Hazardous Materials and Waste ManagementHazardous Materials % accuracy of MSDS books random sample Hazardous Materials & Waste – lbs. Infectious waste/patient day prior year comparisonFire Prevention and Life SafetyLife Safety – staff score at least 95% on fire drill performanceLife Safety – all staff participate each yearLife Safety – BMP compliance rates > 95%Medical Equipment ManagementMedical Equipment Management – percent PM completed monthlyMedical Equipment Management – percent repairs completed (m)Medical Equipment Management – average turn around timeMedical Equipment Management – User Error Rate as % of reported equip. failuresUtilities ManagementUtilities Management – percent PM completed monthlyUtilities Management – percent repairs completed monthlyUtilities Management – average response time

SiteFM™

How To - Scope

• A statement of what the plan is intended to manage• The people, facilities and equipment, as related to the

particular discipline being evaluated• Example: For the Fire and Life Safety Program, the

Scope could be stated as;

How To - Scope Example

• The Management Plan for the Fire and Life Safety Program applies to all hospital staff, contract staff, general and sub contractors, physicians, patients and visitors, and all buildings and grounds. The plan includes the management of Fire Safety Equipment, Life Safety features of the building, Interim Life Safety Measures, Life Safety drawings, staff knowledge of Life Safety Requirements, and the ability of staff to respond in the event of a fire emergency.

How To - Performance

• An objective evaluation of how the plan was managed in the prior year

• Relative to each goal or measure• What was planned?• What was done?• What did the performance indicators show?

How To - Effectiveness

• Did indicators show improvement?• Were goals met or exceeded?• If “yes”, then deem the process “effective”• If “no” then deem the process not as effective as planned• There is no “failure”, only opportunities for improvement

How To – Next Year’s Goals

• If no further opportunity for improvement is indicated (goal met), is continued monitoring required?

• If goal was not met, should efforts continue? • Was the goal reasonable? Adjust target?• Have new issues arisen that present an opportunity for

improvement?

The ProcessIdentify

Opportunities

Set Goals

Take ActionMeasure

Evaluate

When to Conduct Evaluations

• Evaluation sets the course for the Safety Committee• Must be the first undertaking each year• One extra committee meeting recommended• Sole purpose of meeting is review of annual evaluations

and setting goals for the coming year

When to Conduct Evaluations

• Example: Committee meets bi-monthly in the even months (Feb, Apr, June, etc.)

• Hold extra meeting in January• Each plan owner presents their evaluation to committee• Committee provides input, sets goals for coming year• Evaluations completed now Management Plans can be

updated

CMS

• Sec. 482.21 Condition of participation: Quality assessment and performance improvement program.

• (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

• The CMS COP (Condition of Participation) are not prescriptive in terms of the process

• Hospitals must have a process that they can demonstrate the effectiveness of

• The annual evaluation process makes sense but is more open in terms of the manner in which it is conducted

CMS

• The CMS COP (Condition of Participation) are not prescriptive in terms of the process

• Hospitals must have a process that they can demonstrate the effectiveness of

• The annual evaluation process makes sense but is more open in terms of the manner in which it is conducted

CMS

Det norske veritas (The dnv)

• PHYSICAL ENVIRONMENT (PE) • PE.1 Facility ……………………………………………………………………………………. 130 • PE.2 Life Safety Management System ……………………………………………………… 132 • PE.3 Safety Management System …………………………………………………………… 134 • PE.4 Security Management System …………………………………………………………. 135 • PE.5 Hazardous Material (Hazmat) Management System ……………………………….. 136 • PE.6 Emergency Management System …………………………………………………….. 137 • PE.7 Medical Equipment Management System ……………………………………………. 139 • PE.8 Utility Management System ……………………………………………………………. 140

Det norske veritas (DNV)

• The DNV relates directly to the CMS COP (Condition of Participation) are not prescriptive in terms of how this is done, however;

• Hospitals are expected to integrate the ISO 9001 Quality Management Process into their operations, including this process

• Accreditation surveys are conducted annually…

The Joint Commission

• EC.04.01.01 EP 15 – “every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan’s objectives, scope, performance and effectiveness (See also EC.01.01.01, EPs 3-8, and EC.04.01.03, EP 1)”

• EC.04.01.03 EP 1 – “Representatives from clinical, administrative and support services participate in the analysis of environment of care data (See also EC.04.01.01, EPs 3-6, and 8-15 and EC.04.01.05, EP 3)”

The Joint Commission

• EC.04.01.01, EPs 3-6… – “based on its process(es) the hospital reports and investigates the following;

• EP 3 – injuries to patients or others• EP 4 – occupational illness/employee injuries• EP 5 – damage to property• EP 6 – Security incidents• EP 8 – Hazardous materials• EP 9 – Fire safety issues• EP 10 – Medical/Laboratory equipment• EP 11 – Utility Systems

The Joint Commission

• EC.04.01.05, the organization improves its environment of care

• EP 1 – action is taken on improvement opportunities

• EP 2 –the effectiveness of actions is evaluated• EP 3 – P.I. results reported• EP 3 refers then to EC.04.01.03, EP 1; and

EM.03.01.03 EP 16

The Joint Commission

• EM.03.01.03 – The organization evaluates the effectiveness of its Emergency Operations Plan

• Rationale statement includes “the organization conducts and annual review of its planning activities”

The Joint Commission

• EM.03.01.03 – The organization evaluates the effectiveness of its Emergency Operations Plan

• EP 1 – annual HVA• EP 2 – annual review of scope, etc.• EP 3 – annual review of inventory process

The Joint Commission

• EM.03.01.03 – The organization evaluates the effectiveness of its Emergency Operations Plan

• EP 16 – the hospital modifies its Emergency Operations Plan based on its evaluations of emergency response exercises and responses to actual emergencies.

The Joint Commission

• Essentially, the objectives, scope, performance and effectiveness of each of the management plans must be evaluated at least annually.

• Include the EOP, HVA, EM Inventory Process • Safety and Security Risk Assessment • Though not listed in TJC’s Life Safety Chapter,

items addressed therein should be included in the Fire/Life Safety Management Plan and should be evaluated annually as before.

The Joint Commission

• Safety & Security Management (EC)• Hazardous Materials Management (EC)• Fire and Life Safety Management (EC,LS)• Medical Equipment Management (EC)• Utilities Management (EC)• Emergency Management Plan, HVA &

Inventory Process (EM)

The Joint Commission

Identify Opportunitie

s

Set Goals

Take Action

Measure

Evaluate

In Review

• Regardless of the accrediting body, the annual evaluation process is valuable

• Measures program effectiveness• Assures appropriate goals and measures• Provide a sense of direction to the

organization• Aligns with quality management processes

In Review

Seminar/Webinar Topics

• The partner presentation to this is our “Managing an Effective Safety Committee”

• The Barrier Management Program• Managing Life Safety Drawings• The Life Safety Code Surveyor• Register at www.SiteFM.com • These programs can be presented for your state

Healthcare Facilities Management association

SiteFM Work Order ManagerHelps you manage the EOC Process

• Full WO-CMMS with Compliance Management Features & Functionality• Mobile Component – Complete PMs and Inspections on Mobile Devices Real-Time• Comprehensive EOC Mgmt. Reporting Solution – Monitor & Measure what matters• Combines Inspection Software with your CMMS.• Provides valuable data for documentation and improvement.

SiteFM Professional ServicesA Healthcare Maintenance Management System is only as good as the system’s data.

Healthcare – CMMS

Implementation/

Data Conversion

Asset Tagging & Bar

Code Implementation

and Support

Space Allocation Cost

Report & Space Book

Life Safety Drawing

Creation

Free Hosting

Utility Management

Professional Services

Next Steps• Please fill out the post-webinar survey to request a copy of presentation.• Sign up for a SiteFM product demonstration for:

• Work Order Manager CMMS• Facility Drawing Management• SiteFM Vision – Critical Asset Monitoring and Equipment Location

• Please share this information with your peers.

Thank you!The SiteFM team…..

The Standard for Healthcare FacilityManagement Compliance

Questions and Answers

Tom Zahorsky CHFM, CHSP-FSMVice President of Client ServicesEmail: tomz@sitefm.comPhone: 281-362-1686SiteFM

Martyn BufflerVice President, Sales and MarketingEmail: mbuffler@sitefm.com Phone: 512-480-0883 x125SiteFM