By Arthur J. Mahanna, Architect
In 1999 The Joint Commission (TJC) issued a revised Statement of Conditions (SOC) document that included a Building Maintenance Program option for Healthcare occupancies under the Part 3, Life Safety Assessment, questions 6I (new) and 6J (existing). This option provided hospitals scoring benefits for ten specific items prone to failure if they could demonstrate they had implemented an effective Building Maintenance Program (BMP). These included specific issues related to fire doors, smoke doors, corridor doors, smoke barriers, corridor walls, exit signs, egress lights, trash and linen chutes, ice and snow removal in the means of egress, and grease producing devices.
By their definition, if a hospital could show a 95% effectiveness rating for these issues, a BMP would be considered effective. What this really meant for example, was that if on the day of the Environment of Care (EOC) inspection, the hospital had a few exit signs burned out, a Requirement for Improvement (RFI) would not be received for each exit sign if you could produce the appropriate inspection and analysis information for a BMP on your exit signs.
For the next 12 years people analyzed, discussed, and microscopically dissected what TJC meant by 95% and the many different ways this data could be reported and managed. In many cases the emphasis was on how to get the scoring benefit rather than the actual reason for the BMP. As a result, the Centers for Medicare & Medicaid Services (CMS), and even some TJC Life Safety Code Specialist Surveyors, would not accept BMP as a legitimate substitute for 100% compliance at all times.
In January of 2009, TJC released its new Hospital Accreditation Standards (HAS) as part of their standards improvement initiative. While this new document mentioned BMP as an effective method for ensuring compliance, the scoring benefits were eliminated. On the surface this may have seemed like TJC was backing off the need for such programs, but in reality for those who truly had taken the BMP concept to heart, the value beyond scoring was clear. Not only does BMP serve as a valuable tool in reducing the risk of RFIs, it also can be used to support a hospital when RFIs and possible Conditional Accreditation become a reality.
In eliminating the scoring, TJC has actually opened up the use of this concept for many more items previously excluded from the BMP methodology. For example, in the 2009 Hospital Accreditation Standards, per Standard EC.02.03.05, “The hospital maintains fire safety equipment and fire safety building features.” Numerous tests and inspections are required, such as: quarterly testing of supervisory signals; semi-annual testing of valve tamper switches and water flow devices; and monthly inspections of fire extinguishers. In particular, items like these, with large volumes of devices to inspect and test, lend themselves well to the BMP concept. This also holds true for some items per Standard EC.02.05.07, “The hospital inspects, tests, and maintains emergency power systems,” e.g., battery operated egress lights, or Standard EC.02.05.09, “The hospital inspects, tests, and maintains medical gas and vacuum systems.”
In addition, if someone is inspecting traditional BMP items such as fire or smoke doors, why not add a check for unauthorized coverings and decorations or even unapproved protective plates at the same time the closers, latches, gaps and undercuts are reviewed?
Interestingly, fire walls were never part of the original ten BMP items. The reason given during the original BMP development process was that fire walls needed to be 100% compliant all the time. While this does emphasize the importance of maintaining fire walls, the words do little to actually ensure 100% compliance. Only a “process approach” to managing these items can truly reduce the possibility of failures and the likelihood of an RFI.
While a “process approach” can assist in the accreditation process with The Joint Commission, this methodology also fits quite nicely with the ISO 9001 standards adopted by Det Norske Veritas Healthcare (DNVHC), the new accrediting body approved last year by the Centers for Medicare & Medicaid Services.
Per ISO 9001, 0.2 Process Approach:
“This International Standard promotes the adoption of a process approach when developing, implementing and improving the effectiveness of a quality management system, to enhance customer satisfaction by meeting customer requirements.
For an organization to function effectively, it has to identify and manage numerous linked activities. An activity using resources, and managed in order to enable the transformation of inputs into outputs, can be considered as a process. Often the output from one process directly forms the input to the next.
The application of a system of processes within an organization, together with the identification and interactions of these processes, and their management, can be referred to as the ‘process approach’.”
An advantage of the process approach is the ongoing control that it provides over the linkage between the individual processes within the system of processes, as well as over their combination and interaction.
When used within a quality management system, such an approach emphasizes the importance of:
a) Understanding and meeting requirements,
b) The need to consider processes in terms of added value,
c) Obtaining results of process performance and effectiveness, and
d) Continual improvement of processes based on objective measurement.
NOTE: In addition, the methodology known as “Plan-Do-Check-Act” (PDCA) can be applied to all processes. PDCA can be briefly described as follows.
Plan: Establish the objectives and processes necessary to deliver results in accordance with customer requirements and the organization’s policies.
Do: Implement the processes.
Check: Monitor and measure processes and product against policies, objectives and requirements for the product and report the results.
Act: Take actions to continually improve process performance.
Note the similarities between a Building Maintenance Program and the “Process Approach” described in the ISO standards:
• “Planning” a BMP requires identifying the locations and quantities of fire doors, smoke doors, etc., within your facility and identifying what requirements should be evaluated for each item.
• “Doing” a BMP involves inspecting the requirements for each item and recording when a specific requirement is non-compliant.
• “Checking” a BMP involves reviewing findings and analyzing the survey results for problem areas.
• “Acting” on BMP results means that the 95% rule can still be used as a means of evaluating success as well as determining where improvements are needed. If the closers and latches on a particular set of fire doors continue to fail, you should determine the reasons for the failure and correct. Perhaps training staff that use carts is warranted. Or, if inspecting fire doors quarterly simply isn’t resulting in a 95% rating, then it may be necessary to conduct monthly inspections of fire doors, or perhaps monthly inspection of fire doors in certain areas.
Another critical aspect of a BMP’s success is your work order repair process. As described earlier, “An advantage of the process approach is the ongoing control that it provides over the linkage between the individual processes within the system of processes, as well as over their combination and interaction.” Another possible cause for continued failure of the same items over and over again is a failure to repair items. Since the BMP and work order repair processes are ultimately linked together, the BMP can help to determine the success of the work order repair process.
Regardless of the AHJ you choose now or in the future, a process approach that follows the ISO “Plan-Do-Check-Act” methodology and/or BMP will improve your quality management system and ultimately reduce problems in future accreditation surveys and inspections. BMP is alive and well for those wise enough to see its benefits.
