Clinical EAM 

Executive Brief

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When we think of Joint Commission audits, we often focus on the more exotic aspects of the healthcare environment like advanced clinical or diagnostic equipment, but a recent analysis suggests it’s the less flashy elements of theEnvironment of Care that are responsible for a substantial portion of typicalJoint Commission audit citations.

Taking Care of the Basics

According to a 2019 strategiesfornursemanagers.com article, the Top 10 Most-Cited Joint Commission Standards are:

1.     EC.02.06.01(maintenance of a safe environment), 56%

2.     EC.02.05.01(management of utility system risks), 53%

3.     IC.02.02.01(reduction of infection risk from equipment, devices, and supplies), 52%

4.     LS.02.01.20(maintenance of egress integrity), 50%

5.     RC.01.01.01(maintenance of accurate, complete medical records for all patients), 49%

6.     EC.02.03.05(maintenance of fire safety equipment and building features), 48%

7.     LS.02.01.10(minimization of fire, smoke, and heat damage via building and fire protection features), 46%

8.     LS.02.01.30(building features provided and maintained to protect from fire and smokehazards), 43%

9.     LS.02.01.35(fire extinguishment features provided and maintained), 43%

10.  EC.02.02.01(management of hazardous materials and waste risks), 36%

Tellingly, of the 10, all but two (#5 and #10) are the direct responsibility of hospital facilities management teams. You read that correctly: the team tasked with responding to clogged toilet calls is also responsible for 8 of the top 10 Joint Commission issue areas. While we tend to focus on the higher-profile clinical engineering teams and the critical work they do to maintain the safety of the equipment directly impacting patient care, the supporting facilities assets like air handlers, filters, doors, and fire safety equipment - however seemingly pedestrian or mundane - are just as important to Joint Commission auditors concerned about the overall Environment of Care.

Modernizing Rounds

Dissecting each item on the list above is unfortunately beyond the scope of this discussion, but it’s notable that citations in the most common 8areas can be reduced if the concept of “rounds” can be automated.  As the name implies, a facilities team“round” is similar to that of a physician. Instead of periodically checking on patients, facilities team members, during their rounds, inspect safety and other equipment, and identify any number of issues that may compromise patient and staff safety, or jeopardize aJoint Commission audit.  

Facilities teams that have yet to deploy modern software solutions often conduct rounds manually, relying on paper and technician hand-written notes; inefficiencies and errors therefore abound. To illustrate the concept of rounds and how they can impact a Joint Commission audit, let’s consider a typical facilities team effort that requires the round concept: inspection of Exit signs, which could number in the hundreds in atypical healthcare facility.  Using a legacy CMMS or otherwise antiquated maintenance management system, inspecting hundreds of Exit signs might require the generation of hundreds of individual work orders, and could even mean hundreds of pieces of paper.  Modern, cloud-based solutions are delivered with features that eliminate all that, replacing those hundreds of work orders with a single “round”; a single round…with hundreds of tasks.  The facilities technician can open that single work order, and make his or her way through each inspection via their mobile device, literally never generating a single piece of paper.  Each task – that is, each Exit sign inspection – has a short checklist that the technician completes on their mobile device (e.g. Is the Exit sign lit? Is there any visible damage to the Exit sign?).  Modern applications can show the technician how many they’ve completed, how many remain, and even track the amount of time the round is consuming 

Since modern software solutions are highly configurable, the round feature can be extended to handle frequent Joint Commission audit deficiencies.  Perhaps oxygen tanks are cited as unsecured, for example.  A round and associated checklist can be created for a technician to visit rooms in the hospital, identify if an oxygen tank is located there, and if so, if it’s properly secured.  If not secured, the technician can create a corrective work order on their mobile device to secure the oxygen tank.

As a related aside, a classic Joint Commission audit question that often stumbles healthcare organizations is: “demonstrate how you create a corrective work order when a technician finds a problem during an inspection or during a preventative maintenance activity.” Modern, mobile-enabled facilities management solutions have little trouble with this kind of audit request, while organizations using older or manual systems rely on the diligence, note-taking skills, and organization of the technician. Needless to say, that’s not the kind of answer that typically impresses auditors.

Modern Technology Enables Pro-Active Work

It’s likely the preponderance of the cited issues listed above are the result of overworked and understaffed facilities technician teams.  When organizations are overwhelmed, they have no choice but to prioritize work efforts, and in such environments, proactive inspection activities are likely to fall to the bottom of the list.  In one example familiar to the author, a company recently demonstrated a 45% reduction in facilities work order MTTC (Mean Time to Completion) after deploying a modern, cloud-based facilities management software solution.  This organization was now able to free precious technician resources to complete work that had gone neglected.  

As this short discussion suggests, healthcare organizations subject toJoint Commission certification may find that the benefits of deploying a modernCMMS replacement include a measurable reduction in Joint Commission audit citations. 

About the Author:  Ben Person is the vice president of product marketing at Nuvolo, a modern HTM software provider. Nuvolo invites readers to view an on-demand webinar that discusses the Nuvolo HTM solution in detail at nuvolo.com.