Compliance Reporting with SiteFM (CMMS)
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Transcript of Compliance Reporting with SiteFM (CMMS)
The Standard for Healthcare Facility
Management Compliance
Online Webinar Series
Compliance Reporting with
SiteFM Work Order Manager
Host: Martyn Buffler Vice President, Sales and Marketing Email: [email protected] Phone: 512-480-0883 x125 SiteFM
Faculty: Tom Zahorsky CHFM, CHSP-FSM Vice President of Client Services Email: [email protected] Phone: 281-362-1686 SiteFM
Agenda
Introductions (5 minutes)
Seminar (45 minutes)
Next Steps (5 minutes)
Q&A (5 minutes)
Housekeeping
We will be in webinar mode – all audio lines are muted
Questions? Enter them in your control panel
Thank you for joining us today!
About SiteFM
SiteFM is Exclusive to Healthcare
• Based in Austin, TX for 22 years
• Over 400 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 Ellis
Compliance Manager and
Fire Marshal
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 Vision
Environmental Monitoring & Asset Locating
SiteFM 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
Life Safety Drawing – Creation and Hosting SiteFM 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
We proudly serve many of the premier healthcare
networks in the United States.
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
and a SiteFM team member will follow up with you.
• SiteFM offers a free CMMS data analysis and or a review of
your Life Safety Drawings.
• Stay connected with SiteFM for future webinars.
•Sign up for a product introductions/demonstrations for:
- SiteFM Work Order Manager
- SiteFM Space and Life Safety Drawing Services
- SiteFM Vision – Asset Locating and Monitoring
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
• Review the focus areas scrutinized by the
Life Safety Code Specialist
• Review compliance strategies for each of
these areas
• Understand the value of Asset
Categorization
• Understand Performance Indicators
• Apply these strategies to the Environment of Care
2014 Focus EOC/Life Safety:
• LS.01.01.01 - Statement of Conditions
• LS.01.02.01 – Interim Life Safety Measures
• LS.02.01.10 – Building and Fire Protection
• LS.02.01.20 – Means of Egress
• LS.02.01.30 – Protection from fire/smoke
• EC.02.03.05 – Fire Safety Equipment
• EC.02.05.07 – Emergency Power
• EC.02.05.09 - Medical Gasses
Life Safety Code Specialists
The Life Safety Chapter
• LS.01.01.01 – Statement of Conditions
– SOC is complete
– Drawings meet requirements
– PFI’s are current
The Life Safety Chapter
• LS.01.02.01 – ILSM
– ISLM Policy
• Assure ILSM Assessment if not immediately corrected
– Evidence of Completed Assessments
– Evidence of Implementation (when appropriate)
The Life Safety Chapter
• LS.02.01.10 – Building and Fire Protection
• LS.02.01.20 – Means of Egress
• LS.02.01.30 – Protection from fire/smoke
EC.02.03.05 – Fire Safety Equipment
• NFPA 101 and TJC Standard EC.02.03.05 state the
required frequency of these tests and inspections.
These items must be 100% on time.
EC.02.03.05 Fire Safety Equipment and Building Features
EC.02.03.05 EP 1 * Supervisory Signals (except tamper switches) Quarterly
EC.02.03.05 EP 2 * Tamper switches & water flow devices Semiannually
EC.02.03.05 EP 3 * Duct, heat, smoke detectors, pull boxes, elect. releasing devices Annually
EC.02.03.05 EP 4 * Notification devices (audible & visual) Annually
EC.02.03.05 EP 5 * Emergency services notification transmission equipment Quarterly
EC.02.03.05 EP 6 * Fire pump(s) tested Weekly
EC.02.03.05 EP 7 * Water storage tank high & low level alarms Semiannually
EC.02.03.05 EP 8 * Water storage tank low water temp alarms (cold weather only) Monthly
EC.02.03.05 EP 9 * Sprinkler systems main drain tests on all risers Annually
EC.02.03.05 EP 10 * Fire department connections inspected Quarterly
EC.02.03.05 EP 11 * Fire pump(s) tested annually underflow Annually
EC.02.03.05 EP 13 * Kitchen auto extinguishing systems inspected (no discharge req) Semiannually
EC.02.03.05 EP 14 * Gaseous extinguishing systems inspected (no discharge req) Annually
EC.02.03.05 EP 15 * Portable fire extinguishers inspected monthly Monthly
EC.02.03.05 EP 16 * Portable fire extinguishers are maintained annually Annually
EC.02.03.05 EP 17 * Fire hoses hydro tested 5 yrs after install, every 3 yrs after that 5 yrs / 3yrs
EC.02.03.05 EP 12 * Standpipe systems tested with water flow Five years
EC.02.03.05 EP 18 * Smoke & fire dampers tested (fus. Links removed where applicable Four years
EC.02.03.05 EP 19 * Smoke detection shutdown devices for HVAC tested Annually
EC.02.03.05 EP 20 * All horizontal & vertical roller & slider doors tested Annually
EC.02.05.07 • The hospital maintains, tests and inspects
its emergency power systems.
EC.02.05.09
• The hospital maintains, tests
and inspects its medical gas
and vacuum systems.
Compliance Strategies
• The requirements for testing, inspection and servicing
will determine the strategy to be applied.
• Measured performance indicators where appropriate
• Detailed scheduling for enriched documentation
• Ownership of these planned actions is accomplished
through either strategy
Compliance Strategies
• LS.01.01.01 - Statement of Conditions
– To manage LS.01.01.01 create an asset with at least an
annual PM to review and update the SOC
– If numerous PFI’s are on file, create a PM to review the PFI’s
sufficient to assure that PFI’s are completed on time
• LS.01.02.01 – Interim Life Safety Measures
– Create an asset with a PM to conduct rounds
– PM can be “turned on and off” as needed (active/inactive)
LS.01.01.01
• Statement of conditions
LS.01.01.01
• Statement of conditions
LS.01.01.01
• Statement of conditions
LS.01.02.01
• Interim Life Safety Measures
– While not a scheduled activity, a schedule can still be leveraged
– Address the requirement for ILSM Assessment in appropriate PM Tasks
Interim Life Safety Measures Item Assessed Yes No N/A
A. EXITS
1. Are Fire Exits identified and unobstructed?
2. If #1 is “No”, has staff been trained on alternate exits?
B. HOSPITAL SERVICES
1. Is access to all hospital services maintained?
2. If #1 is “No”, is an alternate route identified and marked with signs?
3. Has staff been trained on the alternate route?
C. FIRE ALARM
1. Is the fire alarm system fully operational?
2. If #1 is “No”, has Fire Watch been implemented?
3. Is the Fire Protection (sprinkler) system fully operational?
4. If #1 is “No”, has Fire Watch been implemented?
D. SMOKE BARRIERS/PARTITIONS
1. Are smoke barriers, partitions and related doors intact?
2. Has a temporary smoke barrier been constructed of non-combustible material?
3. If #1 and #2 are “No”, has affected staff been informed?
E. FIRE FIGHTING EQUIPMENT
1. Have additional fire extinguishers been placed in the work area?
F. SMOKING
1. Is smoking prohibited in the work area?
2. Is it evident that construction personnel are complying with smoking policy?
G. STORAGE
1. Is combustible storage kept to a minimum?
2. Is the construction site free of hazardous materials over night?
2. Is work area cleaned at the end of each worked shift?
H. FIRE DRILLS
1. If Interim Life Safety Measures have been implemented, are fire drills doubled?
I. SURVEILLANCE
1. Have Hazard Surveillance rounds increased for work and surrounding areas?
J. TRAINING
1. Has staff been trained regarding all compromises of Life Safety for their area?
K. EDUCATION
1. Where major Life Safety deficiencies exist, have all hospital staff been educated?
ILSM rounds can
be made a daily or
weekly PM and
turned on and off
as needed based
on the ILSM
Assessment
Interim Life Safety Measures
Life Safety tasks
remind the user to
assess for ILSM
when a deficiency
cannot be
immediately
corrected.
Inspect all fire department water supply connections per NFPA 25, 1998 edition (Section 9-7.1) and verify the following: as follows: _____ Area surrounding Fire Department Connections are accessible and free of obstructions. _____ Fire department connection is adequately supported. _____ Cap is secure. _____ If cap was found to be loose or missing, inspect piping to assure no foreign objects have been emplaced. _____ Check the hose thread connection for damage. _____ Secure cap, with slight wrench tightness. _____ Repeat for each location. _____ Appropriate signage is in place. _____ Record problems found as a data reading _____ Close this work order upon completion of inspection. _____Open corrective work orders for any deficiencies not immediately addressed. _____ Assess for Interim Life Safety Measures if a deficiency is not resolved during the same shift as discovery. Completed by: _____________________________ Date: _____________________________________ Company Name: ____________________________ Test Results: PASSED - No Deficiencies: __________, or FAILED - Follow-up Action Required: _________
Compliance Strategies
• LS.02.01.10 – Building and Fire Protection
– 2 hour rated structures and openings
• LS.02.01.20 – Means of Egress
– Exits, Egress Corridors, Exit Passageways
– Egress illumination, Exit signs
• LS.02.01.30 – Protection from fire/smoke
– Non-rated and 1 hour rated structures and openings
– Hazardous Locations
Compliance Strategies
• LS.02.01.10 – Building and Fire Protection
• LS.02.01.20 – Means of Egress
• LS.02.01.30 – Protection from fire/smoke
– These are all addressed by the BMP.
– Think of the BMP as a Barrier Management
Program
Barrier Management and Egress Assets
Sub Category Floor Zone Name Frequency
Fire Doors Q
Smoke Doors SA
Corridor Doors SA
Corridor Walls A
Non-Rated Smoke Barrier Walls A
1 Hr. Fire/Smoke Barrier A
2 Hr. Fire/Smoke Barrier A
3 Hr. Fire/Smoke Barrier A
4 Hr. Fire/Smoke Barrier A
Rated Smoke Enclosure A
Non-Rated Smoke Enclosure A
Rated Haz. Location Enc. A
Non-Rated Haz. Location Enc. A
Rated Floor Assembly A
Exit Signs M
Exits M
Egress Lights Q
Unobstructed Exits/Halls M
Egress Control Gates A
Dryer Lint Removal Sys. M
Trash/Linen Chutes M
Grease Prod. Devices Q
Count
This done by scheduling
activities for each group of
similar items.
In addition to scheduled
work orders, reports in
SiteFM can provide
Measured Performance
Indicators for quantifiable
activities.
SiteFM facilitates recording
how many of each of these
are being inspected.
When completing a work
order from this type of
schedule, the number of
failed items can be entered.
The result is the level of
compliance or “score”
calculated on a
percentage basis.
Compliance Strategies
• Performance indicators are not always relevant
• For example, EC.02.03.05 provides no such leeway
• Services are either on time or not
• When the requirement is 100%, measured
performance indicators should not be used.
• Detailed scheduling, however, helps to assure 100%
compliance is maintained.
EC.02.03.05
• The hospital maintains fire safety
equipment and building features.
Although these are usually contracted,
scheduling PMs will help assure services are
conducted on time and provide management
level documentation through the SiteFM Report System.
By applying the filter of Category Fire Safety Equipment we can see the desired 100%
EC.02.05.07
• The hospital maintains, tests and inspects
its emergency power systems.
Emergency Power
• Emergency Generator Inspection – Weekly Inspection
• Emergency Gen. Full Load Test - Monthly Test
• Automatic Transfer Switch - Monthly Test
• Emergency Generator – Quarterly/Annual Maintenance
• Fuel Oil Supply System – Annual Maintenance
• Emergency Generator Load Bank - Annual Test
• Extended Full Load Generator Test 3 Year
• SEPSS Lighting – Monthly Test – (non-healthcare egress)
• SEPSS Lighting – Quarterly Test – (Critical)
• SEPSS Lighting – Annual Test – (both)
• Electrical Distribution System Infrared Scan – 2 Years
PM Tasks for the Emergency Power System
PM % Completion Report can be filtered by any
Type, Category and/or Subcategory for any date
range.
EC.02.05.09
• The hospital maintains,
tests and inspects its
medical gas and vacuum
systems.
Medical Gas Systems
• Medical Gas System Certification
• Medical Gas Alarm System – Annual Test
• Medical Air Compressor Maintenance
• Medical Vacuum Pump Maintenance
• Medical Gas Manifold Inspection
Medical Gas Systems Tasks
The Current Physical Environment Disciplines
• Safety and Security Management - EC
• Hazardous Materials & Wastes – EC
• Fire Prevention & Life Safety – already shown
• Emergency Preparedness – new Chapter
• Patient Care Equipment* - EC
• Utilities Management – EC – already shown
*Often in a separate application or reported by the contracted
vendor.
The Environment of Care
• Scheduled activities can include;
• Annual Evaluations
• Emergency Management Activities (HVA, etc.)
• Fire, Security and Emergency Drills
• Periodic Risk Assessments
• Statement of Conditions Review/Update
• Periodic Policy Reviews
• Environmental Tours
The Environment of Care
Carefully written
tasks are presented
in an organized
manner making it
easy to create
reminders that
provide guidance on
the conduct of EOC
related activities
• Measured Performance Indicators
• Percent compliance measured by the number of items being inspected verses the number found deficient
Performance Indicators
Performance Indicators Math
• Example: You inspect 100 exit signs and 3 are not
illuminated.
• The compliance level is 97%.
• (100-3=97, 97/100=97%)
Beyond Utilities and Life Safety
• Example: You conduct hazard surveillance rounds
with 40 probes on your checklist.
• 2 of these fail inspection.
• The compliance level is 95%.
• (40-2=38, 38/40=95%)
PM & Inspection Tasks in SiteFM
We then support these
Assets with over 200
pre-defined tasks that
include built-in Life
Safety and EOC
Management Expertise.
Inspection Tasks Detail
Where desired, the end user can edit the pre-defined tasks
or create their own.
Inspection Tasks Detail
Steps can be configured to require various types of input
to satisfy that task step as desired.
Safety and Security Management
• EC.01.01.01
• The hospital identifies safety and security risks associated with the environment of care.
• Patient Care Area Hazard Surv. - SA
• Non-patient Care Area Hazard Surv.- A
• Hazard Surveillance - Grounds
• Mechanical Area Inspection - A
• Patient Room Inspection - Q
• Fume Safety Hood Certification - A
• Laminar Flow Hood Certification - A
• Environmental Sweep
• Annual Evaluation of EOC Plans
• Safety Training - A
• Safety Management Risk Assessment
• Safety Officer Appt & Authority
• Safety Policy Review
• Safety Committee Agenda
Safety Management Scheduled Tasks
• Security Risk Assessment - A
• Security Director Appointment
• Infant Security System Test - Q
• Combination or Digital Code Change - SA
• Access Control System Test - Q
Security Management Scheduled Tasks
• Security Alarm Test - M
• CCTV System Check - M
• Infant Abduction Drill - Q
• VIP Security Plan Drill - A
• Security Drill - Q
Security Program
Security Program
Hazardous Materials Management
• EC.02.02.01
• The hospital identifies risks associated with the hazardous materials and waste.
• Hazmat Risk Assessment - A
• Hazmat Inventory - A
• Hazmat Audit Rounds - M
• Hazmat Training - A
• Personnel Exposure Monitoring - A
• Hazardous Waste Disposal - SA
• Manifest Review - M
Hazardous Materials Scheduled Tasks
Emergency Management
• EM.01.01.01
• The [organization] engages in planning activities prior to developing its written Emergency Operations Plan.
• Hazard Vulnerability Analysis - A
• Emergency Preparedness Plan Review - A
• Disaster Drill With casualties - A
• Disaster Drill - Without Casualties - A
• Hospital Callback Roster Audit - A
• Emergency Vendor Contacts Review - A
• Emergency Agency Contact Audit - A
• Emergency Equipment Inventory - SA
Emergency Management Scheduled Tasks
Joint Commission Specific Reports • Utilizes an external reference to relate the
EC standards and Elements of Performance to the Asset Sub-categories
• Reports are under the Compliance Reports menu
– Life Safety Surveyor’s Report
– Elements of Performance Report
When in survey, these reports will help address requests for information by the Standard and Element of Performance
• Any recurring activity can and should be
scheduled in the CMMS
• This provides several benefits
• Work order generation when it is time to conduct a task as a reminder
• Instructions on how to conduct an activity
• Documentation of the activity having been conducted
• Measured results, when appropriate
• An effective management process
Summary
Thank you
• Thank you for your time today
• We hope that you found it worthwhile
• Check our website for future webinars:
– www.SiteFM.com
• Encourage others to participate
Next Steps
• Please fill out the post-webinar survey!
• Sign up for a SiteFM product demonstration
and/or request a competitive proposal for:
•SiteFM Work Order Manager
•SiteFM Life Safety Drawing Manager
•SiteFM Vision
• Please share this information with your peers.
Thank you!
The SiteFM team…..
is hereby granted to
for participation in the webinar
Compliance Reporting in SiteFM April 17, 2014
Thomas A. Zahorsky, CHFM, CHSP-FSM
SiteFM – Compliance Management Software
____________________
Certificate of Training
Thomas A Zahorsky
The Standard for Healthcare Facility
Management Compliance
Questions and Answers
Tom Zahorsky CHFM, CHSP-FSM
Vice President of Client Services
Email: [email protected]
Phone: 281-362-1686
SiteFM
Martyn Buffler
Vice President, Sales and Marketing
Email: [email protected]
Phone: 512-480-0883 x125
SiteFM