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

mailto:[email protected]


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.

http://www.cirrushealth.com/

http://www.nchmd.org/default.aspx?id=1&link=header

http://www.healthsouth.com/

http://www.baptisthealthsystem.com/

http://www.nshinc.com/

http://www.centerrehc.com/index.htm

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


• LS.01.02.01 – ILSM

– ISLM Policy

• Assure ILSM Assessment if not immediately corrected

– Evidence of Completed Assessments

– Evidence of Implementation (when appropriate)

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


• 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.01.02.01

• 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: _________



– 2 hour rated structures and openings


– Exits, Egress Corridors, Exit Passageways

– Egress illumination, Exit signs


– Non-rated and 1 hour rated structures and openings

– Hazardous Locations





– 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




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.


• 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

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



compliance reporting with sitefm (cmms)

Healthcare

hosting sitefm

life safety chapter

sitefm work order compliance

life safety drawing

specified life safety

sitefm team member

new sitefm program

x125 sitefm faculty