Untangling the Compliance Web

In the world of healthcare facilities management, keeping track of compliance documentation is an overwhelming task, especially when you consider the intricate web of regulations that must be followed. Dennis Ford, who manages Corporate Facilities Management at Atrium Health, knows this challenge all too well. With over 25 years of experience in healthcare facilities engineering, Dennis has seen firsthand the complexities that come with maintaining accurate and up-to-date compliance documentation.

The three key areas of healthcare compliance include Emergency Management, Life Safety, and Environment of Care. These chapters are crucial for Joint Commission compliance, and the documentation required for each is extensive and intricate.

To put things into perspective, the Environment of Care chapter alone has 189 codes, 87 of which require documentation. Emergency Management has 126 codes, with 33 needing documentation, and Life Safety includes 239 codes, 7 of which require documentation. In total, there are 554 codes to keep track of, with 127 requiring documentation. The sheer volume and detail of these requirements make compliance a monumental task for facilities managers.

When polled about how compliance documentation is managed, the results were telling: 47% of the participants maintain 100% of their documentation in binders, while 37% rely mostly on paper with some digital records. Only 16% of the audience is mostly digital, with some paper documentation. This poll confirmed what Dennis and many others in the field already knew: the reliance on paper is still prevalent in healthcare facilities management.

Obstacles faced by facilities managers who rely on manual, paper-based processes to maintain their documentation include:

• Updating policies and procedures across multiple binders, especially in a multi-hospital system where the same policies need to be applied uniformly. When one binder is updated, every other binder must be updated accordingly, creating a labor-intensive and error-prone process.
• Another significant issue is managing vendor-provided documentation. Often, this documentation isn't delivered in a timely manner or in the format required for compliance. This means facilities managers must spend considerable time reformatting and verifying documentation to ensure it meets regulatory requirements.
• Documentation must clearly show the specific version and date of the regulatory requirement being referenced, which adds another layer of complexity.

The differences in building codes across facilities can complicate things further. Not all codes are grandfathered when new versions are released, so it's essential to ensure that documentation reflects the correct codes for each building. This becomes particularly tricky in multi-hospital systems where different buildings may be subject to different codes.

Keeping track of voluminous documentation is challenging. At some facilities, Excel spreadsheets are used to outline the contents of the binders and track when documents needed to be reviewed or updated. This approach requires constant attention and can quickly become consuming, especially if left until the end of the year.

The sheer number of people involved in maintaining these binders is surprising. From facility management supervisors to safety and emergency management personnel, many hands touch these documents, each bringing their own perspective and potential for error. This makes it even more critical to have a system in place to ensure that nothing is missed.

“People need to grow up and get used to using computers and data banks. If the policies and procedures are stored in a central electronic location, when changes are made, everybody gets them. When requirements are met, everybody gets the information at the same time. TJC allows this method of managing documents and there are commercial sources,” said Leo M. Gehring, CHFM, CHC, FASHE, a Lead Faculty member in the ASHE Healthcare Construction Certificate, Healthcare Project Management and Certified Healthcare Faculty Manager Training Programs.

Collaboration and diligence are important in maintaining these documents. A missed date, even by a single day, can result in a finding during a survey, underscoring the need for meticulous attention to detail. There’s an undeniable connection between compliance documentation and building maintenance information. Documents required for Emergency Management, Life Safety, and Environment of Care all originate from the building maintenance documents. The real opportunity lies in efficiently storing and accessing this information. Without a better way to manage these documents, the problem of cumbersome compliance documentation will persist.

“Too many members of our profession see the compliance document as another set of requirements,” said Gehring. “I always counseled that the TJC and other guidance documents should be seen as the backbone of your plans and policies. You should only augment the outside documents with individual elements where guidance is needed on how to specifically accomplish the tasks,” he added.

While the healthcare compliance challenges are significant, there's hope that with the right tools and collaboration, the burden of compliance documentation can be lightened, allowing facilities managers to focus more on their primary mission: ensuring safe and efficient healthcare environments.

ARC Facilities helps healthcare organizations streamline and simplify the management of compliance documentation by offering a digital platform that centralizes, organizes, and automates the documentation process.

Download the Whitepaper here.