Complying with Joint Commission's Two Biggest Challenges

Indoor environments and building occupancies often create problems for healthcare facilities managers.

By Dan Hounsell, Senior Editor


Healthcare facilities managers face a complex challenge in ensuring their facilities comply with a range of standards and regulations. Among the most critical of these organizations issuing requirements is the Joint Commission, which plays a critical role in not only setting clinical standards but in making hospitals and other healthcare facilities accountable to monitor their performance against commission guidelines and to continuously improve.  

Kathy Neal, director of regulatory compliance with Medxcel, offers managers insights into compliance with two of the most challenging requirements from the Joint Commission. 

HFT: Which Joint Commission requirements related to facilities pose the most common challenges for healthcare facilities managers? 

Neal: For me, this is two areas: temperature and humidity in critical care areas; and off-site clinics’ business occupancies. 

HFT: Why are these requirements the most challenging? 

Neal: Control of temperature and humidity in an environment is based on a lot of factors: equipment supporting this, age of the equipment, and environmental conditions. Then throw in the requests from surgeons to lower the temperature in the operating rooms. 

Frequently, the clinical staff, including physicians, do not realize the relationship between temperature and humidity. Once you lower the temperature and the humidity rises, infection control now becomes part of the decision-making process. The Joint Commission issued the following update on May 9, 2023: 

"The Joint Commission references NFPA 99-2012 Chapter 9, that requires the use of ASHRAE 170-2008, Ventilation Table 7-1. This document provides allowances to exceed minimum temperature ranges. To use this exception, it must be done by following the established organizational policy. In accordance with the allowances, the policy or formal process must be limited to cases based on either surgeon, patient, or procedure. It is not acceptable to consistently maintain temperatures outside of the required ranges." 

This is not a blanket exception but one to be used on a case-by-case basis. Once the surgical procedure has been completed, the temperature is to be returned to the normal range. Additionally, when the temperature is temporarily adjusted outside of the established range, there is still an expectation that relative humidity levels remain below 60 percent. 

The Joint Commission last year published new 05 Life Safety (LS) standards for business occupancies. Applicable to hospitals, critical access hospitals and behavioral healthcare and human services organizations with business occupancy buildings or spaces, the new LS requirements took effect July 1, 2021. Business occupancies can be geographically widespread and not on the radar as much as the hospital itself. 

HFT: What are the critical steps managers can take to improve their facilities' compliance with these requirements? 

Neal: In relation to temperatures and humidity, facilities managers need to know their equipment first. They need to understand the capability of the system, including during heightened environmental conditions, such as excessive heat. They need to communicate this to the leadership team at the hospital so when requests are made to change the normal operating parameters, there is an understanding of the ability, as well as the consequences. 

Relative to business occupancies, it is important to have a relationship with the teams at the clinics and conduct scheduled rounds, educating the associates there and encouraging them to call with any work requests or if they are planning any renovations. 

HFT In general, what are the biggest myths and misconceptions among facilities managers related to the Joint Commission? 

Neal: That facilities managers are responsible for the environment of care. Maintaining the physical environment and life safety of a facility is a team effort, and if everyone is part of the process, then facilities can stay in an ever-ready state and better manage their workloads. 

HFT: What else should facilities managers know or remember about Joint Commission compliance? 

Neal: It’s about being proactive. Have formal processes in place for preventive maintenance, required testing and inspections, as well as rounding. Ensure that the associates on the facilities team have an understanding of the why and how a Joint Commission inspection looks like, from document review to having a parade route for the building inspections. 

Dan Hounsell is senior editor for the facilities market. He has more than 30 years of experience writing about facilities maintenance, engineering and management. 



August 30, 2023


Topic Area: Maintenance and Operations


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