The prescription for a healthy JCAHO audit

By Kevin Price/ Special to Healthcare Facilities Today
January 20, 2020

Whether it’s inadequate parking lot lighting or something as patient-facing as medication errors, a failed Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

audit threatens the survival of every healthcare facility. At the same time, ongoing safe and responsible management builds the reputation of the facility, and is crucial to patient outcomes and the core mission of patient care. 

Getting ahead of the audit

While there is no way to predict the timing of a JCAHO audit, there are plans, processes, and infrastructure that can be put in place to ensure the evaluation will run smoothly.

The goal is to create a prescriptive enterprise asset management (EAM) system. Prescriptive mode eliminates reactive approaches, and even goes beyond predicting maintenance and management needs. That means we can see an asset is on its way to failure, but also have the documented steps, data, and precise maintenance information we need to ensure it remains operational. That prescription is built into a system that outlines the process needed to avoid failure, and includes the people who need to know and be involved –including outside vendors. 

What the industry is finding is that paper recordkeeping and manual processes will not move an organization toward such a prescriptive system. It is slow, cumbersome, and prone to errors and risk. Instead, EAM technology is key to achieving a culture of prescriptive maintenance. It enables digital images, creates one point of data entry, and completely automates the asset cycle. It tracks and centralizes data on every piece of medical equipment and all facility assets—from complex medical devices to ventilation to golf carts. Real-time alerts and analytics ensure every asset is fully operational, audit ready, and that it adheres to any third-party requirements, such as CMS guidelines.

Achieving prescriptive maintenance

The right EAM solution is built for the unique complexity of the industry. This not only makes it easier and more intuitive to use, but helps achieve a very important first step toward creating a culture of prescriptive maintenance: staff buy-in. 

Success ultimately depends on engagement across the organization - from top leadership through every other level of staff.  Involving a cross-functional team in the process of creating a prescriptive maintenance plan helps successfully kick off the transformation. 

We suggest the following steps toward a prescriptive maintenance program:

 - A survey and inventory of all assets, from the water fountains, to the multi-million dollar x-ray machine, to the environmental assets such as air conditioning, heat, and fuel.

 - Creating a consolidated registry of those assets, listing every detail including manufacturer, serial number, warranties, and required maintenance and service levels.

 - Prioritizing assets based on risk. Assets are like patients: none of them are the same, nor is how we are to treat them.

 - Documenting all maintenance details. For example, in the HVAC environment, not only record when and how to change parts such as the filter, but who does it, and when. 

Keep in mind that not all assets will be, or can be, maintained by internal staff. Some equipment, such as the MRI machine and other more sophisticated equipment, requires specific certification or expertise for maintenance and/or testing. A JCAHO audit still requires detailed maintenance and management documentation, and a centralized EAM system creates a central, viewable repository of that information. 

That brings up a related issue: HIPAA guidelines and the need for patient privacy even under audit scrutiny. When looking for an EAM system, ensure that it is attentive to those sensitivities and includes that privacy functionality and the ability to quarantine specific patient information and names. 

Ongoing savings

Creating a prescriptive system pays off in a big way far beyond the JCAHO audit. It sets a path toward optimized efficiencies and cost savings across the entire organization. One of the biggest impacts of prescriptive maintenance is savings in the number one cost area for organizations: energy. With automated and prescriptive EAM, hospitals and facilities can decide where to adjust heating and cooling and, in some cases, shut off rooms with no patients. 

As organizations continue to refine their prescriptive maintenance cultures, there will be additional returns on investment. More sophisticated data collection creates opportunities to hone a more strategic asset management system, and find other ways to streamline and create efficiencies. And that, above and beyond the immediate need to pass an audit, saves time and money. 

Kevin Price is a Technical Product Evangelist for Infor.

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