This presentation includes: The purpose and value of the annual evaluation; Requirements for annual evaluations (Objectives, Scope, Performance, Effectiveness) The annual evaluation process Impact on Safety and Operations

1. The Standard for Healthcare Facility
Management Compliance
Online Webinar Series
EOC Annual Evaluation
of the Management Plans
for the Physical Environment
Faculty:
Tom Zahorsky CHFM, CHSP-FSM
Vice President of Client Services
Email: tomz@sitefm.com
Phone: 281-362-1686
SiteFM
Host:
Martyn Buffler
Vice President, Sales and Marketing
Email: mbuffler@sitefm.com
Phone: 512-480-0883 x125
SiteFM

2. Thank you for joining us today!
Agenda
• Introductions (5 minutes)
• The Annual Evaluation Process (40 minutes)
• Next Steps (5 minutes)
• Q&A
Housekeeping
• We will be in webinar mode – all lines muted
• Please enter questions in the control panel
• If you have technical difficulty press *0 for
operator assistance.

3. About SiteFM
SiteFM is Exclusive to Healthcare
• Based in Austin, TX for 22 years
• Over 425 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

4. SiteFM Customers – Over 400+ Across the US

5. 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

6. 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.

7. 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

8. 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
• SiteFM offers a free data analysis of your CMMS data
•Sign up for a product introductions/demonstrations for:
-Work Order Manager
-Facility Drawings
-Area and Equipment Monitoring
at www.SiteFM.com.

9. Faculty Background
Tom Zahorsky CHFM, CHSP-FSM
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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

10. Webinar Objectives
At the end of today’s program you will be able to discuss:
• The purpose and value of the annual evaluation
• Requirements for annual evaluations
– Objectives
– Scope
– Performance
– Effectiveness
• The annual evaluation process
• Impact on Safety and Operations

11. Purpose
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Determine effectiveness of program(s)
Measure progress towards goals
Organize the approach to Safety Management
Determine appropriateness of goals
Continue similar goals if appropriate
Establish new goals and measures
Provide a sense of direction

12. Value - Internally
• One of the most important internal Quality Improvement
documents in the hospital
• Determines program effectiveness
• Determines appropriate performance measures
• Used to update Management Plans
• Provides guidance for Safety Committee

13. Importance - Externally
• Insightful document for surveyor review
• Indicates program effectiveness
• Indicates understanding of process

14. Importance – TJC survey success
• From a survey success standpoint, the annual
evaluation used to be required by one element of
performance under one standard.
• Now, there are 4 standards and multiple elements of
performance that relate to the annual evaluation
process

15. Requirements
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Objectives
Scope
Performance
Effectiveness
Conducted in a timely manner
Put to use

16. How To - Objectives
• States the responsibility of the program(s)
• A statement of what it is that is to be accomplished by
this plan
• Comes directly from the Management Plan
• Rarely changes from year to year

17. How To - Objectives Example
• To provide a fire safe environment for staff, patients, and
visitors through a comprehensive program for the
management of Fire Prevention and Life Safety
systems, equipment, staff training and planned
inspections, maintenance and service to related
systems, equipment and building features.

18. How To - Objectives
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Specific actions planned to affect improvement
Objectives support program goals
Objectives should be measurable
Performance Indicators measure progress towards
specific objective
• Objectives can change from year to year

19. Objective Examples –
Fire/Life Safety Program
• Improve average staff performance on fire drills by 5%
• Achieve specifically identified improvements based on
scores from the Building Maintenance Program for Life
Safety.
• Monitor compliance with the Above Ceiling work permit
and Hot Work Permit programs (new).
• Maintain consideration of the Statement of Conditions
(SOC) at each meeting of the Environment of Care
Committee by keeping it as a standing agenda item.

20. How To - Performance Indicators
• 100% Verification Testing-Yes or no, target 100%
• Average staff score on fire drills, trended monthly
• Improve fire door latching scores from 88% to at least
95% by changing frequency from semi-annually to
quarterly
• Monitor number of Hot Work Permit program violations
verses total number of permits issued(new).
• Provide summary reports of discovered Life Safety
deficiencies and if they are work order correctable or will
require PFI and or ILSM

21. Safety Management
Monitor the knowledge of employees in the safety components of annual re-training. Test s cores from each of
Performance Indicators for the EOC
the EOC Categories are at least 95% taken by random sampling.
 Safety Management
 Employee Safety Management
 Security Management
 Emergency Management
 Hazardous Materials and Waste Management
 Life Safety Management
 Medical Equipment Management
 Utilities Management
National Patient Safety Goal Compliance Rate
Inpatient Fall Rate (falls/1000 patient days)
Employee Safety – Lost Time Injury Rate is Below State Average for SIC Code
Employee Safety – Needle stick or other injury rate below prior year (per 100,000 worked hours)
Hazard Surveillance – percent of probes found to be in compliance
Product Recalls – percent of recalls and notices responded to by deadlines
Security Management
Security Incidents per month by type
Security - % of CCTV system operational monthly
Security – staff scores on security drills
Security – response time to events of different types
Security – number of incidents of different types compared to year prior
Emergency Management
Emergency Preparedness scored staff performance on drills
Percent of HRSA Grant Funded Supplies Locatable
Percent of Emergency Contacts Valid During Random Test Calls (after hours)
Hazardous Materials and Waste Management
Hazardous Materials % accuracy of MSDS books random sample
Hazardous Materials & Waste – lbs. Infectious waste/patient day prior year comparison
Fire Prevention and Life Safety
Life Safety – staff score at least 95% on fire drill performance
Life Safety – all staff participate each year
Life Safety – BMP compliance rates > 95%
Medical Equipment Management
Medical Equipment Management – percent PM completed monthly
Medical Equipment Management – percent repairs completed (m)
Medical Equipment Management – average turn around time
Medical Equipment Management – User Error Rate as % of reported equip. failures
Utilities Management
Utilities Management – percent PM completed monthly
Utilities Management – percent repairs completed monthly
Utilities Management – average response time
SiteFM™

22. How To - Scope
• A statement of what the plan is intended to manage
• The people, facilities and equipment, as related to the
particular discipline being evaluated
• Example: For the Fire and Life Safety Program, the
Scope could be stated as;

23. How To - Scope Example
• The Management Plan for the Fire and Life Safety
Program applies to all hospital staff, contract
staff, general and sub contractors, physicians, patients
and visitors, and all buildings and grounds. The plan
includes the management of Fire Safety Equipment, Life
Safety features of the building, Interim Life Safety
Measures, Life Safety drawings, staff knowledge of Life
Safety Requirements, and the ability of staff to respond
in the event of a fire emergency.

24. How To - Performance
• An objective evaluation of how the plan was managed in
the prior year
• Relative to each goal or measure
• What was planned?
• What was done?
• What did the performance indicators show?

25. How To - Effectiveness
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Did indicators show improvement?
Were goals met or exceeded?
If “yes”, then deem the process “effective”
If “no” then deem the process not as effective as planned
There is no “failure”, only opportunities for improvement

26. How To – Next Year’s Goals
• If no further opportunity for improvement is indicated
(goal met), is continued monitoring required?
• If goal was not met, should efforts continue?
• Was the goal reasonable? Adjust target?
• Have new issues arisen that present an opportunity for
improvement?

27. The Process
Identify
Opportunities
Evaluate
Measure
Set Goals
Take Action

28. When to Conduct Evaluations
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Evaluation sets the course for the Safety Committee
Must be the first undertaking each year
One extra committee meeting recommended
Sole purpose of meeting is review of annual evaluations
and setting goals for the coming year

29. When to Conduct Evaluations
• Example: Committee meets bi-monthly in the even
months (Feb, Apr, June, etc.)
• Hold extra meeting in January
• Each plan owner presents their evaluation to committee
• Committee provides input, sets goals for coming year
• Evaluations completed now Management Plans can be
updated

30. CMS
• Sec. 482.21 Condition of participation: Quality
assessment and performance improvement program.
• (3) The hospital must document what quality
improvement projects are being conducted, the reasons
for conducting these projects, and the measurable
progress achieved on these projects.

31. CMS
• The CMS COP (Condition of Participation) are not
prescriptive in terms of the process
• Hospitals must have a process that they can
demonstrate the effectiveness of
• The annual evaluation process makes sense but is more
open in terms of the manner in which it is conducted

32. CMS
• The CMS COP (Condition of Participation) are not
prescriptive in terms of the process
• Hospitals must have a process that they can
demonstrate the effectiveness of
• The annual evaluation process makes sense but is more
open in terms of the manner in which it is conducted

33. Det norske veritas (The dnv)
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PHYSICAL ENVIRONMENT (PE)
PE.1 Facility ……………………………………………………………………………………. 130
PE.2 Life Safety Management System ……………………………………………………… 132
PE.3 Safety Management System …………………………………………………………… 134
PE.4 Security Management System …………………………………………………………. 135
PE.5 Hazardous Material (Hazmat) Management System ……………………………….. 136
PE.6 Emergency Management System …………………………………………………….. 137
PE.7 Medical Equipment Management System ……………………………………………. 139
PE.8 Utility Management System ……………………………………………………………. 140

34. Det norske veritas (DNV)
• The DNV relates directly to the CMS COP (Condition of
Participation) are not prescriptive in terms of how this is
done, however;
• Hospitals are expected to integrate the ISO 9001 Quality
Management Process into their operations, including this
process
• Accreditation surveys are conducted annually…

35. The Joint Commission
• EC.04.01.01 EP 15 – “every 12 months, the hospital
evaluates each environment of care management
plan, including a review of the plan’s
objectives, scope, performance and effectiveness (See
also EC.01.01.01, EPs 3-8, and EC.04.01.03, EP 1)”

36. The Joint Commission
• EC.04.01.03 EP 1 – “Representatives from
clinical, administrative and support services participate in
the analysis of environment of care data (See also
EC.04.01.01, EPs 3-6, and 8-15 and EC.04.01.05, EP
3)”

37. The Joint Commission
• EC.04.01.01, EPs 3-6… – “based on its process(es) the
hospital reports and investigates the following;
• EP 3 – injuries to patients or others
• EP 4 – occupational illness/employee injuries
• EP 5 – damage to property
• EP 6 – Security incidents
• EP 8 – Hazardous materials
• EP 9 – Fire safety issues
• EP 10 – Medical/Laboratory equipment
• EP 11 – Utility Systems

38. The Joint Commission
• EC.04.01.05, the organization improves its
environment of care
• EP 1 – action is taken on improvement
opportunities
• EP 2 –the effectiveness of actions is evaluated
• EP 3 – P.I. results reported
• EP 3 refers then to EC.04.01.03, EP 1; and
EM.03.01.03 EP 16

39. The Joint Commission
• EM.03.01.03 – The organization evaluates the
effectiveness of its Emergency Operations Plan
• Rationale statement includes “the organization
conducts and annual review of its planning
activities”

40. The Joint Commission
• EM.03.01.03 – The organization
evaluates the effectiveness of its
Emergency Operations Plan
• EP 1 – annual HVA
• EP 2 – annual review of scope, etc.
• EP 3 – annual review of inventory process

41. The Joint Commission
• EM.03.01.03 – The organization evaluates the
effectiveness of its Emergency Operations Plan
• EP 16 – the hospital modifies its Emergency
Operations Plan based on its evaluations of
emergency response exercises and responses
to actual emergencies.

42. The Joint Commission
• Essentially, the objectives, scope, performance and
effectiveness of each of the management plans
must be evaluated at least annually.
• Include the EOP, HVA, EM Inventory Process
• Safety and Security Risk Assessment
• Though not listed in TJC’s Life Safety
Chapter, items addressed therein should be
included in the Fire/Life Safety Management Plan
and should be evaluated annually as before.

43. The Joint Commission
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Safety & Security Management (EC)
Hazardous Materials Management (EC)
Fire and Life Safety Management (EC,LS)
Medical Equipment Management (EC)
Utilities Management (EC)
Emergency Management Plan, HVA &
Inventory Process (EM)

44. In Review
Identify
Opportunities
Evaluate
Measure
Set Goals
Take Action

45. In Review
• Regardless of the accrediting body, the
annual evaluation process is valuable
• Measures program effectiveness
• Assures appropriate goals and measures
• Provide a sense of direction to the
organization
• Aligns with quality management
processes

46. Seminar/Webinar Topics
• The partner presentation to this is our “Managing an
Effective Safety Committee”
• The Barrier Management Program
• Managing Life Safety Drawings
• The Life Safety Code Surveyor
• Register at www.SiteFM.com
• These programs can be presented for your state
Healthcare Facilities Management association

47. SiteFM Work Order Manager
Helps you manage the EOC Process
• Full WO-CMMS with Compliance
Management Features &
Functionality
• Mobile Component – Complete PMs
and Inspections on Mobile Devices
Real-Time
• Comprehensive EOC Mgmt.
Reporting Solution – Monitor &
Measure what matters
• Combines Inspection Software with
your CMMS.
• Provides valuable data for
documentation and improvement.

48. SiteFM Professional Services
A Healthcare Maintenance Management System
is only as good as the system’s data.
Healthcare – CMMS
Life Safety Drawing
Space Allocation Cost
Utility Management
Asset Tagging & Bar
Implementation/
Creation
Report & Space Book
Professional Services
Code Implementation
Data Conversion
Free Hosting
and Support

49. Next Steps
• Please fill out the post-webinar survey to request a copy
of presentation.
• Sign up for a SiteFM product demonstration for:
•Work Order Manager CMMS
•Facility Drawing Management
•SiteFM Vision – Critical Asset Monitoring and Equipment Location
• Please share this information with your peers.
Thank you!
The SiteFM team…..

50. The Standard for Healthcare Facility
Management Compliance
Questions and Answers
Tom Zahorsky CHFM, CHSP-FSM
Vice President of Client Services
Email: tomz@sitefm.com
Phone: 281-362-1686
SiteFM
Martyn Buffler
Vice President, Sales and Marketing
Email: mbuffler@sitefm.com
Phone: 512-480-0883 x125
SiteFM