SR CFG 73197

User Manual: 73197

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The JCAHO’s building

maintenance program:

Scoring and compliance tips

Asupplement to HCPro, Inc., publications

The JCAHO’Sbuilding maintenance program:

Scoring and compliance tips

Table of contents

How to succeed with your building program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Items under the building maintenance program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Crosswalk of building maintenance requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

An analysis of SOC scoring benefits for hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Take the edge offof potential penetration problems..........................................7

Inventory holes patched by colored firestopping ............................................8

Exploring the building maintenance program

The optional building maintenance program has been part of the Statement of Conditions (SOC)for hospitals

since 1999.

It’s clear today that those in charge of environment-of-care concerns at the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) are proponents of the building program because it offers advantages to hospitals

while also encouraging facilities to faithfully keep maintenance activities up to par.

With the JCAHO now switching to only unannounced surveys at accredited facilities, it’s a good time to explain the

scoring thoughts behind the building maintenance program, along with ideas about how to best comply with the

program’s intents.

We’ve culled our information from the SOC and the following experts:

§Frederick Bradley, PE, principal at FCB Engineering in Alpharetta, GA

§Mark Forstneger, spokesperson for the JCAHO

§George Mills, FASHE, CHFM, CEM, associate director of the JCAHO’s standards interpretation group, who

spoke during the American Society for Healthcare Engineering’s conference in July 2005 in Anaheim and dur-

ing an October 2005 audioconference presented by Joint Commission Resources, Inc.

§Steven MacArthur, safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA,

which also published this special report

Please contact me if you have any thoughts about this special report or ideas for futurestories.

Sincerely,

Scott Wallask

Senior Managing Editor

swallask@hcpro.com

781/639-1872, Ext. 3119

December 2005

The JCAHO’s building maintenance program:

Scoring and compliance tips

How to succeed with your building program

JCAHO official outlines good ideas to keep you ahead

It’s a virtual guarantee that surveyors from the Joint

Commission on Accreditation of Healthcare Organiza-

tions (JCAHO) will review the Statement of Conditions

(SOC).

Medical sites should anticipate that as surveyors look

over SOC concerns, they will ask facilities whether they

use the SOC’soptional building maintenance program,

says George Mills, FASHE, CHFM, CEM, associate

director of the JCAHO.

The building program allows facilities to correct com-

mon maintenance-related Life Safety Code® (LSC) defi-

ciencies without worrying about whether surveyors will

cite them for each problem. In exchange for this relaxed

scoring, facilities arrange scheduled, documented main-

tenance reviews for a set list of items (see the box be-

low). Facilities may choose to adopt all or some of the

items listed.

Sites must show that at least 95% of the program’s items

work properly at any given time.

Mills helped develop the idea for the building mainte-

nance program when he worked at the American

Society for Healthcare Engineering (ASHE) during the

late 1990s. The idea behind the program is to provide

relief to facilities who are trying to stay on top of small-

ticket LSC deficiencies, he says.

“It makes so much sense” to use the building mainte-

nance program, Mills says. He offers the following tips

to stay on top of the program:

3Consider adopting a policy addendum for your

building program. If your facility uses a building

maintenance program, the JCAHO would prefer to see

something in writing that formally indicates the pro-

gram’s existence, Mills says. Suggestions include a poli-

cy, memo to the safety committee, or declaration that

the building program is in use, he says.

However, the JCAHO doesn’t require a policy for the

building program, he adds.

3Make sure the program’s inspections meet the

JCAHO’s intent. When inspecting items for building

program compliance, be careful not to tap-dance

around the JCAHO’s wishes. A facilities crew member

who performs work to maintain a smoke barrier

Items under the building maintenance program

Following arethe items listed in the optional building main-

tenance program. You can find the building program in the

Statement of Conditions, Parts 3A and 3B, question 6J:

1. Do one-hour and 90-minute fire-resistance-rated assembly

doors have

• positive latches?

• self- or automatic-closing devices?

• 1/8-in. or smaller gaps between meeting edges of door

pairs?

• 3/4-in. or smaller undercuts?

2. Do linen and trash chute inlet and outlet doors have

•positive latches?

• self- or automatic-closing devices?

3. Do smoke barrier doors

• have self- or automatic-closing devices?

•prevent the spread of smoke?

4. Do corridor doors

• have positive latches?

• restrict the spread of smoke?

5. Are smoke barrier penetrations sealed properly?

6. Are corridor wall penetrations sealed properly?

7. Do lights in the means of egress work?

8. Areexit signs illuminated?

9. Arethe means of egress free from accumulation of ice

and snow?

10. Does the facility clean and maintain

• exhaust hoods?

•exhaust duct systems?

•grease-removal devices?

>p. 4

The JCAHO’Sbuilding maintenance program:

Scoring and compliance tips

Building program <p. 3

is not inspecting that barrier for compliance with the

program, Mills says.

Instead, department managers or similar folks should be

charged with inspecting the barriers for penetrations and

other problems, Mills says.

The inspections should validate whether the mainte-

nance work is appropriate, which is why the same per-

son can’t conduct both efforts simultaneously.

3If you have trouble meeting the 95% mainte-

nance rate, increase your inspections. Suppose that

asmall facility has only 10 fire doors under a building

maintenance program and that crews check those doors

once per year.

If one of those doors doesn’t latch properly, the facility

has already dropped below the required 95% rate in the

program.

Yet a larger site with 100 fire doors could also have one

door in disrepair and still make it above the 95% rate,

even though the number of deficient items is the same

in both facilities.

One way around this dilemma is to increase inspection

frequencies. For example, perform quarterly inspections

of fire doors in the small facility, Mills says.

That brings the total sample up to 40—10 doors multi-

plied by four inspections each. With increased inspec-

tions, one door out of 10 that doesn’t latch now makes it

above the 95% compliance rate in the program.

You can also choose to increase inspections of items in

specific areas, which may be prone to more abuse from

carts (e.g., doors in the dietary departments), Mills says.

3Small sample sizes shouldn’t be a detriment.

Facilities that have small sample sizes for certain items in

the building maintenance program shouldn’t shy away

from the program for that reason, Mills says.

In some cases, it’s reasonable to assume that those items

will remain in good repair.

Take kitchen hoods, for example, which fall under

grease-producing devices in the building program. A

facility might only have three hoods in the entire

building.

“So you’ve got a small number of [hoods]. How many

times are you visiting them?” Mills says. “Immediately,

you’re visiting them twice a year just to be compliant

with [NFPA codes], so that’s a denominator of six. And

if [hood maintenance] is contracted out and you make

sure the guy’s coming in there, is there really a concern

about failure rate on those particular three items? Most

likely not.”

If you run into a problem with the hoods, you could

elect to increase visual inspections of the equipment as

noted above, he adds.

3Take action if you fall below 95%. If your mainte-

nance activities don’t live up to the building program’s

required 95% rate, take one of the following two steps:

1. Fix the deficiencies as soon as possible and determine

what it will take to bring your building program back

up to acceptable levels.

2. Pull the item category in question out of the building

program until you can solve the problem. Although

the deficiency may still receive a citation on its

own, it won’t sink your entire building program,

Mills says.

Editor’s note: For more information about the continu-

ally challenging aspect of tracking penetrations within

the building maintenance program, see the related story

on p. 7.

Contact Senior Managing Editor Scott Wallask

Telephone:

781/639-1872, Ext. 3119

E-mail:

swallask@hcpro.com

Questions? Comments? Ideas?

The JCAHO’s building maintenance program:

Scoring and compliance tips

Crosswalk of building maintenance requirements

This chart traces the items listed under the building maintenance program within the Statement of Conditions (SOC)and how

they tie into NFPA provisions.

The items in the building maintenance program receive scoring advantages when they meet a 95% compliance rate. These

items, when not included in a building maintenance program, fall under the SOC’sregularly scored questions.

Those questions in turn stem from various NFPA code requirements. This chart features NFPA references to the

•Life Safety Code (LSC), 2000 edition

• NFPA 80, Fire Doors and Fire Windows, 1999 edition

• NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition

Building maintenance program item

Positive latches on fire-rated doors

Self-closing or automatic-closing devices on fire-rated doors

1/8-in. or smaller gaps between meeting edges of fire-rated door pairs

3/4-in. or smaller undercuts on fire-rated doors

Positive latches on linen/trash chute inlet and outlet doors

Self-closing or automatic-closing devices on linen/trash chute inlet

and outlet doors

Self-closing or automatic-closing devices on smoke barrier doors

Smoke barrier doors prevent the spread of smoke

Positive latches on corridor doors

Corridor doors restrict the spread of smoke

Properly sealed smoke barrier penetrations

Properly sealed corridor wall penetrations

Lights in the means of egress

Illuminated exit signs

Means of egress free of ice and snow

Cleaned and maintained exhaust hoods

Cleaned and maintained exhaust ducts

Cleaned and maintained grease removal devices

SOC question

NFPA code reference

LSC—8.2.3.2

NFPA 80—2-4.4.3

LSC—8.2.3.2.1

NFPA 80—2-4.1.2

LSC—8.2.3.2.1

NFPA80—2-3.1.7

LSC—8.2.3.2.1

NFPA80—1-11.4

LSC—8.2.3.2.3.1, 19.3.1,

and 19.5.4

LSC—8.2.3.2.3.1, 19.3.1,

and 19.5.4

LSC—19.3.7.6

LSC—8.3.4.1 and 19.3.7.6

LSC—19.3.6.3.2*

LSC—19.3.6.3.1

LSC—8.3 and 19.3.7.3

LSC—19.3.6.2.2

LSC—7.8, 7.9, and 19.2.8

LSC—7.10.5

LSC—7.1.10.1

LSC—9.2.3 and 19.3.2.6

NFPA 96—Chapter 8

LSC—9.2.3 and 19.3.2.6

NFPA 96—Chapter 8

LSC—9.2.3 and 19.3.2.6

NFPA 96—Chapter 8

*An exception under 19.3.6.3.2 allows existing roller latches to remain on corridor doors in certain situations. Effective March

13, 2006, the Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare & Medicaid Services will

override this exception and require all facilities to replace roller latches on corridor doors with positive latches.

Sources: LSC and SOC.

The JCAHO’Sbuilding maintenance program:

Scoring and compliance tips

An analysis of SOC scoring benefits for hospitals

Although the calculations sometimes are complex, the

final tally is clear: Hospitals that successfully use the

optional building maintenance program win a scoring

advantage from the Joint Commission on Accreditation

of Healthcare Organizations (JCAHO). Let’s look at

how this benefit occurs.

Surveyors score each item within the Statement of Con-

ditions (SOC),including the questions that allow the

building maintenance program (question 6J under Parts

3A and 3B).

But the scoring is different than the typical 0, 1, and 2

ranks you find alongside each environment of care

(EC) element of performance. In those scores, a 0

equals noncompliance with an element, 1 translates to

partial compliance, and 2 is full compliance. In turn,

those element scores work into overall EC standard

scores.

In this case, learnyour XYZs

As Mills explains it, instead of using 0, 1, and 2 scores,

the SOC items use scores of X, Y, and Z, in which

§X = 1/6 of a 0 score for standard EC.5.20 (which

requires compliance with the SOC and Life Safety

Code)

§Y=1/3 of a 0 scorefor EC.5.20

§Z=0score for EC.5.20

It takes two Xs to equal one Y score, Mills says. Six Xs

equal one Z score, which, as noted in the bullet above,

translates to a 0 score for EC.5.20.

Surveyors use a scoring grid that establishes the X and

Yscores to determine how to rate each SOC item.

Seek out the scoring tables

The tabulations areconfusing to explain, Mills says.

What makes it worse is that it’s not easy to find the

scores.

The last accreditation manual in which HCPro found

the scores was from late 2003. Now the scores are

available online through all facilities extranet connec-

tion to the JCAHO.

If you have access to that grid, you’ll see that all 10

building maintenance program entries have an X next

to them, which means that any deficiency that falls

below the 95% rate receives an X score, says Mark

Forstneger, aspokesperson for the JCAHO.

Corridor doors: A comparison

The “all X” approach to scoring the building mainte-

nance program is advantageous.

Here’s how the benefit plays out, using corridor doors

as an example.

As noted earlier, if at least 95% of your corridor doors

arein good shape, you comply with the building pro-

gram. If enough doors have deficiencies (e.g., not

latching properly) to drop you below 95%, surveyors

will score you with an X.

If you didn’t include corridor doors in a building main-

tenance program, surveyors will score those doors in

the regular SOC.In this case, corridor door latching

falls under question 2I.3 in Part 3A.

If one latch doesn’t close properly on a corridor door

because of poor maintenance, surveyors will hand you

ascoreof X under 2I.3. A second latching problem

will get you another X, for a total of two Xs or one Y.

What’s the bottom line?

In theory, if you had six latching problems for corridor

doors covered under the building maintenance program,

you might still make it above 95%, and even if you did-

n’t, you would receive one X for all of the deficiencies,

Mills says.

But if you didn’t use the building program, six latching

deficiencies under question 2I.3 result in a 0 score

under EC.5.20, which could lead to a requirement for

improvement citation.

With the building program in place, “we’regiving you

the grace by reducing the scoring,” Mills says.

In return, hospitals must show the JCAHO that they have a

process in place to oversee routine maintenance issues.

The JCAHO’s building maintenance program:

Scoring and compliance tips

Take the edge off of potential penetration problems

Strive for a successful maintenance effort, not a number-crunching exercise

Smoke barrier penetrations have always been the bane

of the building maintenance program because the Joint

Commission on Accreditation of Healthcare Organiza-

tions (JCAHO) has never offered much guidance about

how a facility should track penetrations.

Remember, facilities that use a building maintenance

program need to maintain all the

items that they’ve included in the

program at a deficiency rate of no

more than 5%.

This goal is generally easy for items

such as extinguishers and exit signs

because it’s simply a matter of establishing an inventory

and then inspecting for deficiencies, says safety consult-

ant Steven MacArthur.

However, meeting the 95% compliance rate can be a

challenge when in comes to barrier penetrations.

For example, does the 95% rate come from the total num-

ber of penetrations that a facility notes? Or is it based on

the amount of penetrations per the average barrier area?

‘Pretty darn close’ compliance

The JCAHO’s George Mills, FASHE, CHFM, CEM,

doesn’t see barrier penetration measurement as a black-

or-white issue.

Suppose that a facility has 200 smoke barriers and the

maintenance director inspects 10 barriers each week. One

week, he notes four penetrations among the 10 barriers.

That works out to a 60% rate, which is far out of compli-

ance with building program requirements, Mills says.

“On the other hand, if you hit 10 of them and one of

them had a hole in it, I’d say we’re pretty darn close” to

compliance even though the rate is still only 90%, he says.

95% rate isn’talways literal

It isn’t the JCAHO’s intent for facilities to calculate the

total surface area of their smoke barriers and then allow

5% noncompliance, Mills says.

Common sense would dictate that if a campus has

100,000 sq. ft. of smoke barriers, then the JCAHO

would never be happy if 5,000 sq. ft. of that total

were deficient, even if it still met the 95% rate, he

says.

In other words, there’s a practical approach to barrier

penetration maintenance that goes

beyond the numbers.

“You know when your program is

effective,” Mills says. “Don’t go into

the mathematics of it and do crazy

calculations. [Focus on] what’s rea-

sonable with your barriers.”

Ways to embrace barrier monitoring

Consultant Frederick Bradley, PE, has come up with

useful ideas to help facilities better track barrier main-

tenance and penetrations:

§Develop accurate drawings that clearly show the

locations of barriers. If necessary, talk to long-time

engineering employees about this issue because

they may have knowledge that others don’t about

the barriers.

§Each year, take a copy of these drawings and

check the facility for barrier penetrations.

§Provide the drawings to contractors so they know

which walls are barriers.

§Put into any construction or renovation contract

that workers must repair and properly seal any

penetrations they create.

§Make contractors submit penetration sealant data

ahead of time so the facility is familiar with the

product that will be used.

§Inspect any penetration sealing before the facility

issues final contractor payments.

“The key is the first two steps. Find out where your

smoke barriers are” and inspect them, Bradley says.

“It’s important that you establish a program for check-

ing [barriers for penetrations].”

There’s a practical approach to

barrier penetration maintenance

that goes beyond the numbers.

The JCAHO’Sbuilding maintenance program:

Scoring and compliance tips

Inventory holes patched by colored firestopping

Your building may use various firestopping materials de-

pending on the area in which crews applied them and

what vendors supplied the products.

During inspections of healthcare sites that he’s perform-

ed, safety consultant Steven MacArthur has noted

firestopping that’s white, black, red, and green in the

same facility.

Take advantage of the different looks of firestopping by

cataloging them, MacArthur says.

Digital photos make it easy

Shoot digital photos of the firestopping materials used

and note with which projects the pictures correspond.

Attach specification sheets to the photos and identify the

vendors from which you bought the firestopping prod-

ucts. Arrange the information in a binder or a chart for

easy presentation.

Not only will it help your facilities and safety employ-

ees, but surveyors and inspectors will find it an easier

way to check on your sealed penetrations, MacArthur

says.

Explain your efforts first

Often, surveyors will move on to other issues if the first

sealed penetration they check meets with their satisfac-

tion. Describe your process for tracking penetration to

surveyors before they pop a ceiling tile.

“You want to make it as easy as you can for [surveyors]

to stop looking,” he says.

You might also be able to exploit firestopping colors by

using certain hues for different departmental work. For

example, when information services runs computer and

data lines through fire walls, insist that it identify its

penetrations by using blue firestopping, MacArthur

says.

in any formor by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please

notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872

or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail:

customerservice@hcpro.com •Opinions expressed are not necessarily those of the editors. Mention of products and services does

not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical,

or clinical questions. HCPro, Inc., is not affiliated in any way with the Joint Commission on Accreditation of Healthcare

Organizations, which owns the trademark.

01/06 SR206

SR CFG 73197

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