Presentation to the: North Carolina Healthcare Engineers Association 51 st Annual Conference Grove...

Presentation to the:

North Carolina Healthcare Engineers Association

51st Annual Conference

Grove Park Inn & ResortAsheville, North Carolina

Presented by:

Jack L. Waisblat, Vice PresidentSmith Seckman Reid, Inc.

August 7, 2003

Managing a Quality Program for the Utility

Management Plan

Focus:

FTE’S Risk Based Operating Budget Capital Budget Management System Regulatory Compliance Patients / Public Satisfaction Organization’s Leadership

What are the key ingredients to a successful Utility

Management Program ?

Managing a Quality Program for the Utility Management Plan, What does it mean?

Predictability factors for credible capital budgeting and forecasts.

A proactive approach to Utility Management from a Compliance standpoint.

Testing, maintaining, and examining components of Utility Management.

How to maintain a complete set of documents for JCAHO and be continuously Ready.

FMEA and Utility Management; If your CEO hasn’t asked you yet, he/she will (we will email this to you).

Implementing, monitoring, collecting data and establishing Performance Measures / Indicators.

Agenda

Quality: according to Webster’s “That which makes or helps to make anything such as it is; a distinguished property, characteristic, or attribute”.

Don’t you want to feel distinguished?

Management: according to Webster’s “To have under control and direction, to conduct, carry on, guide, administer, get under due control; to move or use in a manner desired”

Don’t you want to have control and set direction?

Utility: according to Webster’s “The state or quality of being useful; usefulness”.

Don’t you want to feel useful?

Managing a Quality Program for the Utility Management Plan,

What does it mean?


Learn from the past.

♦ What happened to your budget last year ?

♦ Last year, did you have to gain emergency funding, beg barrow and steal to make your year ?

♦ Were there any unexpected expenditures that sprung up last year ?

♦ Did you just submit numbers, or did you have independent professional support backup?

♦ How well did you know your CFO ?


Do your homework.

♦ Present historical data

♦ Do a Facility Condition Assessment

♦ Do a Risk Assessment

♦ Does your leadership think that because you live there, you’re not an expert ?, then:

♦ Obtain outside independent professional support

♦ Obtain benchmarks


If you put too much food on your plate, you may get less

to eat next time.

♦ Develop a five year capital budget plan, share it with leadership, get buy-in prior to submitting your annual budget

♦ Prioritize your five year plan and only submit that portion for which you got buy-in

21st CENTURY MEDICAL CENTERFACILITY CONDITION ASSESSMENT REPORT

CAPITAL RENEWAL AND DEFERRED MAINTENANCEFIVE YEAR BUDGET PLANSORTED BY PRIORITIES

APRIL 11, 2003

Item No. Item Description Facility / Building Location Floor/Site

Dept./ Cost Center Justification Priority:1=High 2=Med. 3=Low

Total Costs

FIVE YEAR BUDGET ALLOCATION FY2003 FY2004 FY2005 FY2006 FY2007

Payback(Years) Funding source Action


Summary

• Support your claim to the piece of the pie with; Data, pictures, past events, current conditions, code and standards requirements, emergency procedures and Risk Assessments.

• Paint a what if we don’t do it scenario; spell it out in writing.

• Don’t put on your plate what you can’t finish eating.

• Don’t scramble to submit numbers.


A Pro-Active approach to Utility Management From a

Compliance standpoint

What needs to be Managed for JCAHO Compliance ?

• A risk assessment process (EC.1.7.c)

• An inclusion process for identifying critical components of utility management (EC.1.7.e)

• Establishing intervals for inspecting, testing, and maintaining critical components on the inventory list (EC.1.7.g)

• Critical components of piped medical gas systems (EC.1.7.h)




• Construction, modification and repair projects for medical gases (EC.1.7.I)

• Maintaining main and area medical gas shutoff valves accessible and clearly marked (EC.1.7.j)

• Waterborne Pathogens (EC.1.7.k)

• Airborne Contaminants (EC1.7.l)

• Operational plans to ensure reliability, minimize risks and reduce failures (EC.1.7.m)




• Labeling controls and maintaining floor plans, schematics and riser diagrams to make quick determinations when a partial or complete emergency shutdown is necessary (EC1.7.n)

• Problems, failures, or user errors: Investigating, reporting, measuring and correcting (EC.1.7.0 & EC.4)

• Orientation and education program for staff who use and maintain utility systems (EC1.7.p)


• Performance Monitors (EC.1.7.q)• Emergency Procedures (EC.1.7.r)• Annual Evaluation• Reliable Emergency Power System

(EC.1.7.1)• Maintenance, testing and

inspections of Utility systems (EC.2.10.4) :






• Emergency power systems are maintained, tested and inspected (EC.2.10.4.1): Generators, SEPSS, ATS’S, Battery operated exit and egress illumination units

• Other Environmental Considerations (EC.3) : Positive self-image (EC.3.1), space and equipment (EC.3.2), designing the building environment (EC.3.2.1), privacy (EC3.3), patients interest skills and personal growth (EC.3.4)




• Education and Improvement in the environment (EC.4)

• Monitoring conditions in the hospital’s environment (EC.4.1)

• Analyzing identified environment issues and developing recommendations (EC.4.2)

• Implementing recommendations to improve the environment and monitor effectiveness (EC.4.3)

How do I get it done without anything slipping through the crack ?



Manage with tools

Manage with Education

Manage by accountability

Manage with alarms

Manage with Rewards for Success





• Tools:

WK 1 WK 2 WK 3 WK 4 WK 1 WK 2 WK 3 WK 4 WK 1 WK 2

Generator # 1 Load

No less than 20, No more than 40 days T

Generator # 2 Load


Generator # 3 Load


Generator # 4 Load


Generator # 5 Load


Generator # 6 Load


Generator # 7 Load


Generator # 1Levels and Conditions Weekly

M & E


M & E


M & E

February March

21st CENTURY MEDICAL CENTERUTILITY MANAGEMENT SCHEDULE OF EOC TESTING, MAINTENANCE, INSPECTION & EXAMINATION

FOURTH QUARTER 2003

SystemComponent /

Task Frequency TypeJanuary

Annual Utility Management Knowledge Test

47. If the hospital experiences an interruption of electricity or water outage, you should: A-Inform patients we are experiencing a power outage

B- Bring battery operated equipment from home

C- Inform your immediate supervisor and conserve water

48. If electrical power has been lost, you may:

A-Use ice machines and obtain drinking water from the faucet

B- Use red outlets powered by emergency generators

C-Open windows to promote ventilation use

49. When the hospital experiences a telephone system outage, you will report this information to PBX (communication dept) and

A- Departments will pick up a hand held radio in Security

B- Employees will use their cell phones C- administrative staff will pick up telephones for distribution

A Pro-Active approach to Utility Management From a Compliance

standpoint

• Education:



• Accountability:



• Alarms:



• Rewards for success:

Inspecting, Testing, Maintaining and Examining components of

Utility Management

Definitions: Inspecting: By licensed or certified person

Testing: Operational function

Maintaining: Performing routine maintenance / repair as established by organization or required by codes & Standards

Examining: Observing and recording conditions

Inspecting, Testing, Maintaining and Examining components of

Utility Management

When and how to do it ? Assign specific duties and responsibilities Provide Frequency chart streamed-lined to

the task/s Predetermine schedule for the entire year Set alarms in your schedule if individual is

more than 48 hours late in completing the task If multiple individuals are involved in a task,

appoint one as the task leader to be held accountable

If a test can not be completed (broken amp meter on generator), don’t accept “meter broken” entry in test log

Don’t Rely solely on building automation systems

Develop check lists

How to maintain a complete set of documents for JCAHO and be Continuously Ready

Contrary to what we learned as kids, do judge a book by it’s cover

Keep a book for each of the minimum of the tasks, preferably white 3 ring binders with content description on front and side

Implement an automated EOC management program that collects and aggregates data electronically

Enter data for Periodic Performance Review (PPR:2004 EOC requirement for 18 month self assessment) on a regular basis

Aggregate data quarterly (at a minimum) and review if you are on target

Implementing, Monitoring, Collecting data and establishing Performance

Measures / Indicators and Performance Improvement recommendations

Definitions:

• Performance Measures: An instrument (graph, chart, raw data) by which to measure the success or failure of an EOC task: Typically compares this year to last years performance

• Performance Indicator: Provides data to where an EOC task is at present in terms of achievement

• Performance Improvement Recommendation (mostly known as a “PI”): Establishes a goal for improvement in the coming year based on an evaluation of providing the most value to an organization (needs to be approved by the leadership of the organization)

Implementing, Monitoring, Collecting data and

establishing Performance Measures / Indicators and Performance Improvement

recommendations

Establish with leadership who is responsible Automate the system Review and Report Measures Quarterly Establish performance Indicators (no specific

requirement from JCAHO as to the number of measures)

Establish a minimum of two performance measures for each of the seven EOC management plans

Establish your performance improvement recommendation (only one required for the EOC annually) among EOC management team members who will carry the torch

Implementing, Monitoring, Collecting data and

establishing Performance Measures / Indicators and Performance Improvement

recommendations

Thank You!From SSR

[email protected]

Presentation to the: North Carolina Healthcare Engineers Association 51 st Annual Conference Grove...

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