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Healthcare leaders discuss the ongoing challenges of compliance

By Theresa Walsh Giarrusso

After Robert Faure, Healthcare Segment Leader at ImaginIt, presented his compliance survey results at the 6th Annual New York Hospital, Outpatient Facilities & Medical Office Building Summit, Jared Shapiro, system senior director, Environmental Health and Safety, Montefiore Health System, and Sukhjit Tom Singh, director, Facilities Environment of Care Compliance, New York-Presbyterian Hospital, joined him on stage for a roundtable discussion about compliance.

Here are some highlights from the discussion:

Singh: Compliance is an ongoing challenge. He says you have structural issues and behavioral issues. “Top hospitals put in place electronic systems to proactively inspect building conditions. The behavioral side is always a challenge.” He says go on any patient care side and there is always stuff in the hallway. He says most Joint Commission violations are the physical environment and because they are often behavioral issues, they are really challenging. 

Shapiro agrees. He says it’s hard to have folks constantly performing patient care and be conscious of code violations. He says when you look at the joint commission reports, they are typically compliant with life safety, but when it comes to the environment of care we have some work to do. 

He says, “We educate. We try to make the best approach to notify the staff and tell them why. . .  Do you mind moving this and the reason is if you had to push this patient out for an emergency, you’re really going to have a hard time doing that. It typically changes their perspective.”

Singhsays they use Archibus Web Central to track life safety issues. Prior to that if you have a fire drill and a door fails, you don’t know if it’s a consistent problem or just a problem that day. You also don’t know why it happened. But with an electronic tracking system, you get historical data with a graphic interface.

He says, “Over the course of time you can get into root cause analysis. Is it the behavior of staff? Are they propping the door? Are they using a cart of push it?” You can use the data to make a permanent solution.

Shapiro says fire safety, mold, lab, ergonomic, all go into one big database. He says they try to really understand where our problems are, and then they present that at board meeting.

He says they are moving to a new system, and they will be tagging every door, HVAC unit and tracking and trending very specific issues. He says they really can do some future forecasting and understand what’s happening.

Shapiro says they also track behavior issues such hand hygiene and clutter. He says they track and trend to correct.

Singh says it takes commitment from top-down, patience and hand-holding initially to train frontline staff.

Shapiro says they had staff compliance issue with hand hygiene. At first, they didn’t believe us. Then we had secret shoppers go out and prove it. This got the attention of the VP and a hand hygiene compliance program was created. Now our hand hygiene is very, very high.

Singh agrees, “You can never go to the C-suite without data.” He says you need to make the business case that we need X amount to correct Y deficiencies.