by Gregory Cochran, BS, LSCS, CHFM
Accreditation Advisor

In my career I’ve heard many facilities and non-facilities personnel question the value of all the regulations that hospitals have to comply with. I’ve actually heard staff say, “We’ve never had a fire, so our safety systems are working.” I’m sure Jazan General Hospital in Saudi Arabia, which burned in December 2015, generally felt the same way prior to their fire.  

The loss

According to news reports, 25 people died and more than 100 were injured. Several sources noted that the hospital had systems on top of systems that failed. These included, but were not limited to fire sprinklers and alarms, communications plans and staff training.

In addition to families enduring the sudden and unexpected loss of loved ones, the community suffered the loss of access to care, and hospital staff experienced the loss of jobs and income. Officials required the hospital to be totally evacuated and the electrical power to be cut until a full investigation and corrections to the building construction and systems could be made.

Why all the regulations

There are so many regulations, including construction and fire codes, as well as equipment, training, and documentation requirements, which are driven by codes, accrediting organization standards and the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). These codes, standards and CoPs exist because of past process and system failures in health care, as well as lessons learned from many other industries.

Whether it’s a fire sprinkler, electrical, infection control or communications system, medical equipment, medical procedures, documentation requirements, or construction itself … all of these components of health care interact with one another and support each other. One system’s failure may cause an unrecoverable chain reaction. This is why having the systems is important, but not sufficient. These systems must be maintained at least to code and manufacturers’ recommendations.

Multiple systems with redundancy are, by design, for increased safety. Not knowing what safety systems you need to have in place, and how to maintain them, can lead to a catastrophic failure similar to the massive fire in the Saudi Arabian hospital. The codes, standards and CoPs are primary tools that require safer health care construction, maintenance and safety practices. Adopted codes by local, state and federal authorities having jurisdiction make these codes not just informational, but also required and therefore enforced by law.

In the case of hospitals that accept Medicaid and Medicare reimbursements, meeting the CoPs – or in the case of ambulatory care facilities, Conditions of Coverage – the conditions are legally enforceable. If a facility does not meet the conditions, they can lose CMS reimbursement and may be charged financial penalties for non-compliance. 

The key to success is knowledge

Staff who manage these systems need to know the codes, standards and CoPs that support good practices, and they need to perform and document these practices appropriately. Knowledge shouldn’t stop at the manager level. As someone once said, “Familiarity dims the vision.” In other words, the closer you are to something, the less you see and the more you take it for granted. So the more people with access to and knowledge of the codes, standards and CoPs, the more eyes there are to confirm that what is being done is correct and safe.

This knowledge deficiency and dimmed vision can also happen to contractors and vendors who support the hospitals. These groups are hired as the experts. However, if you don’t have the knowledge of the codes, standards, CoPs and the expectations of what is provided by your vendors, then how can you be certain that the expert is, in fact, the expert?    

Moving forward

I hope that what happened that day in Saudi Arabia never happens here in the U.S., or anywhere else in the world for that matter, as the tools to have a safe environment of care are readily available.

But just having these regulatory guidelines is not enough. Teams must immerse themselves in these to get the maximum value from them. Don’t protect your knowledge from others. Share it. And you must hold yourself and fellow team members to the highest level of performance and compliance to standards, as any one of us can be effected by an incident like the horrific fire at the Jazan General Hospital.

About the author. In his role as accreditation advisor, Greg Cochran is responsible for delivering accreditation and regulatory services to members encompassing hospital, ambulatory and critical access organizations. He provides content expertise on CMS conditions of participation and The Joint Commission (TJC) accreditation standards interpretation. Additionally, Cochran performs project management services for all accreditation services activities, including compliance assessments, on-site or virtual coaching during TJC surveys, and delivering educational presentations on accreditation and CMS compliance topics. In his role he ensures that leaders are receiving maximum value from their participation in Vizient accreditation advisory services. Prior to joining Vizient, Cochran worked for eight years as a full-time life safety surveyor for TJC. He has more than 28 years of experience managing the physical environment, which includes 24 years of hospital safety and facilities management programs and services in a variety of health care settings.

Published: October 18, 2019