Be Prepared.

The motto that served for decades for the Scouts resonates equally well with Hospital Administrators and Facility Managers today.

MSL diligently works with our customers and clients to “be prepared” to deliver the best environment for patients, families and hospital staff with the by-product of those efforts resulting in the ability to withstand the rigorous visits by the various regulatory agencies that govern healthcare today. To that end, we will share three new questions that The Joint Commission is asking Facility Managers prior to starting the building tour associated with the TJC visit:

  1. What type of fire stopping is used in the facility?
  2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
  3. Which materials are used (glutaraldehyde, ortho-phthalaldehyde (OPA), peracetic acid, etc.) for high-level disinfection or sterilization?

The first question regarding fire stopping helps the surveyor understand what they should be seeing as they encounter sealed penetrations in fire and smoke barriers. Ideally, a best practice is to use a standardized product throughout a building; however, many hospitals have changed vendors over time and may have two or more manufacturers’ products in use.  Product colors and installed appearance may vary and knowing what to expect at the beginning of a survey is beneficial to the survey process.  In addition, the question is intended to help gain an understanding as to the training of those with responsibility for barrier management and the skill set of those actually installing the material. 

The question regarding the ceiling access policy is intended to help prepare for any areas which may require special equipment for ceiling access and to help the surveyor understand how the hospital manages risk in different healthcare environments within the hospital. This particular question allows the surveyor to gain insight into the thought process used in infection control and risk management and, as the ASHE article states, exposes the level of “sophistication” of the Facilities Management and Infection Prevention team.   In addition, the expectation is that the next iteration of Joint Commission Standards will add an Element of Performance regarding maintenance practices in regard to the Infection Control Risk Assessment (ICRA).

The third question helps the surveyor cross reference the chemical manufacturer’s recommendations for air quality against the current standards for affected areas.  (In some instances, the chemical manufacturer’s recommendations may be even more stringent than the requirements set forth in ASHRAE 177.)  This particular question touches on a number of elements of performance in Joint Commission Standards.  For example, is the chemical inventory and SDS information complete and correct? Does the hospital and its staff know where various chemicals are stored or in use? And, how well are air relationships managed in the hospital and is the maintenance staff familiarized with how different sterilization and cleaning equipment are used?

MSL is a strong supporter of the American Society of Healthcare Engineers (ASHE), and wishes to acknowledge ASHE for publishing this information in the August 23, 2016 edition of ASHE’s online news service.  For more information and detail visit ASHE Insider <>