The data that drives your BMP during a survey

There are a couple of important points with The Joint Commission’s building maintenance program that somehow seems to get lost in the shuffle:

• The critical role of data in this process
• The practical application of the BMP during a survey

As the decisions you make regarding inspection frequencies and related activities should be validated by the data you’ve collected, remember that the findings of Joint Commission surveyors also are rendered based on the data collected during survey. This data collected during survey is a significantly smaller sample size than you would be using to validate your program (your entire inventory of a device versus the number viewed during survey).

As a result, you must be prepared to demonstrate the compliance of your program as a function of the post-survey clarification process. A rated door that doesn’t latch here, an exit sign that is not illuminated there, a couple of penetrations somewhere else—you can get into RFI territory very quickly.

My consultative advice for starting this process is the following:

1. Pick whatever BMP elements you're going to manage in this fashion (the current list if items you may include can be found on Page 3-15 of the Statement of Conditions)
2. Identify an inventory of the devices in each category (that's really the only way to be able to demonstrate that you have a 95% compliance rate for that device)
3. Determine what frequency you can attain given current resources, though I would counsel at starting frequency of no less than quarterly

Again, there are elements that are not going to require as much attention, but you need to make that decision based on the failure data collected during BMP activities. That can be another challenge: getting the folks doing the inspections to tell you when they found something that wasn't working properly. Frequently they will just do the repair work and move on without documenting, but the key data is knowing how often the device is not working correctly.

For some additional information, almost akin to a glimpse behind the velvet curtain, you can access the technical paper about the BMP that George Mills (senior engineer at The Joint Commission) and some other folks penned for the American Society for Healthcare Engineering some time ago.

While the paper is somewhat outdated in terms of specific compliance concerns (for example, it references the 1997 Life Safety Code®, it does provide a good overview of the intentions guiding the BMP’s development and implementation.