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Built Environment Best Practices Projects to Operations to Compliance Jim Inzeo & Anthony Younan
Built Environment Best PracticesProjects to Operations to Compliance
Jim Inzeo & Anthony Younan
Agenda
Where do you begin?
Document Management
Owner Requirements
Best Practices
Industry Best Practices
Compliance Best Practices
Goals & Objectives
Begin with the end in mind
A safe and functional environment
Understand the process
Take control
Lower your risk
Do a better job with patient safety and HCAHPS
Different Documents in Different Places
Organization
A Mess!
Owner’s Requirements
What do you need for operations?
What do you need for compliance?
Electronic records vs. paper records
How is it organized?
Review your agreements
Agreement Between Owner and Architect
Agreement Between Owner and Contractor
General conditions
Changes Coming?
Let’s Start With Project Documents
Drawings
Specifications/Project Manuals
O&M Manuals
Product/Equipment Information
Vendor Reports
Compliance Documentation
Contract Documents
Bid/Construction Documents
Addenda
Bulletins
RFI/ASI
Submittals
What does this have to do with compliance?
*8 of the Top 10 Findings by TJC surveyors have to
do with the built environment.
Information created during projects is critical to
obtain and maintain compliance.
Wall Construction
Ceiling Assemblies
Door Hardware
Manufacturers’ Recommendations
* Joint Commission Perspectives September 2017
Best Practice: Step 1
Stop the madness!
• The best time to capture information is when it
is created.
• Take control by creating a document
management policy which puts you in control
• Capture Benchmarks
• Programming/Feasibility studies
• Schematic Design, Design Development
• Construction Documents and Revisions
• Closeout Information
Best Practice: Step 2
• Get your house in order
• Figure out what you have
• Paper drawings
• 3 Ring binders
• CD’s DVD’s
• Local copies
• Network drives
• Aggregate and organize paper and digital files
• Start with most recent and work backwards
Best Practice: Step 3
• Identify Compliance Specific Documents
• Equipment list
• PM Schedules
• Test & Balance
• Life Safety Drawings
• Inspection Reports
• Certifications
• Local AHJ Inspections
• Etc., Etc., Etc…
What do you want/need in the end?
Project Contact List
Asset information – Make, model, mfg, PM sched.
BIM/CADD Files
As Built and/or Record Drawings
Lien Waivers & Warranties
Reports/Certifications
Updated Life Safety Drawings
Typical Project Information
How do YOU want things organized?
Develop a Checklist
Folder Structure
File Naming Convention
Document Audit Process
Sample Closeout Organization
Maintaining Compliance
Project Closeout – Snapshot in time
What’s your model?
3 Year Episodic Cycle?
Continual Compliance?
Two components:
Documentation
Observations
Maintaining Compliance
How do you maintain?
How do you organize?
How do you know what you need?
How do you identify compliance gaps?
How do you know the state of compliance?
How do you measure compliance?
Compliance Best Practices
Documentation organized by Standards
Physical Environment
Life Safety
Emergency Management
Documentation Organized by Frequency
Weekly, Monthly, Quarterly, etc.
Compliance Best Practices
Adopt a system which is scalable and repeatable
Analog or digital?
Binders, filing cabinet, network or cloud drive
What’s Next?
Review your agreements
Are you asking for the right stuff?
How are you providing guidance on organization?
Insource or outsource?
When everyone is responsible for document
management, no one is responsible for document
management.
Someone needs to take ownership!
Big Picture
Succession planning…
A very large part of the patient experience is tied to
the facility.
How do you implement systems for document and
compliance management that define your legacy?
Jim Inzeo
615-250-9131
Anthony Younan
614-956-6069
Go Ahead, Drive the Ultimate Patient Experience
