Case Study: The Joint Commission Statement of Conditions™
The Challenge
Rush University Medical Center (RUMC) is an academic medical center that encompasses a 613-bed hospital serving adults and children, the 61-bed Johnston R. Bowman Health Center and Rush University. Rush University is home to one of the first medical colleges in the Midwest and one of the nation’s top-ranked nursing colleges, as well as graduate programs in allied health, health systems management and biomedical research. The Rush campus encompasses more than 3,000,000 square feet of clinical, research, educational and administrative space throughout 14 buildings. The project scope covered approximately half of the campus.
Managing code compliance issues, especially at a healthcare institution of Rush University Medical Center’s (RUMC) size, can be a painstaking process. To make matters even more pressing, the ever-increasing compliance demands imposed by the Joint Commission meant that RUMC had to safeguard its reputation as one of the most prestigious and progressive healthcare institutions in the nation. At the same time, facility administrators had to ensure that their campus-wide solution was cost-effective in both the short and long term.
RUMC’s greatest challenge was to adopt an intuitive and proactive approach when dealing with regulatory issues. They were in search of a solution that would be capable of meeting its present code-compliance needs, as well as new compliance demands that would come from the Joint Commission.
The Joint Commission had informed all accredited facilities that the Statement of Conditions™ (SOC) process would be migrating to an electronic format. This presented another challenge for a large institution such as RUMC. In addition, the new “Unannounced Survey” policy of the Joint Commission meant that RUMC needed to take its approach to the SOC to a new level.
The Solution
Advanced Technologies Group, Inc. (ATG) devised a comprehensive facilities management strategy that would address RUMC’s challenges and specifically their Joint Commission SOC audit preparation. The project scope entailed:
- Taking an accurate inventory of fire and smoke barrier walls and integrate data into the corresponding architectural CAD files to form a master life safety plan.
- Surveying and detecting code-deficiencies according to NFPA 101 standards as defined by the Joint Commission. The survey was conducted by ATG’s code-consulting partner, Rolf Jensen and Associates, Inc.
- Incorporating deficiencies and the corresponding Plans For Improvement (PFIs) into the master life safety CAD files utilizing ATG’s SOC-specific, back-end technologies.
- Formulating post-SOC methodologies to transform SOC reports into living documents that would allow for the automatic updating of completed PFIs. This allows RUMC to be ready for the “Unannounced Survey” policy of the Joint Commission.
- Providing authorized users with easy access to the full range of RUMC’s facility management data through ATG’s web-based front end solution, called the Active Visual System (AVS).
- Providing RUMC with the support and capability to facilitate the Joint Commission eSOC requirements, including the posting of the eBBI and ePFI data on the Joint Commission site.
Authorized users can instantly access facility-related information
and run reports via the Internet.
The Results
Following the implementation of ATG’s solution, RUMC can now benefit from a wide array of solutions including:
- Increasing the accuracy and reliability of Life Safety Code (LSC) deficiency reports
- Automatically compiling Plan For Improvement (PFI) forms, eliminating time-consuming manual work
- Instantly informing SOC surveyors of previously identified LSC deficiencies, corrective actions and status of completion
- Creating and distributing deficiency reports in seconds, expediting corrective action
- Allowing authorized users at all levels the of the organization to instantly access SOC and all other facility-related data from any computer with internet access with no training in CAD or other proprietary software through the AVS
- Addressing the eSOC requirements seamlessly
- Preparing for and easily passing the impending Joint Commission unannounced survey
- Managing and updating the PFI list as a true “living document”
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