Compliance+Operations

Insourcing services for accreditation surveys

Building the case for hiring staff in-house for compliance tracking
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Most large hospitals and health care systems could benefit significantly from an internal fire-alarm team.

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Health facility professionals may want to consider building a business case to insource services for future accreditation surveys. For critical access hospitals, this likely won’t make sense; however, for large hospitals or multifacility systems, a list of outsourced services can be considered.

Sprinkler systems by themselves likely will not justify hiring a testing, inspection and maintenance team. Instead, facility professionals should consider adding similar systems to sprinkler systems: fire extinguishers, kitchen-hood systems and clean-agent systems. Coupling these systems together might justify building, training and certifying a team. But, even in these cases, some specialized services, such as annual firepump testing or hydrostatic testing for extinguishers, might still need to be outsourced.

Fire alarm systems are a different animal. Most large hospitals and health care systems could benefit significantly from an internal fire-alarm team. It is important to note that several life-safety systems require a recognized certification like a state license or National Institute for Certification in Engineering Technologies (NICET) certification. Facility professionals should know the requirements and train the hospital’s life-safety team to comply with them.

If possible, facility professionals should hire seasoned, licensed technicians. It is likely they will need retraining to test to current code requirements because technicians often are taught to provide expedited or condensed testing. Examples include fire alarm and sprinkler components such as electronically testing waterflow switches,  missing anemometer/manometer readings, magnetically tested heat detectors, and missing or skipped tests for emergency control functions.

If insourcing is not possible, facility professionals should read the testing companies’ quotes and contracts. The legal portion likely contains a note that the quote is based on specific tests and is not a complete code-compliant test and that the remainder of the testing is the owner’s responsibility. This is what leads to a lack of training among technicians on code-compliant testing. 

Insourcing ultimately depends on a hospital’s outlook on resourcing, but it will almost guarantee to reduce the hospital’s annual spending on these systems because overhead and profit will be eliminated.

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