Tools for regulatory compliance

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As the largest organization representing health facilities managers, the American Society for Health Care Engineering (ASHE) is uniquely positioned to provide advocacy and assist its more than 12,500 members with the compliance issues they face.

ASHE does this through an array of tools and resources developed by subject matter experts (SMEs), many of whom emerge from its membership ranks.

These resources are continually evolving to provide greater assistance to members. They are increasingly applicable to day-to-day operations, are ever more accessible to members near and far, and available in a growing variety of formats and media, from online tools to e-learning to health care construction workshops to weeklong academies.

Aiding compliance

ASHE helps members with compliance in a variety of ways, say those who best know the organization’s work. ASHE enjoys a unique position due to it being the largest organization representing facilities managers in the field, says ASHE’s Chad E. Beebe, AIA, FASHE, CHFM, deputy executive director of advocacy.

“We have a very involved advocacy program, having spent the last 15 years unifying the regulations so they’re all saying the same thing,” Beebe says. “Our perspective is unique in that we are interpreting regulations that help our members understand the rules and regulations. We understand our members have to deal with compliance, and it’s a small part of what they do. So, our mission is to take the hard work out of that and drill down to the answer of, ‘How do you comply?’

“We’ve actually physically advocated for changes to the regulations to make things easier,” Beebe says. “And through that effort, we are literally able to make things easier and disseminate that to members. All our efforts focus on that with members in mind, as we try to make their jobs as easy as possible.”

Asked his thoughts on how ASHE helps, ASHE’s Jonathan Flannery, MHSA, FASHE, FACHE, senior associate director of advocacy, adds that delivering resources and alerts is another resource ASHE provides. Flannery says the organization helps members optimize the health care physical environment so they are not only compliant with all the CMS regulations, but also so they are providing the best environment for patients to heal and be safely cared for.

ASHE’s programs have always been patient focused but have evolved to be more accessible and more applicable to day-to-day operations, Flannery says. 

“A lot of our compliance resources are available online, instead of having to do face-to-face training,” he says. “But face-to-face training is still part of our program, allowing for questions and interaction. We understand that having to travel for training is more difficult. That’s why accessibility of resources is key.”

In Flannery’s view, the greatest compliance tools offered by ASHE include the Health Facilities Management compliance tools and articles and the My ASHE online community. “Another one we’re working on updating is the Focus on Compliance program,” he says. “It’s a website where we monitor the most often-cited citations, and provide tools and resources for members to address those issues.”

Russell Harbaugh, area director of support services for Boise, Idaho-based St. Luke’s Health System, is an ASHE faculty member working with leading experts to prepare a newly revised 2020 program titled, “Managing Accreditation for the Physical Environment Workshop.” He calls ASHE a trusted industry leader in developing educational programs to help health care professionals gain the knowledge and tools needed to stay compliant with accrediting bodies and maintain a safe environment.

“Whether a facility manager, an engineer, a contractor or an architect, the programs offered are there to enhance the skills of the health care professional,” he says. “Through ASHE’s many learning courses or through their certifications, they truly provide avenues for professionals to obtain the education that benefits their hospital or health care system.”

Gary L. Hempeck, CHFM, FASHE, a former health care leader at North Memorial Health System in Robbinsdale, Minn., has served on the ASHE Board, as well as on several committees. “ASHE is a good resource for its members to get answers,” he says. “ASHE has a strong code advocacy program.”

ASHE helps its members with compliance, Hempeck adds, through the advocacy group, “Just Ask ASHE” service and its web forums, among other venues.

ASHE’s capacity to help “facilities folks to understand the connection between the codes existing in our industry and how they need to be used within their facilities to be code compliant, is ASHE’s compliance education programs strong suit,” says Dave Dagenais, senior director of facilities in clinical engineering and emergency management for Wentworth-Douglass Hospital in Dover, N.H. Dagenais has maintained several roles with ASHE. “I’m very much involved in educating the compliance readiness program,” he says. “But I also do education around [the National Fire Protection Association’s] NFPA 99 [Health Care Facilities Code] and NFPA 101^® [Life Safety Code^®].”

Program types

Types of programs offered by ASHE range from conference reporting to PowerPoint presentations to videos. “One of the most important initiatives we’ve provided over the last four years is the launch of tools to facilitate members’ compliance,” Flannery says.

Beebe says the organization offers educational opportunities through different means, including distance learning, face-to-face programs and ASHE Education Showcase programs that spotlight a number of its initiatives. “We are planning to have six or seven showcases yearly, always in Chicago,” Beebe says.

“We also have weeklong education events called ASHE Academies,” he says. “Go to the academy, attend one or two days, or attend the entire week and take a number of courses over those five days. They will be held in different cities. In 2020, they will be in Nashville [Tenn.] and Las Vegas.”

The single most popular program is the health care construction workshop, primarily for those working for health care contractors and laboring to understand the health care environment, Beebe says. The fast-paced world of infrastructure upgrades in health care, coupled with a lack of, or limited, contractor resources is making this concern more important.

“There are a lot of contractors out there, and new ones coming in,” Beebe says. “And that’s where we have to be really cautious, because not everyone understands the uniqueness of the health care environment, which involves infection prevention, continuity of utilities, privacy and other issues. Working in an environment that is still open and functioning inherently brings a number of risks to patients, staff and visitors.”

Hot topics

ASHE has an annually established task force that evaluates a number of the current issues most important to members. The task force prioritizes those compliance issues and creates articles and tools focusing on these issues. 

The materials and tools, increasingly in video form, are made available to ASHE members on an ongoing basis through Health Facilities Management articles and the ASHE website, Flannery says.

An excellent example is a recent ASHE-produced video to educate surgery staff on the critical relationship between temperature and humidity, he says. In an operating room, the surgery staff is clothed in operating garb and is warmer than the patient, who is likely unconscious and minimally clothed. When the temperature is lowered, the humidity in the room is increased, which can elevate the risk to the patient.

“Being able to explain that is important,” Flannery says, noting that prior to the video’s creation, the relationship was explained via a complicated psychrometrics chart. “This is a simple video showing how the relationship works, and we encouraged sharing it with clinical as well as support staff.”

Another recent production was a safety video that addressed the tendency to decorate hospital rooms during the holiday season. “In a hospital, that carries inherent risk,” Flannery says. “Cover a fire door in wrapping paper and you create an increased fire risk. Yet, allowing patients, staff and visitors to enjoy the holidays is important. So, we put together a video that shows they can retain the holiday spirit and still maintain safe environments.”

Among the hottest topics on which ASHE is working is sprinkler piping supporting non-system items, according to Flannery. 

“We’ve put together a monograph for people on that,” Flannery says. “It’s one of the leading citations for health care facilities out there. According to code, you’re not allowed to have anything touching nor being supported by the sprinkler piping system. Needless to say, that’s very difficult to do. The monograph tells why that’s important, and identifies some of the major issues and impacts.”

For his part, Beebe says ASHE is currently looking at two very important topics for future courses. The first is infection prevention, which goes beyond simply exploring in-place procedures and policies. “We will investigate actual incidents and how policies and procedures were in place to minimize any negative impacts,” he says. The other is water management. Unfortunately, a number of incidents of waterborne illness have occurred in recent years, some resulting in illnesses like Legionnaires’ disease.

ASHE is releasing programs to give managers tools and resources needed to develop or refine sound water management programs, he says. “Some of what’s involved is due diligence, helping facilities double check that their water management programs are in alignment with what is being recommended by ASHE and [the American Hospital Association],” he adds.

As for whether ASHE anticipates making changes to its compliance education, Beebe reports the organization continually changes compliance education to keep pace with the changing hot topics in the health care environment. Major updates happen every year. Taken into account are the introduction of any new interpretations, he adds.

As for ASHE’s survey readiness program, information gathered and observations identified in the field about surveys help inform the content. This allows ASHE to determine what the accrediting organizations and CMS are looking for, helping facilities stay one step ahead of any changes. 

“We try to really explain why the rules say what they say,” Beebe says. “We’re not just teaching you chapter and verse of what the regulations say. We’re telling you philosophically why they say what they say, so managers can identify solutions to the problems that work for their facilities.”

In developing programs, ASHE has worked with Oakbrook Terrace, Ill.-based The Joint Commission, Flannery says.

“Our Focus on Compliance was developed in partnership with them,” he says. “We’ve also worked with local chapters in coordinating programs. We don’t go directly to the chapters asking for SMEs, but our SMEs are members of chapters. For instance, the Kentucky chapter has a Safe Day One program, a health care facilities orientation and safety training program. And we’ll use that in our work, and they will use our health care physical environment worker certification.”

Learning more

To learn more about education, ASHE urges members to visit the education section of the organization's website. As well, they should consider attending ASHE’s Planning, Design and Construction (PDC) Summit each March, and its annual conference in the summer.

Both highlight a couple of the organization’s programs in pre-conference showcase sessions, offering attendees opportunities to gain a greater understanding of the education ASHE offers, Beebe says.

Those who would like to see ASHE develop content for compliance education, and have resources to share, should reach out to ashe@aha.org, Beebe says. They should also share their insights in the My ASHE community forum and volunteer, he adds.

Nonmembers can take advantage of some of ASHE’s compliance education resources, but not all of them, Flannery says. “The senior management team decides that,” he says. “If it’s a program we feel everyone needs, we’ll make that available to everyone. For instance, the Focus on Compliance program is available to everyone.”

Beebe agrees there are ways non-ASHE members can avail themselves of compliance education resources. 

“We often provide member pricing to members of ASHE-affiliated chapters,” Beebe says. “And if there’s anyone interested in taking these courses, I’d encourage them to work with the chapters to see if they are offered, or for the chapters to work with ASHE to bring them to their memberships.” 

Jeffrey Steele is a freelance writer based in Chicago.