Joint Commission official offers code perspectives

The McKenzie File

CV

• Director of department of engineering in the standards interpretation group at The Joint Commission, Oakbrook Terrace, Ill.
• Manager of facilities management at Alexian Brothers Health System, Arlington Heights, Ill.
• Administrative director of support services at Adventist Bolingbrook Hospital, Bolingbrook, Ill.
• Manager of ambulatory facilities at University of Illinois Medical Center, Chicago.

Distinctions

• Past president of the Healthcare Engineers Society of Northern Illinois.
• American Society for Health Care Engineering member.
• Certified Healthcare Safety Professional

Education

• Master of Business Administration, Governors State University, University Park, Ill.
• Bachelor of Science, electronics management, Southern Illinois University, Carbondale.

As director of the department of engineering in The Joint Commission’s standards interpretation group (SIG), Herman A. McKenzie, MBA, CHSP, leads SIG and customer support activities relative to the Life Safety (LS) and Environment of Care (EC) standards. This month, he talks to Health Facilities Management about his role.

Why did you decide to join The Joint Commission? 

Throughout my career in health care, I have been attracted to administrative tasks, especially issues of compliance. I had always wanted to transition to a second career of teaching, and I find my role at The Joint Commission lends to that skill set. During my hospital career, I have had the responsibility of chairing EC committees at more than one facility. Consequently, I had a good idea of the issues that compliance dealt with. 

What are your duties and responsibilities as director of the department of engineering’s SIG?

I will separate the duties of the director of the department of engineering SIG into three major categories. 

In the first category, my responsibility is to serve as content expert for the department of standards and survey methods within The Joint Commission. This department holds accountability for ensuring that our standards and elements of performance match the Centers for Medicare & Medicaid Services (CMS) conditions of participation. They rely on my team and me to be the technical content experts. For instance, if there is a change to a standard or a requirement for a new element of performance, I need to ensure that it matches the requirements set forth by the National Fire Protection Association’s NFPA 99-2012 and/or NFPA 101-2012, which are the Health Care Facilities Code and the Life Safety Code^®, respectively.

Our second role is to support the field staff. My team in SIG conducts annual surveyor refresher training as well as what we term “real-time calls” with Life Safety Code surveyors while they are on-site at surveys. We review the observations that they have cited as deficiencies for validity prior to these findings entering into a final survey report. 

The third category of duties revolve around post-survey tasks. In this role, SIG reviews survey reports for accuracy, reviews organizations’ corrective action plans and provides interpretation to The Joint Commission’s EC, LS and emergency management standards. 

SIG also serves as the faculty for educational programs such as EC and LS base camps, ambulatory conference and behavioral health care conferences. 

What was your experience prior to joining The Joint Commission? 

I started in health care in the biomedical engineering field. My first hospital job was maintaining medical equipment in a one-man shop in South Bend, Indiana. My biomedical experience included eventually becoming a manager and director. 

In 2000, a former supervisor recommended a facilities manager position for an ambulatory network. This was my entry into facilities management. 

Prior to coming to The Joint Commission, I had the opportunity to lead multiple hospital support departments. This scope has included plant operations, security, housekeeping, respiratory therapy and sleep lab.

Do you see any differences and similarities between your background in biomedical and your current focus on LS and EC? 

Both deal with maintenance management of equipment and utility components. However, in the biomedical field, there are hands-on equipment users such as technologists, nurses and physicians. 

The utility equipment that maintains and controls the environment is critically important, and staff will let you know when it is not working; however, the clinical and allied health professionals have no knowledge of the make and model of the air handlers, boilers, chillers and other utility components that support the physical environment. 

When staff personally interact with equipment such as electrocardiogram machines, infusion pumps, and computed tomography and magnetic resonance imaging machines, they become very particular with how the device is maintained. For me, the interaction with equipment users helped me build communication skills as well as customer focus.  

What is the leading issue for compliance within the LS standards? 

In terms of scoring, issues with sprinkler systems were the most frequently scored Life Safety Code standard in 2019. The specific deficiencies that we find are blocked sprinkler heads, and items other than sprinklers being supported by the sprinkler lines. 

What is the leading issue for compliance within the EC standards? 

Our most commonly cited EC standard in 2019 fell under utilities management EC 02.05.01. There is a spectrum of issues that we find under this standard, with the most impactful of these being EC 02.05.01, EP 15, which has to do with critical spaces maintaining the proper ventilation requirements. 

Specific areas of focus are operating rooms and sterile storage areas. The Joint Commission places great emphasis on this because maintaining these environments is critical to minimizing the potential for infection control issues.

A number of LS and EC standards are repeatedly among the most-cited Joint Commission standards. How are you helping hospitals to improve in these areas?

I have opportunities to address many in the health care field through my speaking engagements. In addition to sharing compliance and code updates, I have made it my goal to educate our customers on possible solutions to compliance issues instead of simply pointing out the problem issues in health care. 

I’ve found that my audiences appreciate an educations approach over one that is punitive. 

I’ve also discovered through my speaking engagements that many managers are not aware of the resources they are provided as a Joint Commission-accredited health care organization. These include the assignment of a dedicated account executive to field general questions. 

Joint Commission account executives can also facilitate meetings with hospital staff and SIG Engineering staff outside of survey activity to address specific questions regarding our standards. I reinforce to my audiences that these resources are available to them. 

What is the best way for health care organizations to get clarifications for survey and day-to-day facility issues? 

If an organization believes that an observation was cited in error after a survey concludes, it may file a clarification. Health care organizations must bear in mind that submitting required paperwork after a survey event would not be accepted as a valid reason for overturning a finding on clarification. 

What procedures can hospitals follow on a day-to-day basis to stay compliant with codes and standards?

I recommend that they commit to the area of compliance. 

This means reviewing standards and elements of performance annually and conducting internal reviews to see that their records are in order and all tasks associated are completed. 

In addition, educate all staff that compliance is an important part of their jobs in health care.