1. Part 6: The Monitoring and Reporting Challenge Healthcare Engineering Consultants What is the most effective method to provide EC monitoring and reporting?

2. Monitoring Regulatory Compliance Healthcare Engineering Consultants How should regulatory compliance be monitored?

3. Monitoring Regulatory Requirements Healthcare Engineering Consultants

4. Monitoring Regulatory Requirements Healthcare Engineering Consultants

5. Monitoring Regulatory Requirements Healthcare Engineering Consultants

6. Reporting Regulatory Requirements Healthcare Engineering Consultants Hospital Governing Body Hospital Executive Committee Hospital EOC Committee Accident and Safety Subcommittee Hazardous Materials Subcommittee Life Safety/ Construction Subcommittee Equipment and Utilities Subcommittee Emergency Management Subcommittee Step 1: Create regulatory compliance “dashboard” for the Life Safety/ Construction Subcommittee

7. Reporting Regulatory Requirements Healthcare Engineering Consultants

8. Reporting Regulatory Requirements Healthcare Engineering Consultants Hospital Governing Body Hospital Executive Committee Hospital EOC Committee Accident and Safety Subcommittee Hazardous Materials Subcommittee Life Safety/ Construction Subcommittee Equipment and Utilities Subcommittee Emergency Management Subcommittee Step 2: Create regulatory compliance “dashboard” for the Hospital EOC Committee from each subcommittee “dashboard”

9. Monitoring Regulatory Requirements Healthcare Engineering Consultants Hospital Governing Body Hospital Executive Committee Hospital EOC Committee Accident and Safety Subcommittee Hazardous Materials Subcommittee Life Safety/ Construction Subcommittee Equipment and Utilities Subcommittee Emergency Management Subcommittee Step 3: Create a simplified regulatory compliance “dashboard” for the Hospital Executive Committee from the EOC Committee “dashboard”

10. Reporting Regulatory Requirements Healthcare Engineering Consultants

11. Reporting Regulatory Requirements Healthcare Engineering Consultants Hospital Governing Body Hospital Executive Committee Hospital EOC Committee Accident and Safety Subcommittee Hazardous Materials Subcommittee Life Safety/ Construction Subcommittee Equipment and Utilities Subcommittee Emergency Management Subcommittee Step 4: Create a simplified regulatory compliance “dashboard” for the Hospital Governing body from the Executive Committee “dashboard”

12. Reporting Regulatory Requirements Healthcare Engineering Consultants

13. Monitoring Performance Improvement Performance Improvement “Attempting to measure and improve performance on an ongoing basis in the Environment of Care” Healthcare Engineering Consultants

14. Measurement and Improvement The “PI Continuum” Healthcare Engineering Consultants Very simple Very complex

15. Measurement and Improvement What Measurements are Required? Patient and visitor injuries Property damage incidents Staff injuries and illnesses Security incidents for patients, staff, visitors Hazmat spills, exposures and related issues Fire safety problems, deficiencies and failures Medical equipment problems, failures, user errors Utility system problems, failures and user errors Healthcare Engineering Consultants

16. Measurement and Improvement What Performance Improvement Measures are Required for each “EC” area?  Minimum of seven performance measures  Should be numerical  No maximum number  Should measure performance improvement  Adopt goals, objectives and benchmarks  Regular reporting and tracking to SC Healthcare Engineering Consultants

17. Selection of “EC” PI Indicators Healthcare Engineering Consultants

18. Measurement and Improvement How Should Terms Should be Defined? Goal: The attempted attainment of “perfection” Example: No patient falls during the year! Benchmark: Actual, historical, internal or external data used for comparative purposes Example: “X” patient falls occurred last year Objective: Attempted attainment of “realism” Example: Reduce patient falls from last year by at least 10% Threshold: The point at which action is taken Example: Investigate every patient fall that occurs Healthcare Engineering Consultants

19. Monitoring and Improvement How are “EC” Performance Improvement Measures Monitored? Healthcare Engineering Consultants

20. Monitoring and Improvement Monitoring of “EC” issues through: Creation of the “Multi-Disciplinary Improvement Team” Safety committee membership and meetings Communication to leadership Annual PI initiative recommendation to management Monitoring of Effectiveness Selection of numerical performance measures Establishment of goals, objectives, benchmarks Aggregation of data (“dashboard” or spreadsheet?) Healthcare Engineering Consultants

21. Reporting of “EC” PI Indicators Healthcare Engineering Consultants

22. Monitoring and Improvement The “PI Process” Healthcare Engineering Consultants Measurement Initiative Implementation

23. Monitoring and Improvement The “PI Process” Healthcare Engineering Consultants Measurement without implementation and ongoing monitoring to validate improvement is of little value!

24. Monitoring and Improvement Questions? Healthcare Engineering Consultants