Too often, healthcare facilities are not ready for accreditation the day after they receive their Certification of Occupancy (CofO). Traditional construction processes must be reviewed and evaluated to change this, identify potential gaps, and resolve them by applying industry best practices.

Construction planning is most successful when it occurs in two individual efforts - master planning and project planning. Master plans are developed using population growth modeling, utilization data from EMRs to forecast current and future needs, and physical plant needs to provide a framework to determine and define upcoming project requests.

Once an individual project has been approved, a project plan is created. The project plan should contain a schedule detailing all project-related activities, the budget, the contribution team and roles, and a description of how progress and results will be measured. Soleran’ s Construction Project Manager is a good tool for this kind of project organization.

Design

Design typically occurs in three phases: 

1. Schematic Design (SD)
2. Design Development (DD)
3. Construction Document (CD)
   

Schematic Design (SD)

The purpose of SD is to translate the project plan into drawings of space. The project team determines the areas, physical requirements, and relationships of required building spaces and components, confirming or revising the total building square footage and comprehensive project budget.

Design Development (DD)

In the DD Phase, the schematic plans and elevations are revised and expanded to incorporate details and specifications required for construction. Designers ensure compliance with all applicable local, state, and federal codes and statutes. The design drawings and specifications define the facility's size, function, configuration, spaces, equipment, and construction materials.

Construction Document (CD)

With this information, the project budget, schedule, and related building plans are finalized, and upon final review and approval, DDs become CDs.

Construction

Construction is the process where contractors build structures and grounds in four phases: 

1. Start-Up
2. Construction
3. Occupancy
4. Close-Out
   

Start-Up 

In Start-Up, contractors create a baseline schedule to complete the construction. The construction phase begins and ends the building of the project.

Construction

The project team - including the owner, architects, engineers, interior designers, and construction project managers, monitor and manage the project during the Construction Phase.

Occupancy

Occupancy of a building occurs when the project is complete enough for the fire marshal and other applicable Authority Having Jurisdiction to issue a Certificate of Occupancy or C.O.

Close-Out

Upon Substantial Completion, various documents are produced or obtained that complete the construction documents. These include as-builts, record drawings, markups, closeouts, maintenance, operation manuals, permits, warranties, and other documents necessary to occupy and maintain the facility.

Commissioning

A best practice used by many healthcare facilities is to perform the commissioning of systems. Commissioning is the process of planning, documenting, scheduling, testing, adjusting, verifying, and training to provide a facility that operates as a fully functional system per the Owner's Project Requirements (OPR). Commissioning typically includes verification of test and balance results of mechanical systems and lighting levels as designed.

Verifying that building systems and the building itself meet requirements of applicable codes and standards for healthcare facilities is rarely included, and meets code regulations. Compliance Commissioning demonstrates system design, documents, and programming of building systems.

For commissioning to be most successful, the Scope of Services must be clearly defined, and the commissioning team engaged before design to develop design criteria around the client’s Owners Project Requirements (OPR). These OPRs are produced by various operational, facilities management, compliance, and leadership teams to create the framework for measuring commissioning.

Operations (Facilities Management)

Often, owners wait until substantial completion to consider how the building will be operated and maintained. This routinely results in high operational costs and impedes or prohibits their ability to comply with applicable standards of operation. A best practice would be for operations to be engaged in all project phases. A best practice at the operational level may be to develop or amend its Strategic Asset Management plan during construction. Strategic Asset Management is a long-term planning & approach for maintenance and operations in which a time-based plan is made and executed to maximize stewardship of defined assets.

Strategic Asset Management should begin in parallel with the PDC process. Essential information and data are available during construction and various handoffs. A method and approach to collect this data will add to the success of your Strategic Asset Management plan. Establishing a hierarchy and asset identification process in conjunction with the installation, acceptance, commissioning, testing, or training of these assets should be established and followed during the PDC process. Responsibilities should be set in advance and clearly defined in project specifications and scope of work. This data should be collected and delivered so that the health care facility can ingest it into their CMMS system to accurately track inventories and establish and verify preventive maintenance schedules, all required by accreditation.

Accreditation

Accreditation is a survey that validates that a hospital meets predetermined quality standards to receive payment from Medicare and Medicaid for the care given. Surveyors evaluate each step of patient care to ensure that doctors, nurses, and other staff comply with regulations to treat patients safely and effectively.

Surveyors also evaluate the physical environment looking for proper system function and documentation of each maintenance, inspection, and repair activity. Non-compliance with standards may result in Denial of Accreditation, leading to business disruption, productivity losses, fines and penalties, and settlement costs.

We have clearly defined the necessary components of a successful construction project and operational responsibilities, but what are the gaps for accreditation, and how do they impact the facility?

To bridge the gap between PDC and accreditation, consideration must be given to a more collaborative approach to the process from beginning to end. For example, many mistakenly assume that once the new hospital has received its Certificate of Occupancy (C.O.), it is now ready for accreditation. While a C.O. is a legal document certifying a structure to be safe to inhabit and that the property is built to required building codes, there is a distinction between meeting design and building codes and being accreditation ready.

It is possible, and even probable, that a new facility receives its C.O. one day, only to begin remodeling, alterations, or repairs to meet accreditation requirements the next. This impacts the facility’s ability to achieve accreditation, negatively impacting revenue and CAPEX availability.

One key reason for that gap is a misalignment of outcomes and responsibilities. The PDC team is charged with protecting the budget and the schedule. The Operations team has long-term commitments to maintain and steward the newly completed project, its assets, accreditation, and compliance. To succeed, these responsibilities should be merged into a comprehensive OPR, these incorporated utilized throughout the process, from planning through operations. Without creating and following a comprehensive OPR for the PDC process, owners are left with specifications and drawings that may ignore critical issues related to accreditation.

The implications of the PDC process and the accreditation requirements being treated as independent of each other leads to significant waste in the forms of defects and rework. This waste is caused by construction outcomes not being aligned with operational excellence outcomes required by accreditation. Additionally, this can lead to waiting for renovation of the newly constructed building to meet accreditation requirements.

Long after construction is complete and warranties are satisfied, the ramifications are felt operationally, whether appearing in incorrect or misidentified barrier management systems, equipment selection outside of system or facility norms, value engineered substitutions, or construction methods and practices not in alignment with system expectations - the totality of these gaps tax the capital and operational finances, which should be allocated elsewhere.

Research conducted by VERDANTIX around BIM and the construction-to-operations handoff process suggests significant and costly gaps. This research indicates that up to 30% of the data created during the design and construction phases is lost by project closeout. Additionally, according to the US General Service Administration, the cost associated with understanding project close-out packages is 10 cents per square foot. According to a NIST study, the cost associated with lack of access to accurate information required to service equipment is 23 cents per square foot. 

Successfully performing a project from planning to operations that results in accreditation requires all involved parties to be committed to a unified outcome. Facility leadership, the PDC team, Facilities Management, Quality, Infection Control, or other related departments can work together and achieve long-term success.

A healthy PDC to accreditation process will include Commissioning, Accreditation Assurance, Life Safety Commissioning (NFPA 3), Integrated System Testing (NFPA 4), and a comprehensive asset management program.

Accreditation Assurance Program

A way to bridge the gap between PDC and accreditation is to develop an Accreditation Assurance Program. An Accreditation Assurance program begins in the planning and design phases. While life safety design and installation are one of the engineering disciplines, it is recommended that the Accreditation Assurance Program be administered by an individual or team versed in code requirements and accreditation survey requirements.

A comprehensive Accreditation Assurance Program will begin with specifying the requirements for accreditation in the OPR. This should be used for all phases of the project, from initial SD to substantial completion. A continuous review of construction drawings for accreditation compliance should occur throughout the project as change orders, and requests for information can make changes to the pictures mid-construction that can significantly impact accreditation readiness.

Routine/scheduled project progress surveys should occur to ensure the facility meets building codes and achieves accreditation. Once the design standards are approved, monitoring of construction, means, methods, and practices to meet accreditation requirements should be performed at various critical intervals, including rough-in and top-out.

These inspections should include findings and recommended remediation of potential accreditation hindrances. Inspections should occur to address the proper installation and functioning of life safety-related equipment and building features such as fire-rated doors, fire and smoke dampers, and smoke evacuation systems. This should be done through code-required acceptance testing, verification, and reporting. Frequently fire doors are improperly installed from the beginning, which becomes an operational and capital expenditure incurred by facilities. Additionally, these are life safety features and are required by CMS and the accrediting organizations to be repaired in a compressed timeframe, often adding substantial cost. This is also true for dampers, which are often hard to access at a minimum and costly to replace or repair.

As construction nears substantial completion, the accreditation assurance contractor must perform a final gap analysis survey. This survey resembles a mock survey usually completed in preparation for an accreditation survey. Again, these reports should include findings and recommended remediation of potential accreditation hindrances and be promptly delivered to the owner and PDC team.

As life safety systems are being installed, this is the perfect time to develop baseline inventories complete with naming conventions. These inventories should be captured in the CMMS system. Once collected and entered into the CMMS, establish a system for compliance document compilation, whether electronic or paper. The accreditation assurance contractor should be able to assist in creating the systems and workflows to support this effort.

Life safety drawings are a vital part of PDC, and it is recommended that the accreditation assurance contractor review and approve the life safety drawings due to their familiarity with accreditation requirements. This will ensure acceptance and utilization during a survey. Soleran’s Life Safety Drawing Manager is a handy tool for this kind of documentation.

Conclusion

Bridging the gap between PDC and accreditation is possible. Still, it will require all stakeholders to collaborate from the beginning and remain active and engaged throughout the entire PDC to operations process. The key to success will be creating a culture where accreditation is an integral part, from master planning throughout each of the construction processes to operations. Once this culture is established, developing the needed processes, strategies, systems, checks, and balances as a unified team will allow the organization to succeed in closing and potentially eliminate this gap by becoming ready on day one.

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