Thoughts on How to Successfully Comply with Accrediting Organizations

Every year, the Joint Commission publishes a Top Ten Findings list drawn from the previous year's surveys. And every year, it's nearly the same list. Wires resting on sprinkler piping. Pressure differentials off in critical spaces. Rated walls punched through by contractors and never properly repaired. Some of these deficiencies show up in more than half of all surveys, year after year, with only the ranking shifting.

That pattern raises an uncomfortable question: Are these violations just hard to fix, or is something structurally wrong with how most facilities manage their physical environment?

After four decades in healthcare compliance including two stints at the Joint Commission, where I led the 2016 rewrite of the Environment of Care and Life Safety chapters to align with CMS's adoption of the 2012 Life Safety Code,  I've tested the following approach and believe it works. 

The Problem Isn't Effort. It's Structure.

Most facilities aren't short on people who care about compliance. They're short on a system that catches problems before a surveyor does. Compliance gets treated as a periodic event — something you scramble toward every 18 months — instead of a daily discipline built into how the building is actually maintained.

Fixing that takes three things working together:

1. Document management that can actually prove compliance. If you can't produce clean, on-demand evidence that a deficiency was found and corrected, it didn't happen as far as a surveyor is concerned. That means integrated rounding, work orders, and permit tracking — not three disconnected systems. Self-auditing is what makes this real: you need to be able to check your own program's effectiveness before a surveyor does it for you. Soleran is one of the platforms I'd point to here — its reporting is dependable and tailored to the organization, and because its modules share data, you get a real-time picture instead of a patchwork of exports. Their recent release of Soleran Oro Marketplace brings that integration further, linking modules like Rounding directly to work orders: a deficiency found on rounds automatically generates a work order, and later rounds circle back to confirm the fix actually held and that staff are satisfied — all visible on a shared dashboard. 

2. Equipment inventories you can trust. Many healthcare organizations rely on a CMMS to manage their building systems and equipment, but many of those inventories have become corrupted over the years — equipment gets retired and replaced, software updates cause unexpected duplication, staff fail to accurately input data, and a change of vendor often means old, questionable data just migrates into the new platform with the same questionable integrity of the data pool. While with JLL, I oversaw ATG as CEO, and one of the initiatives we built there was a team dedicated to going on-site and re-inventorying a client's physical plant assets from scratch. Every facility leader I've talked with has wanted to do this; almost none have had the resources on-site to pull it off. Some just throw up their hands and admit they have no idea how accurate — or corrupted — their inventory really is.

That matters more than it sounds. Today's CMMS can generate incredible amounts of data and reports, but the integrity of that data determines the confidence factor behind every decision built on top of it: whether staffing levels are right, whether equipment should be replaced or reconditioned, whether redundancies are adequately covered in the risk assessment. It's also the prerequisite for two strategies worth pursuing once your data is clean — Alternative Equipment Maintenance, the CMS-allowed deviation from a manufacturer's recommendation when your own reliability data supports it, and Reliability-Centered Maintenance, which evaluates the system rather than individual components and builds a maintenance strategy around failure modes ranked by risk and criticality. Both start in the same place: a robust and accurate inventory.

3. Zone Maintenance. This is the piece most facilities are missing entirely.

The Core Idea Behind Zone Maintenance

Zone Maintenance borrows a page from Environmental Services: instead of a maintenance team that responds to tickets building-wide, you assign a dedicated Zone Mechanic to a specific area - a wing, a unit, a defined footprint - who owns that space the way an EVS aide owns their unit.

The Zone Mechanic runs a rotating daily inspection, handles quick fixes on the spot, and is a visible, known presence to the clinical staff and patients in that zone. Bigger jobs get routed to a Support Engineering Team. Over time, the zone stops accumulating the kind of deferred, small-scale neglect that turns into a Top Ten finding.

Facilities often hesitate here because it looks like it requires more headcount. In practice, it's usually a reallocation: once a zone is properly maintained, general maintenance requests from that area drop, and staffing shifts accordingly. The real cost is upfront — a "Zone Repair" period where the mechanic works through years of backlog before the program settles into steady maintenance.

Why It Moves the Needle on the Top Ten List Specifically

A lot of the recurring findings, sprinkler clearance, ceiling penetrations, fire door gaps and latching issues, corridor clutter, aren't complex engineering problems. They're small things that get missed because nobody's regularly looking. A Zone Mechanic walking the same space every day, checking a rotating set of items, catches a fire door closing issue or an unauthorized ceiling penetration long before it becomes a survey finding — or worse, a real safety issue for a patient.

Pair that with an Above Ceiling Permit Management Program (make it socially and procedurally hard to work above a ceiling without Facilities knowing) and you close off the single biggest source of repeated Top Ten findings. 

Where To Go From Here

This is the short version. The full framework - including zone sizing formulas, staffing and training criteria, a sample daily schedule, a patient-room checklist you can start using this week, and a complete technical reference table mapping most CMS Physical Environment requirements to its code citation and required inspection frequency is laid out in the companion whitepaper, Thoughts on How to Successfully Comply with Accrediting Organizations. 

If your facility is tired of seeing the same findings on next year's survey, that's the place to start.

Read whitepaper by George Mills

Read the full unedited whitepaper by George Mills