Reliable sources at The Joint Commission®’s Standards Interpretation Group (SIG) confirmed today that recent changes in the overall accreditation scoring process for 2009 would effectively negate the current scoring advantages a facility enjoys by managing a Building Maintenance Program (BMP). Under the present system, the scoring advantages as published in The Joint Commission’s Environment of Care® News™ are described as follows:

Using a BMP is to an organization’s advantage because of the way the scoring works. Scoring the items in a BMP is different from scoring elements of performance elsewhere in The Joint Commission standards. Each scorable item in the SOC is an X, a Y or a Z. An X is 1 point, a Y is 2 points, and a Z is 4 points. A score between 1 and 5 and no Z scores is a supplemental score (outside the SOC, this would be a 1 score for EC.5.20). Any score 6 or higher will result in a requirement for improvement for EC.5.20 (outside the SOC this would result in a 0 score). Each of the 18 scorable elements in the BMP is capped at an X (1 point), so a total of 6 noncompliant items would result in a requirement for improvement. Most of the items in the BMP, if scored as not being in the BMP, would be scored as X for one occurrence and Y for more than one occurrence. Any three of the BMP items not in the BMP that have more than one occurrence each will result in a requirement for improvement. The scoring advantage of the BMP should be obvious.

Under the proposed new scoring rules, a facility would be scored exactly the same when a surveyor identifies a BMP item (e. g., burned-out exit sign, door latching issue) whether or not that facility had an active BMP. At that point, the advantage of having a BMP becomes truly and only a matter of building occupant safety and best fire safety practice.

The Joint Commission SIG has expressed hope and expectation that organizations will continue to develop and utilize BMP programs and has even indicated that they intend to encourage facilities to utilize the programs because they believe they are a matter of good practice. It is important to note that at this time these scoring system changes are still not final and could be revised. It is also important to note that at least through January 1, 2009, organizations using a BMP will continue to enjoy these scoring advantages. From SMS, Inc.’s perspective, what this means to the hospitals if finalized as currently written is:

• Organizations will need to return to the practice of including itemized details regarding the 10 BMP issues on their SOC’s & PFI’s
• Organizations will be more likely to receive more findings from the Life Safety Surveyors on their reports regarding Life Safety Code violations
• An Increased number of findings should ultimately result in lower survey scores overall

As a result of these anticipated issues as well as other issues, SMS, Inc. recommends:

• Organizations should continue to employ the use of BMP’s purely as a matter of good fire protection practice
• Organizations should increase the frequency of their periodic Life Safety Code evaluations & SOC updates (probably to every 18 months)
• Organizations should continue to look for violations & add them to their PFI list on an ongoing basis
• Organizations should continue to closely manage/monitor persons or groups whose actions could adversely affect the compliance levels of these BMP items (e. g., IS, IT, contractors, vendors)
• Organizations should continue to monitor & evaluate the qualifications of the organizations and individuals who complete their SOC’s/PFI’s

If you have additional questions regarding this topic or any other, please do not hesitate in contacting us at info@safemgt.com or 847-577-6550.