Our Insights

by Bryan Connors, M.S., C.I.H., H.E.M.

Hospitals are dynamic environments, with numerous construction, renovation, and maintenance activities occurring at all times. New services are being added, such as Cardiac Cath labs, radiology and imaging services, and specialty clinics.  Information systems are typically adding new computer and technology-associated equipment; and maintenance of the hospital building and its systems must be conducted in areas where patients receive care. The goal of the Pre-Construction Risk Assessment (PCRA) program is to mitigate the risks associated with construction within a sensitive environment.  The risks include outbreaks of hospital acquired mold infections, elevated fire risks, liabilities associated with the construction activities, and non-compliance with The Joint Commission standards.

These risks are unfortunately all too real. Just this past month, a news story broke of a lawsuit filed against a hospital where three patient deaths were linked to Aspergillus, a common mold found virtually everywhere, including in soil, air, and construction dust. The lawsuit alleges that a renovation project to the hospital’s oncology center, one floor below where all three patients spent time, was the source of the hospital acquired infections.

The PCRA program is a Joint Commission standard that requires hospitals to assess and mitigate the risks associated with any construction, renovation, or maintenance project.  PCRA is an umbrella that includes the infection control risk assessment (ICRA), life safety and interim life safety measures, and a risk assessment program for utility impacts, noise, vibration and indoor air quality.  Once the risks have been identified, mitigation measures must be put in place. Mitigation measures will vary depending on the risk and type of construction projects; a few examples include:

• Patient relocation
• Site isolation
• More frequent surveillance rounds
• Implementation of interim life safety measures
• Specialized training for staff and contractors

Construction project schedules can be slowed by work stoppages that are the result of noise, vibration, and odor complaints from hospital staff who work in areas adjacent to the construction. Having a process in place to anticipate and mitigate these issues, or to respond quickly, can help the project proceed with a minimum of disruptions.

The PCRA program is clearly an interdisciplinary program, involving infection control, facilities design and management, life safety, environmental health and safety, risk management, maintenance, and construction personnel. Bringing together this disparate group in an organized and streamlined way is a challenge all hospitals face. Through our experiences in developing and managing the program at several institutions, we’ve learned several key lessons that may help other hospitals better manage their programs.

Key Lessons Learned from Managing PCRA Programs

Define and Communicate Roles of Responsibility

First, it’s important to clearly delineate responsible parties for each key aspect of the program. Who is responsible for program coordination? Who is responsible for inspections? Who is responsible for contractor training? Air monitoring? Records management? We often find shared or nebulous responsibilities for some of these critical aspects of PCRA, and the result is usually inefficiencies in program performance. When roles and responsibilities are clearly defined and communicated, the program will be much more effective.

Measure Program Effectiveness

Measurement of program effectiveness is critical. Carefully select and track meaningful metrics. Use “report cards” for projects to learn what went wrong in the past. These can be used to train both contractors and hospital personnel.  Inspection results should be reviewed often to identify common violations or omissions. For some hospitals, EH&E has assisted in linking these inspection results to the contractor or even the project manager and use these “grades” as part of their evaluation process for awarding future projects. Use the metrics gathered to perform a critical review of your program and then act on those vulnerabilities.

Contractor Training

Contractor training is critical to program success; hospital environments are unlike almost any other area; construction activities present more risks in these sensitive environments than in almost any other. Contractors and subcontractors must be educated on your hospital’s polices, procedures, and project specific mitigation measures.

Standardize the Process to Ensure Consistency

Standardization of the PCRA process acts as a checklist to ensure all aspects are considered on every project. We’ve created a software tool for this purpose, but the goal is to ensure that the process proceeds in a very consistent manner and that each step of the process is documented. Use a checklist approach to ensure that each step of the process is considered and addressed if applicable on each project.  This standardization also serves to reinforce the roles of team members and make this visible to others on the team.

Conclusion

Once the management approach is solidified and a standardized process is in place, hospitals should see continuous improvement in the PCRA program performance and construction projects proceeding with fewer issues. Making the PCRA program work means moving beyond compliance and developing and fostering a program to protect patients, staff, and vendors, decrease liability, and save the hospital time and money on every project.