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A New Strategy for Standardization and Continuous Improvement

This excerpt is from an article published in American School and Hospital Facility, authored by Judson Orlando, Sr. Director, Facilities Development and Operations, Children’s Health, and Bryan Connors, Practice Director, Healthcare, EH&E.

The Joint Commission Pre-Construction Risk Assessment (PCRA) standard requires hospitals to assess and mitigate the risks associated with any construction, renovation, or maintenance project. The PCRA standard sets specific requirements, but it does not provide a roadmap for compliance nor for an effective, performance-oriented program.

STEP (Standardized Techniques for Execution of Projects), is a new strategy proven to align construction and infection control processes. STEP standardizes PCRA from concept through closeout, focusing on continuous monitoring and improvement.

What Is the STEP Process?

STEP, a four-part process, includes integration of key team members, consistent methods for risk assessment and mitigation, and tools for evaluating measurable outcomes.

STEP standardizes the inputs and outputs of the program, and then leverages data collection to shift PCRA from a compliance-oriented program to one that is driven by performance and risk reduction.

Getting Started

Start by defining priorities and how effectiveness will be measured. Planners should conduct a gap analysis of the program and identify how stakeholders define success.

STEP 1:  Integration

Begin the PCRA process early.
Include end users, infection control, facilities, safety, clinical engineering, and compliance departments in the design phase. This helps avoid costly design changes and delays to the construction schedule. Include design reviews with stakeholders at 30% and 75% design completion.

STEP 2: Preparation

Document construction isolation practices.
Complex mechanical systems and diverse patient areas makes matching containment measures to risks challenging. Infection control and facilities departments must work together to bridge knowledge gaps. Develop a written plan for site isolation practices that matches appropriate containment and safety methods to potential risks for each project type. Plans should allow for some professional judgment. Document and educate team members on the judgment criteria used.

Standardize meetings and processes.
Standardize PCRA processes to ensure that critical risks are not overlooked, and that all parties know their roles and what to expect at each meeting. Reviews and outputs for safety, infection control, and logistics allow success to be charted. Establish consistency with detailed meeting checklists.

Establish entryway guidelines.
The design of construction entryway setups has considerable impact on how they are viewed by a hospital staff and regulators. Establish guidelines on how all construction entryways will be designed and maintained.

STEP 3: Execution

Implement routine construction site audits.
Conduct routine audits (at least weekly) of construction sites and document findings. Audits can be led by a multidisciplinary team or by dedicated personnel trained to recognize the various risks. Document and evaluate the types and extents of vulnerabilities using a standardized checklist (referenced to risk) to track data.

Contractor report cards.
Use inspection metrics to generate contractor report cards, measure the effectiveness of the program and improve contractor training. This also benefits contractors by showing how they will be evaluated and that all contractors will be evaluated on the same basis.

Risk-based audit criteria and prioritized follow-up.
Assign inspections items in the construction safety audit a risk rating from 1 to 3, depending upon the severity of the findings (3 being the most serious violation). Risk ranking increases contractor accountability and assists with enforcement. Prioritize follow-up actions based upon the risk. (Table 1)

STEP 4: Certification

Pre-occupancy checklist.
Develop a pre-occupancy checklist and require sign-off from key stakeholders. Make the checklist available to the project team so they are familiar with requirements before move-in. This helps avoid move-in delays due to missing minor items (e.g., missing medical equipment stickers, dust on furniture).

Annual review and program benchmarks.
Analyze PCRA performance data to measure program success. Compare results against peer and industry standards. Use important metrics (e.g., number of violations per year, number of complaints associated with construction projects) to generate key performance indicators (KPI). Summarize KPIs in a presentation to hospital leadership and incorporated into an Environment of Care annual report.

The STEP strategy has proven successful in aligning construction and infection control processes. Standardization, early involvement of all stakeholders, and the use of inspection metrics to create accountability and provide a method for continually measuring effectiveness are the key drivers of a successful PCRA program. The STEP process moves PCRA beyond compliance. It drives performance — so that hospitals can be sure they are efficiently and effectively mitigating potential risks to patients and staff.