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The Future of the Building Maintenance Program

Accreditation Monthly, January 13, 2009

The concept for the Building Maintenance Program (BMP) began in 1998, as described in an American Society on Healthcare Engineering (ASHE) technical paper, which The Joint Commission eventually adopted as part of the life safety assessment under section EC.5.20, EP 1, part A6J. The plan called for a systematic and routine inspection of key elements of life safety in hospitals' facilities. If a hospital could demonstrate at least 95% compliance with life safety features by documenting the inspections, The Joint Commission would agree that those particular features of life safety were in compliance. This meant a surveyor would not cite the hospital for noncompliance of smoke barrier penetrations, corridor door latching, exit sign illumination, etc., if the BMP documentation indicated the sampling to be at least 95% compliant. It proved to be a terrific advantage for facility directors in hospitals.

However, due to pressure from other authorities, The Joint Commission has decided to eliminate all scoring advantages associated with the BMP beginning January 1, 2009. Surveyors will no longer grant immunity for life safety deficiencies even if the hospital can demonstrate 95% compliance. The expectation now is that all hospitals must comply with the Life Safety Code® (LSC) 100% of the time. Even with this turn of events, I strongly encourage hospitals that have a BMP to continue using it, and hospitals that do not have a BMP to seriously consider starting such a program.

The reason is simple: The BMP is a wonderful tool for assessing the building's compliance with life safety standards. It provides a routine inspection of key elements and will uncover any deficiencies, which either can be resolved immediately or placed on the Plan For Improvement (PFI) section of the electronic Statement of Conditions. This systematic approach to management, once implemented, can easily be supervised via the hospital's computerized maintenance management system.

I believe hospitals need all the help they can get when it comes to life safety assessments. My observations as a LSC surveyor for The Joint Commission indicated hospitals are poorly prepared in this area—and are never as prepared as they think they are. If you would like assistance on starting a BMP at your own facility, please consider The Greeley Company. We would be glad to help.

If you have any questions or comments regarding this information, please feel free to contact me at 815/629-2240 or 815/742-4367.

Thank you.

Brad Keyes, CHSP
Consultant
The Greeley Company

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