By Dan Hounsell,

Healthcare systems rely on maintenance and engineering departments to make certain their facilities operate efficiently, reliably and safely, but who can maintenance departments rely on to achieve these goals? While most healthcare facility managers might not give much thought to this question, facilities operations managers in the NewYork-Presbyterian (NYP) healthcare system know the answer — NYP’s facilities regulatory readiness department. 

The compliance burden for healthcare facilities is never-ending, since healthcare is the second most regulated industry after the nuclear industry, says Frank Rudilosso, P.E., NYP’s director of facilities regulatory readiness. Rudilosso’s presentation, Facility Metrics: Utilizing Data and Technology to Drive Compliance, at the 2022 ASHE Annual Conference, outlined the efforts of his department to ensure maintenance and engineering departments in the system’s facilities are able to comply with the many regulatory requirements for inspection, testing and maintenance (ITM). 

The department faces a tall task. The NYP system includes two academic medical centers and 11 sites within the New York City metropolitan area with 15 million square feet and 4,184 licensed beds. The department helps managers ensure ITM compliance for the array of systems, equipment and technology. Within NYP facilities, maintenance and engineering departments are responsible for 45 emergency generators, 27 fire pumps, 343 automatic transfer switches, more than 100,000 of other utility system assets, resulting in over 500,000 ITM activities. 

The objectives of NYP’s facilities regulatory readiness department are to: use technology as a management tool to improve the overall patient experience, quality and safety; use data-driven applications to improve operational efficiency; and build a culture of accountability and ownership to achieve high reliability. To achieve these goals, the department relies on specialists. 

“We hired five regulatory compliance coordinators, and they are the bridge between facilities and compliance,” Rudilosso says, adding that they monitor ITM compliance and are crucial to the success of the department’s efforts. They are responsible for providing support for regulatory compliance. They manage all regulatory documentation, review documentation to ensure compliance and keep the documentation current. And they ensure scheduling of tests and can speak to related documents during compliance surveys, if needed. 

Beyond those duties, the coordinators notify facilities operations of upcoming ITM activities, confirm that the ITM activities are scheduled for completion, and follow up with technicians on corrective measures for any failures. 

Building on data 

The critical building block for the efforts of regulatory compliance coordinators is ensuring the accuracy of data related to the maintenance of equipment and other facility assets that technicians enter in the CMMS. Technicians need to follow standards for barcode tagging, asset data, and ITM program procedures. The standardization of data early in the process also ensures that newly acquired facilities implement the process. 

“It’s helpful for when we bring on new facilities that are a little behind,” Rudilosso says. 

Once CMMS data is verified and available, the coordinators use it to help technicians plan their preventive maintenance (PM) and ITM tasks to maximize time and resources. CMMS reporting helps building foundation for forecasting PM work orders based upon upcoming due dates. 

“Work can be planned and scheduled to allow for lead times” related to labor, materials and vendor availability, Rudilosso says. To ensure results from the compliance-support process, the coordinators make certain that: 

• NYP data conforms to well-established NYP asset and ITM standards  
• NYP assets are all properly aligned with enterprise-level ITM programs 
• NYP shops and planners can effectively forecast, plan and schedule upcoming work 
• the facilities operations department can maintain a state of readiness for compliance surveys by monitoring ITM schedule compliance and program performance. 

Rudilosso’s department takes the additional step of conducting an internal audit during which they assess their performance. The audit process includes: a quarterly review at each NYP campus that involves a document review and a building tour; physical environment observations; reporting that involves an audit report for the local team and a dashboard that enables NYP leadership to track performance; and a post-audit process that includes developing a plan of correction. 

For all the focus on data and processes, Rudilosso says the success of NYP’s facilities regulatory readiness efforts depends on the human element. 

“Our relationship with facilities operations team is key,” he says. 

Dan Hounsell is senior editor of the facility market. He has more than 25 years of experience writing about facilities maintenance, engineering and management.