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Recently I attended the session entitled “The Statement of Condition (SOC) – Old Game, New Rules” presented by
Philip R. Jose of P.R. Jose & Associates. This was one of the sessions presented at the New England Hospital Engineers
Society fall seminars in Westport, Massachusetts.
My purpose of attending this session was to learn about JCAHO requirements and to see how GRAND-PM can help
hospital engineers to meet these requirements.
I am really happy I decided to attend this session. Philip Jose has a great knowledge in the subject, many
years of hands-on experience, and superb presentation skills. I learned great deal.
With the upcoming “Unannounced Survey” policy of the JCAHO, all healthcare organizations are required to
demonstrate an on-going Plan for Improvement (PFI) of their Life Safety system.
Therefore a well organized and disciplined system is paramount in being ready for “Unannounced Survey.”
I picked up on a couple of items where GRAND-PM can be very helpful.
Following a survey, deficiencies found by a hospital engineer or consultants have to be either fixed
within 60 days or less through the work order system, or Plan for Improvement (PFI) entry has to be
created in the web-base (online) eSOC system.
I believe that GRAND-PM can help with both of the above items. Here is what I would suggest:
1. Create an entry in the Environment of Care Function list of GRAND-PM for deficiencies that can
be fixed within 60 days. For example, name this entry “SOC – Deficiency 60 days”
2. Create an entry in the Environment of Care Function list of GRAND-PM for deficiencies
that you also enter in the web-based eSOC. For example, name this entry “SOC – Plan for Improvement”
3. Create a work order for every deficiency found by the engineer conducting the survey.
Assign the work order to one of the Environment of Care Functions created in step 1 and 2.
Be sure to assign the target date. For the work orders created for deficiencies to be
fixed within 60 days make sure that the target date of the work order is 60 or fewer
days from the date the work order is created. It is important to keep in mind that the work
order has to be completed before or on the target date. Therefore, the work order will be
counted toward higher percent of the GRAND-PM Completion Status report.
If the work order is created for the deficiency for which you also create an online PFI entry,
set the target date of the work order accordingly.
It may seem that creating a work order in GRAND-PM for the deficiencies that you also enter in the
eSOC is redundant. But I believe that GRAND-PM will facilitate the job or tracking these items, assuring
their timely completion, therefore the extra effort will be worth it.
4. Every week you can run an open work order report for the work orders that have the target date
next week or within a couple of weeks. This will allow you to be on the top of the work orders before
they become overdue.
5. You can also run a report of overdue open work orders. Hopefully, the system of keeping on top of
work orders before they become overdue will result in having only a few items (if any) in this report.
6. To see how your organization completes the SOC-related work orders, run GRAND-PM Work Order Completion
Status Report by Environment of Care Function. This report will show the sum number of work orders opened
during the time period (grouped by month). For each period (month) the report will show how many work orders
have been closed on target and how many are open and overdue. The report will have a column indicating the
Percent Completion.
By periodically (weekly or monthly) running the GRAND-PM Work Order Completion Status Report you will be
able to monitor your progress.
And when JCAHO surveyor walks in unannounced you will be ready!
Dmitry Litvak
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