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Pushing for Behavioral Changes to Drive Code Compliance

Published on 10/29/2019

Healthcare facility managers know that compliance is an ongoing challenge. But Sukhjit Tom Singh, Director for Facilities Environment of Care Compliance at New York-Presbyterian Hospital, says that challenge is particularly trying when it comes to solving behavioral issues. "Top hospitals put in place electronic systems to proactively inspect building conditions. The behavioral side is always a challenge," Singh said.

Singh shared with his audience at the 2019 New York Hospital, Outpatient Facilities & Medical Office Buildings Summit in September, co-hosted by AMFP and, that he can typically visit any patient care site and find stuff in the hallway. These types of behavioral issues lead the charge in The Joint Commission violations.

Jared Shapiro, System Senior Director for Environmental Health and Safety at Montefiore Health System, agreed. He pointed out that The Joint Commission reports typically show compliance with life safety but, "When it comes to the Environment of Care, we have some work to do."

For Shapiro, sharing the "why" with staff is key. "We try to notify the staff and tell them 'why' ... 'Do you mind moving this and the reason is if you had to push this patient out for an emergency, you're really going to have a hard time doing that.' It typically changes their perspective," he said.

Data also helps. Shapiroshared that Montefiore Health had an issue with staff compliance around hand hygiene. "At first they didn't believe us. Then we had secret shoppers go out and prove it," he said. This data on compliance rates got the attention of the system's vice president and led to the launch of a targeted hand hygiene compliance program. "Now our hand hygiene is very, very high," Shapiro added.

That data is key for driving improvement around any compliance issue, Singhagreed. "You can never go to the C-suite without data," he said. Data helps drive the case that dollars should be diverted to a maintenance issue over, say, new medical equipment. You must make a business case that you need X amount of funding to correct deficiencies, he urged his listeners.

It turns out that sell may be easier for smaller facilities. IMAGINiT Technologies conducted an online compliance survey in April 2019 and found that smaller companies had more direct contact with upper management and therefore gained greater understanding from senior management around the importance of compliance. Larger companies reported they were less connected with senior management and therefore had less understanding.

For smaller organizations the biggest compliance challenge, Robert Faure, Healthcare Segment Leader for IMAGINiT, reported, typically is around the tactical aspects of compliance. For the smallest facilities (250,000 square feet and under) this may include managing and documenting corrective action, while facilities 251,000 to 500,000 square feet reported challenges in knowing the location and status of compliance-related items.

To read the full Summit takeaways, visit

(From left) Robert Faure, Healthcare Segment Leader, ImaginIt; Jared Shapiro, System Senior Director, Environmental Health and Safety, Montefiore Health System; and Sukhjit Tom Singh, Director, Facilities Environment of Care Compliance, New York-Presbyterian Hospital at the New York Hospital, Outpatient Facilities & Medical Office Buildings Summit.