Helping Hospitals Prepare for Joint Commission Survey in 2018

Posted by Jason Di Marco on March 08, 2018
Jason Di Marco


Patients come to hospitals to be healed and cured. It goes without saying they expect to be kept safe while they’re there. A critical lynchpin to this safety and security is the consistent, dedicated monitoring and testing of a healthcare facility’s medical gas systems. At every point, an incident could conceivably occur–from source equipment to patient rooms.

Because of this, medical gas systems are a point of emphasis by the Joint Commission, and the Centers for Medicaid and Medicare Services (CMS). Past hazards and incidents have warranted this increased level of scrutiny. In fact, Environment of Care Standard 02.05.09 has now been expanded to 14 Elements of Performance (EP's) in 2018. Without clean, contaminant-free medical gases, operational alarm panels and maintained functional source equipment, even the most prudent healthcare facilities may find themselves in violation of code compliance. Or worse, in a situation where the safety of patients is in the balance.

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Traditional testing, with its reams of paper, has proved insufficient. It’s a slow, tedious process rife with potential for mistakes and inconsistency. Uncorrected deficiencies or weak program documentation may result in reduced scoring, which in turn leads to loss of funding until the program is brought up to code. This can be a time-consuming, costly process, threatening the very operational core of the entire organization.

Compliant Healthcare Technologies, LLC (CHT), is a trusted industry partner to hospitals nationwide. We are involved in multiple Joint Commission surveys annually. We have forged a national presence, which serves as a vital pipeline for critical feedback on a daily basis about precisely what’s happening in the field, and in our industry.

We are uniquely qualified to provide you with a smarter, easier and more manageable method of monitoring and testing your medical gas system documentation. And it is for these reasons that we can offer you a rock-solid path, both simple and affordable, to Joint Commission Compliance.

In other words, what you’re holding is the first step towards Regulatory Immunity for your healthcare facility.

A New Evolution of Knowledge

CHT developed comprehensive, proprietary software, which takes the manual compliance monitoring and reporting to a vastly higher level of precision. Working in conjunction with the Cleveland Clinic Foundation in Cleveland, Ohio, the CHx program was developed, tested, implemented and continues to evolve.

While physical man hours still verify the medical gas systems and correct deficiencies, the program allows on-site access, input and viewing of testing results and history for all medical gas system assets, from patient terminals to source equipment. The program contains an asset tree, making it simple to trace all medical gas assets while providing an Environment of Care (EC) Tracer program for  compliance. That means, with mouse-click ease a user can ascertain the source equipment linked to a zone, floor, even a specific room, anywhere within the facility, in an instant.

Traditional tracking of medical gas assets were defined by manual paper reports. The CHx program’s asset management module enables virtual reporting of all assets, testing history and associated deficiencies and corrections. One can drill down through four levels of information, sorting to individual zones and its assets. Vibrant graphs and charts represent how a facility’s program is evolving and improving, and makes every aspect of managing the medical gas system easy.

The precision and sophistication of the CHx program is unparalleled in our industry, and now trusted by numerous hospital facilities and health care systems around the country.

Two Critical, Integrated Steps

Proper, provable testing and maintenance are crucial elements for achieving Joint Commission compliance.

Once a traditional test was completed, a healthcare facility’s weaknesses or inconsistencies would be identified and captured in a paper report. Work order would then be manually generated.

Compare that to CHx program’s method for generating work orders. It can be done daily, weekly, monthly, semi-annually, annually or periodically as determined by the facility and ASSE Qualification Standards. This enables the healthcare facility to continually build and manage their medical gas program.

Pulling stacks of paper was the standard method when showing compliance for a medical gas systems program. One can see how this paper-based process is an invitation for inefficiency, lost time and potential error. Nowhere is this more likely than in multi-site healthcare systems, with facilities spread across a city or even a wide geographic region.

The innovative CHx program transcends all this by allowing for the creation of multi-site databases. User-friendly applications and the ability to retrieve all relevant data from a single location simplify this process.

Each facility is given its own, secure password, yet the director or corporate manager has a 360° view of all facilities (based on administrative rights granted). This feature has proven very useful during the budget cycle.

This spectrum of choice, adaptability and operational ease is why numerous hospital facilities now trust CHT to service their medical gas system programs, whether paper-based or with the online simplicity of CHx program. 

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Security Before, During and After Verification

Training and certification are the simplest routes to confidence across a healthcare system’s medical gas system. Our industry today demands professional credentials to ensure the efficacy for contractors, verifiers or in-house staff.

NFPA 99, 2012 now requires maintenance staff to be qualified according to ASSE 6030, ASSE 6040, or a documented training program.

Options for certification through classes and seminars include:

• ASSE 6005-Medical Gas Systems General Information (for Architects & Engineers)

• ASSE 6010-for Medical Gas Systems Installers (and Brazers)

• ASSE 6020-for Inspectors

• ASSE 6030-for Verifiers

• ASSE 6040-for Maintenance Personnel

• ASME IX-Medical Gas Brazing

These will not only help with continued maintenance and verifications of medical gas systems, but also with initial proper design and installation of new medical gas system projects. Being able to identify design errors and educate installers on proper documentation and required testing, prior to installation and before calling the verifier, is key.

CHT holds a variety of medical gas system training seminars each year, conducted by certified staff. There is simply no better source for ensuring the training and certification elements of Regulatory Immunity are being met and surpassed.


Every hospital or healthcare system wants to ensure patient safety. One aspect of this is achieved through the proper design, installation, verification and maintenance of the facility medical gas systems.

Inspections and compliance now warrant a higher level of visibility and knowledge in these systems. Only through achieving Regulatory Immunity can you feel secure that you are both keeping patients safe and keeping your organization free of the time-consuming and costly realities of coming up short during a planned or surprise inspection.

And while technology like the innovative CHx program is an intrinsic part of assuring Regulatory Immunity, CHT offers much more than that. You’ll get a certified, dedicated team of experts who will work with you as a partner, propelling you toward becoming a world-class leader in healthcare.

To learn more about how CHT’s expertise and experience can help deliver true Regulatory Immunity to your facility, get in touch with a medical specialist.


Topics: Medical Gas Compliance

Jason Di Marco

Jason Di Marco

President at Compliant Healthcare Technologies, LLC
Jason Di Marco has been intimately involved with helping hospitals protect and improve their medical piped gas systems from CHT's beginnings. He is certified by ASSE, NITC, and NFPA as an inspector and installer and has worked with major institutions from construction to risk assessment planning.