Facility Maintenance

The 6-Step Guide to Implementing a Healthcare Quality Assurance Program

A quality assurance program in your hospital is essential to help you achieve top-notch care. Learn how a CMMS can help with that through this 6-step guide.


Quality assurance programs in hospitals are essential to help you achieve efficient care and satisfactory patient outcomes. You cannot manage what you do not know, and your worker safety depends on knowing and keeping up with scheduled rules and maintenance procedures. 

Therefore, it is essential for you to maintain good practices regarding your asset management by implementing a healthcare quality assurance program. After all, if you let things get out of hand, you are at risk of breaking regulatory compliance, such as those under the Center for Medicare and Medicaid Services, or The Joint Commission.

How to implement a quality assurance program in your healthcare system using a CMMS

Organization is essential for coordinating processes and making certain that your essential tasks are completed as designated. Having a standard set of procedures to follow will help you keep track of all your assets, identify the ones that are high risk, and schedule any necessary preventative maintenance (PM).

One of the best tools to help implement an efficient, useful quality assurance program is a computerized maintenance management system (CMMS). Your CMMS should provide you with all the necessary tools to keep you on track and stay compliant. Follow these six steps for a complete QA program using your CMMS.

1. Develop scalable standardization procedures

Developing a standardized schedule program for PM is important to ensure that you stay compliant with regulatory groups such as The Joint Commission. It is essential to keep two things in mind when developing your procedures: frequency and task listing. 

For example, let’s say you are getting ready to install a new widget. As you add it, you should make a habit of updating and scheduling the PM frequency. Doing this prevents you from forgetting to schedule PMs and saves you money in the long run. Plus, you can guarantee that your assets will be up-to-date with regulatory compliance and will match quality of care measures.

Including task listing items in your work orders allows you to get a list of items to perform and readings that need to be taken. For example, if you want to document readings, such as output, certain types of pressure, or temperature, you can include a spot on your work order for documentation. This allows you to show in your reporting that you are maintaining what you need and are therefore staying compliant.

2. Maintain an accurate, updated inventory database

It’s important to know what assets you have. In order to maintain an accurate, updated inventory database, you need to follow best practices regarding asset management. This includes accurately entering all the proper fields and keeping them up to date as time goes on. By maintaining an accurate inventory record, you can easily identify low and high-risk assets and act accordingly. 

It’s easy for asset management to get out of hand, which is why sticking with a procedure is vital. For example, a regulatory compliance surveyor could come to your hospital, pull random asset numbers, and ask for a complete history. You need to make sure to have the right records showing that you’re maintaining your inventory.

If you are behind on your asset data collection, you can bring in a third party to do a survey of your assets and get your inventory up-to-date. Many CMMS providers will do this service for you, so that when you start on the platform, everything is 100% accurate moving forward. 

Don’t forget to implement your standardized scheduling procedure once you have a complete asset inventory database. For your clinical engineering departments for example, it’s especially important to make sure your PMs are always scheduled and completed to meet the Center for Medicare and Medicaid Services regulatory compliance.

3. Ensure asset name standardization

In the medical world, it is not uncommon for companies to change hands. To more easily keep track of your assets in the event that this happens, adopt a standardized naming system and stick with it. This will allow you to track and document your asset history, see all services performed, and more. 

If there is a hazard recall on a model, you can properly handle and document the situation by easily pulling up the asset model with the correct information. This system also helps manage all your assets. For example, you can identify aging equipment and replace it. You can also document if a procedure fails and link a corrective maintenance work order to the PM order. This will help show regulatory groups that you are staying on top of your assets. 

In the end, you are once again maintaining proper regulatory compliance by keeping track of all your assets, whether or not they have changed company hands. 

4. Identify both regulatory standards and labor resources

The Joint Commission and DNV are looking for a 100% completion requirement. By identifying each regulatory standard and mapping it to the appropriate procedure, you ensure that you meet all standards and that your PM program is in compliance.

Keep track of your resources, such as labor hours and materials used each day. You can then compare your internal costs to third party or other outsourced groups and prove how much more efficient and effective your in-house program can be. You can then continue to do your important work each day knowing you are justifying each and every task.

Identifying and keeping track of both regulatory standards and labor resources will help you justify your existence and show your hospital how much money you are saving and/or avoiding spending.

5. Keep track of equipment to stay ahead of replacement parts 

In addition to keeping a thorough inventory database, it’s important to track each piece of equipment on a granular level. After all, you need to have a 100% PM completion rate at all times, even when replacement parts are due. 

Let’s say you have around 300 pumps with batteries that need to be replaced every two years. In this case, how would you remain in 100% PM completion with an upcoming replacement part due?

If you’ve kept track of all your equipment, you would be aware of the battery replacements before the due date, and order your stock ahead of time. This way, you’ll have everything replaced on time and still remain compliant.

6. Implement proper regulatory reporting to prevent errors

Your CMMS will include proper regulatory reporting dashboards where you can easily check in on compliance statuses at a glance. It’s crucial to ensure you have the right reporting in place so that you always know your regulatory compliance status and proactively prevent errors before they happen. 

In fact, look for a reporting system that goes above and beyond. For example, if you are missing several pumps and a few others are in use, find a program that marks them as such and excludes them from your completion report.

You’ll still have 100% PM completion compliance, and you’ll be within the Center for Medicare and Medicaid Services regulatory requirements as they allow exceptions for equipment that is in use or temporarily lost. Be sure that the report includes a policy that updates the report accordingly once these situations are resolved.

Find the right CMMS to support your healthcare quality assurance program

As you look to create a useful quality assurance program, keep in mind how your CMMS can help. It should help you with any need, from a simple list of work orders or preventive maintenance checks to a complex variety of information and requests.

Here at FSI, we provide the best tools to promote safe and efficient hospital operations. With a cloud-based CMMS purpose-built for healthcare professionals, we help empower efficient operations for healthcare systems. The six steps in this article are all driven from our experience in the healthcare industry, and from best practices we’ve gathered over the last 20 years.

FSI’s CMMS includes helpful features such as reporting and data collection to help you keep track of your asset PM schedules, regulatory compliance statuses, and more. You can also use our CMMS to complete inventory and asset tagging to ensure that everything is documented, scheduled, and meeting regulatory requirements.

To learn more about FSI's CMMS modules and services and how they can support your quality assurance program, check out our products and services pages, and feel free to contact us for more information. 

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