Facilities – Aging / Maintenance

Service: Insurance , Risk Management
Subject: Facilities
Setting: Property
Type: Risk Profiles

An organization’s aging infrastructure and lack of maintenance can lead to several impacts including and not limiting to loss of operations, injuries, increase in waste/inventory, poor patient experience and flow, financial impact, and reputational loss. This risk can also impede an organization’s ability to meet strategic goals and objectives, and result in risk of non-compliance with regulations, codes, and standards. This Risk Profile includes building facilities and equipment-related aging and maintenance issues. This document contains information identified by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls / Mitigation Strategies

  • Strategic planning/budgeting
    • Capital planning and long-term planning for anticipated infrastructure needs
    • Annual capital budgeting process
    • Dedicated funds allocated for upgrades of aging infrastructure and emergencies 
    • Infrastructure and facilities align with the organization’s strategic priorities (e.g., service excellence, safety)
    • Computerized maintenance management system which provides advanced notice of replacement needs and assets nearing end of life (e.g., utilized for medical asset planning) 
    • Emergency Department infrastructure planning with expertise in safety and security considered 
    • Prioritization of redevelopment or replacement of aging infrastructure across multiple sites based on resource availability
  • Funding
    • Strong relationship with regional health authorities
    • Regular communication with government representatives to increase awareness 
    • Prioritization of funding requirements
    • Continuous efforts to apply for grants and funded infrastructure projects
  • Internal policies and processes
    • Safety and security of staff and patients are always kept at the forefront when making decisions related to capital planning and equipment purchases
    • Formal committee to oversee all capital projects and emergency requests
    • Regular inspections and assessments to identify potential problem areas (e.g., fire inspections, infrastructure risk assessments, life safety assessments, environmental assessments, etc.)
    • Formal risk analysis (e.g., matrix) to understand impact of circumstances and urgency
    • Continuous risk identification and prioritization process for infrastructure upgrades 
    • Grouping of similar repair costs together to get better pricing/funding
    • Appropriate level of information about conditions and life expectancy of facilities and equipment are provided to decision makers
    • Formal preventative maintenance program actively followed, manufacturers recommendations identified 
    • Access to knowledgeable and experienced maintenance team and/or engineers – on call 24/7
    • Appropriately managed contracted service providers 
    • Monitor temperature and humidity in areas such as operating room and medical devices reprocessing, etc.
    • An inventory of equipment and infrastructure assets are maintained
    • Regular alerts and recalls reviews
    • Infection control issues are identified and managed as required
    • Inventory of all manufacturers’ warranties
    • Spare parts inventory management 
    • Participation in groups with other facilities regarding planned maintenance
    • Documented plant management to reduce the risk of knowledge loss (e.g. succession planning)
    • Contingency plans/Emergency Code procedure and response plans in place including back up equipment (e.g, backup generators) 
    • Decommissioning of unsafe equipment 
    • Backup equipment (e.g. smaller cooler, additional ventilators)
  • Physical  controls
    • Electrical improvements and red emergency power outlets
    • Updated plumbing in older buildings
    • Sprinkler system
    • Updated fire alarm system, fire exit door replacement
    • Appropriate sewers and storm drainage system
    • Updated communication system
    • Roof repairs
    • Heating, Ventilation, and Air Conditioning (HVAC) system replacement
    • Upgrade security systems such as cameras, building access, and alerts
    • Oil tank replacement
    • Floor plan review of current design functionality (use of space designer/architect)
    • Workplace hazards monitored and addressed on a timely manner
    • Signage of any hazards 

Monitoring / Indicators

  • % of scheduled preventive maintenance tasks completed on time
  • % of reported broken/hazardous equipment reported which are within the preventative maintenance program
  • % downtime or % uptime 
  • # of Infection Prevention and Control (IPAC) audits for specific medical equipment 
  • Hospital occupancy and use of isolation room (flow metrics) 
  • Problem areas and # of maintenance service requests
  • Alerts and recalls-code/standard compliance (e.g. building codes, fire codes, Canadian Standards Association)
  • # capital project requests
  • Budgets/forecasting
  • Missing equipment
  • Workplace hazards
  • Facility conditions (e.g., daily monitoring of HVAC)
  • Infrastructure projects and their statuses
  • Staff/patient/visitor complaints
  • Building automation system to monitor equipment and report on performance
  • Regular audits
  • Periodic inspections by third parties to verify condition of assets
  • Air quality testing results
  • Emergency code testing results (i.e. code grey, red)
  • # of code grey and/or loss of a critical service/equipment annually
  • Accreditation results
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.