Facilities – Aging / Maintenance

Subject: Facilities
Setting: Property

Aging infrastructure and lack of maintenance can lead to loss of operations, staff injuries, increase in waste/inventory, poor patient experience and flow, financial impact and damage to reputation. This risk can also impede the organization’s ability to meet strategic goals and objectives and result in risk of non-compliance with regulations, codes and standards (e.g. CSA, wheelchair accessibility, National Association of Pharmacy Regulatory Authorities (NAPRA), etc.). This risk includes both building facilities and equipment-related aging and maintenance issues. This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Ranking / Ratings

  • Likelihood – average score 3.05
  • Impact – average score 3.22

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key Controls / Mitigation Strategies

  • Strategic planning/budgeting
    • Capital planning and long-term plan for anticipated infrastructure needs
    • Annual capital budgeting process
    • Dedicated funds allocated for upgrades of aging infrastructure
    • Dedicated allowance funds available for infrastructure emergencies
    • Infrastructure and facilities align with the organization’s strategic priorities (i.e. service excellence, safety)
  • Funding
    • Lobbying efforts in place
    • 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
    • Formal committee in place to oversee all capital projects and emergency requests
    • Close monitoring of conditions of the facilities
    • Regular inspections and assessments undertaken to identify potential problem areas (e.g. fire inspections, infrastructure risk assessments, life safety assessments, environmental assessments, etc.)
    • Risk analysis is done to understand the impact of circumstances such as lack of funding and/or lack of maintenance
    • 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 is actively followed
    • Maintenance on call 24/7
    • Access to knowledgeable and experienced maintenance staff and engineers at all sites
    • Appropriately managed contracted service providers
    • Policy and process in place to monitor temperature and humidity in areas such as operating room and medical devices reprocessing, etc.
    • An inventory of equipment and infrastructure assets is maintained
    • Computerized maintenance management system that provides advanced notice of replacement needs and assets nearing end of life
    • Safety and security of the staff and patients are always kept at the forefront when making decisions related to capital planning and equipment purchases
    • Workplace hazards monitored and addressed in a timely manner
    • Continuous risk identification and prioritization process for infrastructure upgrades
    • Regular alerts and recalls reviews
    • Infection control issues are identified and managed as required
    • Inventory of all manufacturers’ warranties
  • Contingency plans
    • Contingency plan includes plans for alternate site usage
    • Comprehensive emergency code in place
    • Water intrusion response plan
  • Physical  controls
    • Backup generators
    • Electrical improvements and red emergency power outlets
    • Updated plumbing in older buildings
    • Boiler maintenance and replacement
    • Sprinkler system
    • Updated fire alarm system
    • Appropriate sewers and storm drainage system
    • Updated communication system
    • Roof repairs
    • HVAC system replacement
    • New elevators
    • Floor/carpet upgrades
    • Decommissioning of unsafe equipment
    • Upgrade security systems such as cameras, building access, and alerts
    • Oil tank replacement
    • Fire exit door replacements

Monitoring / Indicators

  • Facility conditions
  • Facility assessment results
  • Problem areas and service requests
  • Maintenance activities
  • Alerts and recalls
  • Available funding
  • Ability to receive funding
  • Code/standard compliance
  • Capital project requests
  • Budgets
  • Missing equipment
  • Workplace hazards
  • Infrastructure projects and their statuses
  • Downtime
  • Staff/patient/visitor complaints
  • Building automation system
  • Work orders for maintenance
  • Regular audits
  • Funding received aligns with, or in accordance of, needs
  • Air quality testing results
  • Emergency code testing results (i.e. code gray, red)
  • Accreditation results

Note: Information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.