Healthcare News & Insights

Establishing and maintaining compliance with vendors to provide the best care

Working with vendors can be challenging. In this guest post, Larry Lacombe, VP of program development, support and FM compliance at a company specializing in facilities management, safety, environment of care, emergency management and compliance, tells you how to provide quality care while remaining compliant.


While all hospitals strive to establish and maintain a safe, functional environment, 100% compliance isn’t as easy as it seems. Having an environment that provides the best possible care to patients is a common goal for caregivers and executives alike. However, 70% of hospitals surveyed by The Joint Commission (TJC) in 2017 were non-compliant with this requirement.

The top five requirements identified as “not compliant” for hospital accreditation from TJC’s surveys include providing and maintaining systems for extinguishing fires (86% non-compliant); managing risks associated with utility systems (73%); providing and maintaining building features that protect individuals from fire and smoke hazards (72%); reducing the risk of infections associated with medical equipment, devices and supplies (72%); and establishing and maintaining a safe, functional environment (70%).

The theme running through these requirements is they’re all related to hospitals’ systems. These systems can require extensive maintenance, and hospitals often outsource control of these systems to third-party vendors where inconsistencies can arise. However, these issues can be mitigated to help your hospital reach compliance.

Efficient reporting

The biggest compliance headache for hospitals in 2017 was maintaining systems for extinguishing fires. Also high on the list was maintaining features to protect from fire and smoke hazards, such as fire alarms and sprinklers. Likely, a third-party vendor is testing these systems. Although the ideal approach to all third-party-reliant procedures is to bring those in-house, it’s not necessarily budgetarily friendly to do so, specifically for fire alarm testing. The biggest problem with those third-parties is often reporting.

No matter the size of the hospital or system, it can take a great deal of time to receive testing reports. The problem, however, lies in that the vendor has identified issues that need to be addressed that day. It could be a matter of life and death to make those changes, which means time where your facility could be unsafe.

When working with a third-party vendor for sprinkler or fire alarm testing, establish a non-negotiable timeline for vendors’ reports. Have the vendor make you aware of any failures, as soon as they’re found, so your facility can execute the appropriate interim life safety measures (ILSMs) immediately.


Even in large companies that operate on standardized protocols, it can be challenging to obtain consistent reporting from vendors. Sometimes even simple compliance benchmarks can be reported inconsistently from location to location.

Lack in consistency can lead to oversights, both in your facility and for a TJC survey. You never want to go into a survey with a report that doesn’t provide adequate information. That leads to inquiries which lead to more work to fix something that may not have been broken.

Work with your vendors to provide consistent information across reports and locations. This may mean cultivating a stronger relationship to file reports in a new way, but it’s an investment of time that will pay dividends.

Ideal partnerships

Not every vendor is going to be the perfect fit for every facility. It’s not wrong to recognize that and search for a new partner that’s a better fit. If consistency and reporting continue to be an issue, look at your vendors. Does your facility utilize four or five vendors across different reporting functions? Reducing the number of vendors to one or two will immediately streamline disparate reporting and lengthy timelines. With a heavy reliance on reports, don’t forget to take the ability of a vendor’s technicians and the quality of their work into consideration – the report’s only as good as their ability to fix what’s wrong.

It’s unlikely that every system in your hospital can be run in-house, but for the safety of your patients and employees, there are several elements that should remain nonnegotiable. Ensure your relationships with your vendors are strong and beneficial to your facility, then work with them to establish consistent, streamlined and timely reporting.

Larry Lacombe is VP of program development, support & FM compliance at Medxcel, a company specializing in facilities management, safety, environment of care, emergency management and compliance. Medxcel provides healthcare service support products and drives in-house capabilities, savings and efficiencies for healthcare organizations. 

Subscribe Today

Get the latest and greatest healthcare news and insights delivered to your inbox.