While the Facility Guidelines Institute (FGI) and the Joint Commission continue to emphasize more extensive systems commissioning for new hospital buildings and major building renovations, it’s also time to consider “clinical operations commissioning” as an effective means of identifying and addressing operational risks before any patients, staff, or visitors walk through the doors of a new facility. 

The American Society for Healthcare Engineers defines commissioning as "a process intended to ensure building systems are installed and perform in accordance with the design intent, that the design intent is consistent with the owner’s project requirements, and that operations and maintenance staff are prepared adequately to operate and maintain the completed facility.” Too often, patient care and other operational processes simply aren’t put through the same rigorous testing and training as technical systems prior to occupancy of new facilities. The implications for the safety of patients, staff, and others can be quite profound.

Even when new integrated communication systems, technical systems, and other equipment are functioning exactly as intended, hospital staff often haven’t received the full-scale training necessary to be thoroughly competent and comfortable in managing them effectively. Factors influencing this are cost, time, and availability of staff. For a legacy hospital, its current staff are busy taking care of patients and often can’t be spared for long training sessions. For a new facility, the challenges often come from the fact that staff may not be hired until about a month before opening, in order to save costs.

Clinical operations commissioning simulations are able to provide in-depth testing of how processes will work and where inherent risks to safety and quality may lie. Major flows and processes—such as patient admissions, transfers, response to code situations, patient deaths, and discharges to and from all facility settings—should be practiced, even if it a basic level, with potential failure points identified, prioritized by risk, and remediated either through training, process change, or some type of facility alteration. While the major flows and processes, like admissions and discharges, are a good start, a more exhaustive and structured framework for modeling real-life scenarios increases the chances that key risks can be identified in advance of operations, so as to better prepare the staff and hospital for safe occupancy.

The framework
In Joint Commission Resources’ consulting work with new hospitals in the U.S. and around the globe, the structured approach developed involves developing multidimensional simulations that model both normal and non-normal situations that can arise on any given shift. Based on these experiences, efforts are focused in-depth on seven of the key medical flows that, together, make up the majority of the clinical processes that unfold in day-to-day operations of a hospital. Reviewing each of these flows individually, as well as how these flows interact with one another, helps to reduce the risks associated with a new opening by proactively identifying areas for improvement, boosting staff familiarity and confidence with new processes and equipment, and serving as a final check-off process before opening a building to the public. What follows are practice implications for each of these major flows.

Prior to the opening of a new facility, months of staff time and planning will have already been spent in aligning the design and desired processes. But not until the equipment and systems are up and functioning can an organization really test if patients are going to have the desired experience during their stay. Joint Commission Resources’ recommendation is to have both staff and members of the community “live” the patient experience through simulation and provide feedback on the facility and equipment. The inclusion of community members offers the new hospital a source of unbiased feedback that’s essential. When reviewing the flow of patients, key functions to consider for inclusion in the scenarios are access to the facility, confidentiality and privacy for patients and caregivers, and overall safety.

Orientation, scavenger hunts, and equipment training have all been reliable tools in the “occupancy toolbox” of new hospitals and continue to be of substantive value. Clinical operations commissioning provides the next level of provider readiness by integrating all of the functions needed for patient care and testing them simultaneously. One of the most crucial areas to test is the communication systems. Most often, new facilities have installed systems with which staff have little or no familiarity. These systems are often serially integrated so that one system (e.g., equipment alarms) notifies a second or even a third system, such as nurse call or the phone system. These interconnected systems need to be carefully tested with as many staff members as possible during the simulations. Too often, this is a major area of vulnerability during early occupancy in a new facility.

Although physicians are critical to the success of a new facility, they often inadvertently become one of the biggest challenges for successful preparation. By incorporating a focus on physicians’ critical functions during the simulations, such as the ability to navigate appropriate and timely access routes during code situations, an organization can substantially reduce the time needed for physician training. Scheduling short, intense drills and offering multiple times for physician involvement will help bring physicians into the equation.

Also, too often, attempts at “day-in-the-life” drills focus exclusively on daytime operating hours. It’s recommended that scenarios be developed that test staffing and processes around the clock. As an example, one organization learned only through simulation that it had neglected to provide an administrative point person for evenings and nights who could coordinate functions during codes or crises.

With so much focus put on designing new processes for patients and providers, a very common oversight is the flow of families and visitors through a new facility. Issues such as the locations to which families are directed during crisis moments in the emergency department, or how wayfinding instructions will be delivered by staff, all must be identified prior to the occupancy of a new building. Simulations offer the opportunity to include “mock” family members who might be assigned to act as if they are angry, frightened, or just plain bothersome. Insights gained from each of these types of scenarios can help prepare for a smoother transition.

While scavenger hunts are wonderful introductions for orienting staff to the location of supplies, simulations can help the organization take that next step toward preparing for how those supplies will actually be utilized in patient care areas. Critical issues, such as where kits are opened, how their disposal is accommodated, and how asepsis or sterility is managed in patient care areas, can all be integrated into simulations for new or non-standard supplies.

For staff members working in an OR, for example, concern is already focused on supporting a critical surgical procedure, such as neurosurgery; but when a new space like a hybrid OR comes on line, the situation becomes even more complex. Now, a sterile field must be maintained as the CT or MRI moves in and out of the surgical suite. Add to those conce
rns the numerous safety issues for nonferrous materials because of the MRI. Think of all the scalpels, clamps, etc., that need to be safely housed so they’re not disrupted when equipment is turned on. Having staff trained not only on the new equipment itself but also on exactly how to use it in a particular patient care area—whether an OR, imaging area, or patient room—is crucial to providing safe patient care. Developing code scenarios in patient rooms or other likely places to test equipment accessibility, staff movement, etc., is important for ensuring a safe environment and boosting staff confidence.

In addition, as more and more facilities utilize multiple moveable booms for monitors, gases, power, and other critical supports, staff need to be able to practice using these items in a variety of challenging scenarios that create realistic situations, so that patients and families can feel confident of the staff’s ability to navigate the new environment safely. Another key safety concern can also be mitigated by including the facility management staff in developing scenarios that incorporate the need for finding and appropriately using shut-off valves for medical gases, fire alarms, and other life safety practices.

From the delivery of medications at the shipping dock to charting administered doses and their effect, the medication system will almost always be affected by a number of features in a new facility. Frequently, each of these process steps are managed and designed solely by the various departments responsible, such as materials management, pharmacy, or nursing; and too often, the key safety issue—how well those individual process have been integrated into the complete process—is left to chance. Clinical operations simulations can effectively test each of these steps, as well as the integrated process as a whole, focusing on any electronic interface as well as other issues such as safe storage, safe dispensing, and safe administration.

Information technology
Testing the reliability and efficiency of information systems for the proper flow of reports, documentation, and placement of data entry equipment has always been an industry standard for safe IT adoption. During clinical commissioning, the focus is on testing the efficacy of each of these needs while providing patient- and family- centered care. Finding if the proposed system supports the information needs of the providers for the right person, at the right time, is the goal.

Implications for practice
A methodical approach to clinical operations commissioning can reduce the number of items that will need to be changed or modified after a new facility opens, by reducing negative or unsafe experiences for patients and staff. Just as systems commissioning for utilities and major equipment is conducted after full installation, it’s imperative that this process be conducted after staff orientation, equipment training, and scavenger hunts are completed, so that all parts of the clinical care system can be integrated and tested for their readiness.


Kathy Reno, PhD, MBA, RN, EDAC, is a safe health design consultant with Joint Commission Resources/Joint Commission International. She can be reached at kreno@jcrinc.com. David Grazman, PhD, is global manager of safe health design consulting at Joint Commission Resources/Joint Commission International. He can be reached at dgrazman@jcrinc.com.