Article from Building Performance ()
March 22, 2012
Improving Fire & Life Safety Compliance in Healthcare with MS SharePoint
by Robert Foster, M.S.

EC.02.03.05 (inspection, testing, and maintenance of fire protection equipment) has been consistently in the top 10 most cited standards for many years.  Hospitals continue to struggle to meet the rigorous requirements of testing and documentation of literally thousands of individual pieces of equipment associated with this compliance area.  Responsibility for inspection, testing and maintenance/repairs is typically assigned to the Facilities Department, but third party vendors are often enlisted to perform some of these duties. The Facilities Department must provide oversight of any vendors and is always ultimately responsible to The Joint Commission (TJC) for ensuring that testing is conducted on-time, is complete down to the device level, and that all deficiencies are addressed and documented. Often the responsibility of oversight and documentation overwhelms the ability of the hospital staff to administer the program, resulting in citations during surveys.

EH&E has found that Microsoft SharePoint can be utilized to help significantly reduce the administrative burden associated with monitoring fire/life safety program effectiveness; ensuring completeness of inspection across all devices, verifying inspection results, and documenting the completion of any necessary repairs as a result of inspection findings.  SharePoint is a readily available, customizable, collaboration platform that allows the user to create data repositories that can be programmed via workflows to analyze, process, and display information for the user.  Unlike spreadsheets or hard copy files, SharePoint makes it possible to automatically administer much of the minute details of this large program to both improve overall compliance and reduce the administrative burden. 

In a recently deployed application, SharePoint helped minimize the administrative requirements of maintaining compliance with EC.02.03.05 via the creation of two applications: a compliance dashboard and an electronic third party inspection system.

1. Fire /Life Safety Compliance Dashboard

Virtually all hospitals utilize work order systems to monitor the completion of compliance-related tasks, however, they generally do not present managers with visual cues of overall compliance status, nor do they single out key compliance tasks from the large number of Preventive Maintenance (PM) tasks to be completed for special tracking.  In this hospital application, compliance task work orders number approximately 350 per year compared to over 5,000 scheduled PM work orders and over 10,000 total work orders.  It is this relatively small number of work orders that requires special monitoring to prevent program non-compliance.  

In this case SharePoint can be integrated into the maintenance program in two ways; it can be programmed to monitor these compliance tasks in a separate task list built for that function (separate from the work order system), or it can be linked directly to the existing work order system.  Constructing a separate task list may be necessary when no electronic work order system is in place or the existing system is inadequate. Linking directly to the work order system is preferred since it requires no additional data entry (the existing work order system serves as the task list).  In this case, PM tasks critical to compliance are labeled within the existing work order system along with the Standard they apply to, and SharePoint can capture this information and create rules for the various tasks that allow the manager to get visual and email cues when tasks are coming due or are in danger of being missed (Figure 1).



In Figure 1, the dashboard displays the number of days prior to the compliance deadline that the manager would like the items within that Element of Performance completed by (Goal).  The Value is the actual number of days to completion, and the visual cues illustrate the status, both in terms of the next scheduled task or work order, and a Year-to-Date value.  Clicking on the hyperlink for any Element of Performance item shows the individual tasks or work orders comprising the Element of Performance with responsible party and scheduled and actual completion dates.

The Compliance Dashboard provides the manager with a clear indication of their compliance status, and having the Goals linked to email alerts provides a way to take corrective action before a critical deadline is missed.  Once in place, the system requires no administrative overhead to support.

2. Electronic Inspection Forms for Third Party Inspections

One of the vulnerabilities within EC.02.03.05 is inspection of fire device and sprinkler systems that are routinely assigned to third party vendors.  Citations in this area are rooted in inadequate forms that do not meet TJC standards, missing devices (varying numbers from inspection to inspection), undocumented repairs, and missed inspection dates.  The administrative overhead normally required to properly track and document this massive amount of information (the 350,000 sq. ft. hospital in this installation has over 2,000 fire safety devices requiring inspection by third parties) often overwhelms the limited hospital resources, and vendors rarely have systems in place to provide the required documentation.  Errors and omissions are inevitable. 

In this case, SharePoint was used to deploy electronic inspection forms modeled on the existing vendor forms and vetted by EH&E compliance experts, knowledgeable in current TJC requirements. 

Electronic forms for these inspections offer a number of significant benefits:


  • Draw from a single master device list, thus eliminating any potential discrepancies between hospital and vendor lists.
  • Monitor device inspection frequencies against compliance requirements and force inspections when compliance is jeopardized.  This was very important to this application since inspections were staggered over the year due to the number of devices, making it easy to miss devices.
  • Electronic forms eliminate the need for interpretation of any handwritten notes made by the inspectors.


Inspection form data is automatically analyzed upon submission, and any devices requiring attention trigger alerts to designated personnel for follow-up.  Repairs can be assigned a work order or purchase order, depending on individual hospital protocols, and the repair and verification noted in a permanent record. 

Utilizing vendor labor to populate the electronic data system, and then allowing SharePoint to analyze data, track compliance details, and document the repair trail improves compliance status but also dramatically decreases the administrative requirements to do so.  In this instance, the pre-existing manual processing of information involved 9 separate manual steps and averaged 30 days to complete the resolution of any issues noted during the inspection.  After implementation of the electronic forms, the number of manual steps was reduced to 2 and the time required to address items was cut to less than one week – with no errors.



Microsoft SharePoint is a readily available platform that can be adapted to address many of the common issues associated with compliance deficiencies within EC.02.03.05 (inspection, testing, and maintenance of fire protection equipment).  Its ability to automate the display, analysis and processing of existing work order and inspection forms allows it to simultaneously improve compliance performance and dramatically reduce the associated administrative effort.  It can also be easily customized to meet the specific needs and workflow requirements in each hospital.

As Director of Products & Services at EH&E, Bob organizes the development of web-based applications to support Environmental Health & Safety and Biosafety programs. Applications uniquely focus on utilizing in-house expert knowledge to develop customized solutions on a Microsoft collaboration platform. For more information, contact Bob at or go to:

Published by Environmental Health & Engineering
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