FMS Committee

F.
Westergaard RN MSN MBA, Senior Consultant JCI
2014
Facilities Management Committee Guidelines
Facility Management and Safety Committee:

Guidelines for membership and function
In many hospitals, the functions of Facility Management activities are managed by multiple
individuals who may report to multiple members of the leadership team. One way to provide
effective oversight of the Facility Management functions is to form a multidisciplinary
committee that meets on a regular basis. Minutes of these meetings should be documented.
Membership of the Facility Management Committee
A Facility Management committee should comprise of a multidisciplinary group focused on the

continuous improvement of the hospitals environment of care. The committee should consist of
select representatives from the service and support departments with primary and collaborative
responsibility for providing a safe, secure, and comfortable environment to facilitate patient care.
The committee should include representation for each of the seven Facilities Management functions
(safety, security, hazardous materials, emergency management, fire safety, biomedical equipment,
utilities) and should include appropriate representation for outsourced, vendor services (e.g. waste
management, housekeeping) and other hospital functions such as construction management and infection
control. A member of hospital leadership should be a member of the team in order to facilitate
communications with leadership and to assist in authorization of specific projects. A member of the
hospitals Quality Improvement Committee may be included as a resource for data management and
analysis as well as facilitating communication between the committees. Additionally, representatives for
the Laboratory Safety and Radiation Safety programs may be included as members or be invited
periodically to present summary reports or to discuss specific events or issues.
A chairperson should be appointed. At least in the initial phase of forming this committee, the chairperson
should preferably be a member of the hospitals leadership team.
To summarize, membership of the Facilities Management Committee may include:
Chairperson
Representative from hospital leadership team (may serve as chairperson)
Representatives with responsibility for:

o Safety
o Security
o Hazardous Materials
o Emergency Management
o Fire Safety
o Biomedical Equipment
o Utilities
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Representatives from outsourced services that impact the environment of care (e.g. food services,
housekeeping, laundry, hazardous materials, etc)
Representative from Construction Management team
Representative from Infection Control Committee
Representative from Quality Improvement Committee
Representative for Laboratory Safety Program
Representative for Radiation Safety Program
To optimize functionality, the size of the committee should be limited (e.g. 10 to 12 persons). It should be
noted that each member may represent more than one Facilities Management function or hospital
committee. Also, some representatives may be invited on an as needed basis.
Relationship with other Hospital Committees
The organizational responsibility and structure of the Facility Management and Safety Program
at a hospital requires a partnership and strong communications between the Facilities
Management Committee and the hospital departments and associated committees. These would
include existing committees such as Quality Improvement as well as Infection Control and
Construction Management. Membership in the Facilities Management Committee should be
drawn from these departments and committees as appropriate. This organizational structure and
partnership should provide an opportunity for clear and expedient communication of the
Facilities Management program requirements and identified issues.
It should be noted that the standards require that the organization has a process to periodically
review and to update the Facilities Management plan(s). As part of the annual review process,
the review may be presented to the hospitals Quality Improvement committee or to the
hospitals leadership team for approval.
Functions of the Facility Management Committee:
The functions of the Facility Management Committee responsibilities might include:
Provide leadership associated with Facilities Management functions.
Plan, direct, implement, and improve the organizations performance of the Facilities
Management activities.
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Identify applicable laws and regulations that apply to Facilities Management functions
(e.g. local fire safety regulations, regulations for disposal of hazardous materials, etc.)
and to ensure continued compliance.
Evaluate and assess existing conditions, operations, and practices to determine the impact
of and general compliance with the Standards.
Establish performance criteria and monitor performance of outsourced services that

impact the hospitals environment of care (e.g. housekeeping, waste management,
laundry, security, food services, etc.)
Assess and mange risks associated with construction or renovation projects located in or
adjacent to the hospital environment
Identify and generate improvement opportunities and process change to facilitate the
safety, security, and comfort of patients and their social environment.
Establish and maintain risk assessment and evaluation criteria to identify the priority of
performance improvements and process changes.
Prioritize new improvement opportunities related to the environment of care.
Recommend, coordinate and facilitate new performance improvement projects.
Provide the stimulus, vision, and resources to permit implementation.
Analyze and discuss results of performance monitoring for each of the FMS plans.
Develop and participate in a process for the annual review of the FMS plans
Routinely report to the hospital departments and committees to communicate progress,

resource requirements, and planning activities.
Frequency of Meetings
The frequency of the Facilities Management Committee meetings should be determined by the
hospital. Most hospitals hold monthly or bimonthly meetings. In the initial phase after forming
the committee, or when the hospital is preparing for a survey, the meetings may be held more
frequently (e.g. every 2 weeks).
The committee may decide to form smaller task oriented groups to work on specific issues.
These groups would meet on a more frequent basis and report back to the main committee at the
regularly scheduled meeting.
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F.

Westergaard RN MSN MBA, Senior Consultant JCI

Facility Management and Safety Committee:

Membership of the Facility Management Committee

A Facility Management committee should comprise of a multidisciplinary group focused on the

To summarize, membership of the Facilities Management Committee may include:

Representative from hospital leadership team (may serve as chairperson)

Representatives with responsibility for:

Representative from Construction Management team

Representative from Infection Control Committee

Representative from Quality Improvement Committee

Representative for Laboratory Safety Program

Representative for Radiation Safety Program

Relationship with other Hospital Committees

Functions of the Facility Management Committee:

The functions of the Facility Management Committee responsibilities might include:

Provide leadership associated with Facilities Management functions.

Establish performance criteria and monitor performance of outsourced services that

Prioritize new improvement opportunities related to the environment of care.

Recommend, coordinate and facilitate new performance improvement projects.

Provide the stimulus, vision, and resources to permit implementation.

Routinely report to the hospital departments and committees to communicate progress,

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