Competency Assessment – Plant Operations Engineer and Staff
What are the expectations for defining and assessing competencies for staff responsible for managing and maintaining the physical environment in hospitals?
Any examples are for illustrative purposes only.
Although there are no regulatory mandated licensing or certifications for the plant operation engineer(s) or staff responsible for plant operations or facilities services, there must be evidence that the person(s) in this role understand the major systems and processes that support the physical environment in healthcare.
This can be a combination of formal education, knowledge acquired during employment or the acquisition of knowledge through prior experience in an adjacent field. It is the ultimate responsibility of the organization's Governing Body to define expectations related to competencies for all staff, as the Governing Body is responsible for all facility operations.
The National Fire Protection Association (NFPA) does require formal certifications for those who perform inspection, testing and maintenance tasks on specific systems; these include:
- Medical gas systems (training and certification or credentialing to the requirements of AASE 6030 or 6040)
- Fire alarm systems
- Fire door maintenance (certification is not required but demonstrated knowledge of the code and operating requirements)
In addition to NFPA requirements local municipalities may require licensure or certification for maintaining utility components, examples include:
- Boilers / High pressure vessels
- Fire/Smoke dampers
Organizations must be able to provide evidence that staff or vendors performing these duties possess the necessary skills to carry out these duties competently. Failure to provide evidence of compliance with this requirement during a survey will result in a requirement for improvement.
Manual:
Hospital and Hospital Clinics
Chapter:
Human Resources HR
New or updated requirements last added: April 05, 2024.
New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: April 05, 2024
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on April 05, 2024
with update notes of: Reflects new or updated requirements
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
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