---
title: The importance of compliance & safety in healthcare facilities
description: Learn why compliance, safety, and risk management are crucial for healthcare facilities to ensure patient care and operational integrity.
image: https://healthcarefacilitiesnetwork.com/hubfs/13_45_13.png
---

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Compliance, Safety & Risk

# The importance of compliance & safety in healthcare facilities

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[ Peter Martin ](https://healthcarefacilitiesnetwork.com/insights/author/peter-martin)  24 Jun 2025 •

7 min read

#### Contents

#### Contributors

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Larry Rubin is a seasoned healthcare facilities professional with extensive experience in both plant operations and regulatory compliance. He began his career as a nuclear-trained machinist mate in the Navy, which shaped his focus on procedure, safety, and preventive maintenance. In a distinguished career marked by service to others, he was a Boston police officer and a teacher before transitioning into healthcare. In healthcare, Larry has held numerous leadership positions, including Director roles at facilities in Ohio and Florida.

Larry has also served as a Life Safety Code Surveyor with The Joint Commission, giving him a unique dual perspective from both inside and outside of hospital walls. In his current work, with [Rubin Healthcare Compliance](https://www.linkedin.com/in/larryfrubin/), he supports facility leaders through interim roles and consulting, emphasizing mentorship, continuous improvement, and system-level thinking.

Facilities management is about patient care. Watch the full discussion with Larry.

[![YouTube Logo](https://healthcarefacilitiesnetwork.com/hubfs/YouTube_2024.svg) ](https://www.youtube.com/watch?v=b1Z4Yok3G80) [ ![Apple Podcasts-1](https://healthcarefacilitiesnetwork.com/hs-fs/hubfs/Apple%20Podcasts-1.png?width=175&height=40&name=Apple%20Podcasts-1.png) ](https://podcasts.apple.com/us/podcast/career-paths-and-the-top-5-life-safety-and-ec/id1508513507?i=1000637734159) [![Spotify Logo](https://healthcarefacilitiesnetwork.com/hs-fs/hubfs/Spotify_logo_with_text.svg.png?width=133&height=40&name=Spotify_logo_with_text.svg.png)](https://open.spotify.com/episode/1YBbEy7PC9b58lZRJ88XJM?si=41879a3fc6384646)

 

---

 

## **Why It Matters**

Why Compliance, Safety & Risk Matter in Healthcare Facilities Management

Larry provides his insights into why Compliance, Safety, and Risk Matter in Healthcare Facilities Management.

1. Patients’ Lives Are at Stake  
   Larry underscores that healthcare facilities are not just buildings—they’re environments where vulnerable patients receive critical care. Any lapse in compliance or safety can directly endanger lives. Unlike other industries, even small oversights (e.g., a malfunctioning fire door or mislabeled gas shutoff) can have catastrophic consequences in a hospital setting.
2. Hospitals Are High-Risk, High-Regulation Environments  
   Larry likens healthcare to the nuclear industry in terms of regulatory oversight. Hospitals are subject to numerous codes (e.g., Joint Commission, CMS, NFPA), and failure to comply can lead to penalties, lawsuits, or even shutdowns. This heavy compliance load isn’t optional—it’s foundational to how hospitals operate and are evaluated.
3. Continuous Compliance is Non-Negotiable  
   Larry criticizes the "cram before the exam" culture some hospitals adopt before Joint Commission visits. He believes this reactive approach creates gaps in safety and quality. Compliance must be part of the daily workflow—not a temporary sprint to meet an audit.
4. Facilities Leaders Bear Legal and Ethical Responsibility  
   As Larry emphasizes, the Director of Facilities will be the one held accountable if an issue arises—from electrical failures to fire hazards. This legal and ethical burden means that risk mitigation isn’t just best practice; it’s a professional imperative.
5. Deferred Maintenance = Increased Risk  
   Skipping preventive maintenance (PMs) due to staffing shortages, budget constraints, or burnout can allow risks to accumulate. Larry explains that pencil-whipped logs or unverified repairs compromise system integrity and increase the likelihood of equipment failure, fire, or contamination.
6. Safety Requires a Team Culture  
   Larry promotes the idea that “it takes a village” to maintain a safe hospital. Safety can’t just fall on the facilities team—it requires training, awareness, and partnership with clinical staff, contractors, and leadership. Facilities managers must lead this cultural shift.
7. Workforce Instability Compounds Risk  
   With increasing turnover and fewer skilled tradespeople entering the field, Larry sees a growing risk in knowledge gaps and incomplete work. Interim leadership can help, but without structured systems and mentorship, safety and compliance efforts become harder to sustain.
8. Crisis Readiness Is Now Part of Risk Management  
   Larry points to modern threats like workplace violence, active shooter events, and cyberattacks as expanding the traditional definitions of facility risk. Today’s hospital facilities manager must plan beyond boilers and sprinklers—they must also support organizational resilience.
9. Training, Certification, and Oversight Make the Difference  
   Larry stresses the value of real-world experience, [certifications (like CHFM)](https://www.ashe.org/chfm), and in-house verification of contractor work. These elements close the gap between policy and practice—ensuring compliance isn’t just documented, but real and effective.

Compliance, safety, and risk management are at the heart of a hospital’s mission. Without  
strong pillars in these three areas, patient care is compromised, leadership is exposed to  
risk, and the entire system becomes vulnerable. Strong facilities management is not just  
about fixing things—it’s about protecting lives, ensuring accountability, and building trust  
in healthcare environments.

---

 

## Facility Compliance

Compliance

1. Healthcare is a compliance-heavy industry: Larry compares it to the nuclear power  
   industry and says hospitals may be worse in terms of compliance demands.
2. Continuous compliance is key: He criticizes hospitals for rushing to complete work  
   orders right before Joint Commission visits instead of maintaining continuous  
   compliance.
3. Importance of proper documentation and oversight: He stresses that all work should  
   be tied to a permit and that permits must be verified by trained in-house staff before  
   sign-off.
4. Lack of follow-through on work orders: Many staff falsely claim they’ve submitted  
   work orders; his audits often find no record.
5. Increased regulatory pressure post-2010: Compliance shifted from education to  
   enforcement under CMS pressure; Joint Commission surveyors were told to find more.
6. Return to educational compliance: Larry notes a recent shift back toward teaching  
   and support from surveyors, especially newer ones post-COVID.
7. Certifications over degrees: He argues certifications like CHFM/CHC are more  
   important than academic degrees for proving compliance competency.
8. Data integrity in PMs: He warns about signs of pencil-whipped preventive  
   maintenance logs and stresses checking actual equipment conditions.

---

 

## Safety Culture

Safety

1. Patient safety is the core mission: He emphasizes that the facilities team’s top priority  
   must be patient safety at all times.
2. Fire safety violations are common: Frequent findings include wires on sprinkler  
   pipes, wedged-open fire doors, blocked extinguishers, and improper fire-stopping  
   techniques.
3. Safe environments require team effort: He believes maintaining a safe hospital is a  
   collective responsibility — it takes a village.
4. Training staff to notice hazards: Larry shares success stories where facilities  
   managers involve staff in identifying and fixing safety issues.
5. Daily safety blind spots: He mentions that small issues (e.g., stained ceiling tiles,  
   unsecured oxygen cylinders) are often overlooked, leading to safety violations.
6. Eye wash stations misused or misunderstood: Many are installed unnecessarily or  
   poorly maintained, which creates risks rather than mitigating them.

---

 

## **Managing Risk**

Risk

1. Burnout increases operational risk: Larry identifies burnout among facilities leaders  
   as a growing risk due to workload and 24/7 responsibilities.
2. Turnover and lack of tradespeople: A dwindling and inexperienced workforce  
   increases the risk of missed PMs and poor compliance.
3. Legal liability from overlooked issues: If something goes wrong (e.g., fire, explosion),  
   the facility director will be held responsible.
4. Deferred maintenance implications: Incomplete PMs and neglected infrastructure  
   elevate the risk to patients and staff alike.
5. Labeling utilities is crucial for risk mitigation: Without proper labeling of shutoffs  
   (gas, water, power), emergency response is jeopardized.
6. Crisis readiness and systemic risks: Active shooter protocols, workplace violence, and  
   global instability now impact hospital safety planning more than ever.

 

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