Hospital Commissioning Checklist: Before You Admit the First Patient

Opening a hospital represents one of the most complex undertakings in healthcare infrastructure. Before admitting your first patient, you need to ensure every system functions flawlessly, every staff member is trained properly, and every regulatory requirement is met. This comprehensive checklist will guide you through the critical steps of hospital commissioning.

Understanding Hospital Commissioning

Commissioning a hospital is a systematic process that verifies all building systems, equipment, and procedures operate according to design specifications and owner requirements. The commissioning process provides step-by-step instructions for implementing commissioning in a healthcare facility and ensuring its equipment, systems and structures meet standards and owner requirements.

Unlike conventional commercial facilities, hospitals have specialized systems and technologies that demand extra rigor during commissioning. Hospital systems needed for life saving functionality must be always-on with non-interruptible power supplies and supported by sophisticated heating, ventilation and air conditioning systems. Working with experienced hospital project management consultants can help ensure this complex process is executed properly from start to finish.

Infrastructure and Facility Requirements

Site and Construction Verification

Infrastructure required includes land, construction, residential accommodation, material, water and electricity, telephone, communication cables, and accessibility to the public without any disturbances. Before opening day, verify that all construction meets approved architectural plans and local building codes.

Conduct a thorough walkthrough with your facilities team to check:

All construction work is complete with no outstanding punch list items
Building codes and safety regulations are met
Fire protection systems are installed and functional
Proper signage is installed throughout the facility
Landscaping and exterior areas are complete

Utility Systems

All utility systems must be tested and certified before patient admission. This includes:

Electrical systems with backup generators
Water supply and plumbing
HVAC systems with proper air pressure controls
Medical gas systems and vacuum systems
Emergency power systems
Fire suppression and alarm systems

Medical gas systems fall into the highest level of risk for health care facilities, Category 1, which means there is a high likelihood of severe injury due to poorly installed equipment.

Licensing and Regulatory Compliance

State Licensure Requirements

Every hospital must obtain proper state licensure before admitting patients. Hospitals must be licensed to provide services before they can receive Medicare or Medicaid certification. The licensing process typically includes:

Submission of completed application forms
Payment of licensing fees (varies by state and bed count)
Fire safety inspection approval
Architectural review unit approval
Certificate of occupancy
Proof of full staffing capability

Applicants should submit a hospital licensure application, fees, and supporting documents 60 to 120 days before the anticipated effective date.

Accreditation Process

While voluntary in most cases, accreditation from organizations like The Joint Commission demonstrates your commitment to quality and safety. The Joint Commission accredits a wide range of healthcare facilities, including hospitals and surgery centers, based on rigorous quality and safety standards.

Accreditation requirements include:

Compliance with patient safety standards
Quality improvement programs
Infection control procedures
Medical staff credentialing
Patient rights policies
Emergency management plans

Medical Equipment Installation and Testing

Equipment Acceptance Procedures

The adoption of pre-commissioning checklists helps hospitals ensure safety of patients and staff while using equipment and aligning to hospital accreditation requirements. A standardized equipment commissioning process should include:

Commissioning Phase	Key Activities
Delivery Verification	Verify equipment matches purchase order, inspect for damage, document receipt
Installation	Ensure proper placement, connections, and environmental requirements
Testing	Conduct safety testing, performance verification, and calibration
Documentation	Collect manuals, warranties, maintenance schedules, and training materials
Training	Conduct hands-on training for all users and clinical staff

Acceptance testing occurs at two times: immediately after the equipment is installed before commissioning, and about one month before the end of the warranty period.

Medical Equipment Categories

The Joint Commission requires hospitals to test all medical equipment for safety and performance before it is initially used in the hospital. Categories to commission include:

Life support equipment (ventilators, defibrillators, monitors)
Diagnostic imaging equipment (CT scanners, X-ray machines, MRI)
Laboratory equipment (analyzers, centrifuges, microscopes)
Surgical equipment (operating tables, lights, surgical instruments)
Patient care equipment (beds, IV pumps, feeding pumps)
Sterilization equipment (autoclaves, washers)

Building Systems Commissioning

HVAC System Verification

The commissioning authority should witness equipment and systems start-up as well as functional performance tests, which assess the performance of the commissioned systems under design, part load and emergency conditions.

HVAC commissioning must verify:

Proper air flow rates in all areas
Correct temperature and humidity levels
Pressure relationships between rooms (negative pressure isolation rooms)
Air changes per hour meet code requirements
Emergency backup systems function properly
Controls and automation systems operate as designed

Medical Gas Systems

Medical gas pipeline systems must be commissioned after installation and then be subjected to a certification inspection by an approved testing agency. Required tests include:

Alarm notification testing
Piping pressure testing
Cross-connection verification
Gas concentration testing
Particulate contaminant testing
Terminal unit flow testing

Staff Recruitment and Training

Recruitment Timeline

Recruitment of personnel, including medical, nursing, paramedical, supportive, administration, finance and security staff should be carried out simultaneously according to planned priorities.

Begin recruitment at least 6-12 months before your planned opening date. Your hiring plan should include:

Clinical staff (physicians, nurses, specialists)
Allied health professionals (pharmacists, therapists, technicians)
Administrative staff (billing, records, management)
Support services (housekeeping, food services, security)
Facilities and maintenance staff

Comprehensive Training Programs

Applicants must provide proof that the hospital will be fully staffed when it opens, meaning staffed 24 hours a day, seven days a week.

Before opening, all staff must complete:

Orientation to hospital policies and procedures
Department-specific training
Equipment operation training
Electronic health record system training
Safety and infection control training
Emergency response procedures
Patient rights and HIPAA compliance

Infection Control Measures

Infection Prevention Program

Hospitals must recruit hospital epidemiologists and infection preventionists and establish an infection control committee to organize prevention programs.

Your infection control program must include:

Written policies and procedures for all aspects of infection control
Hand hygiene protocols and supplies throughout the facility
Personal protective equipment availability
Environmental cleaning protocols
Isolation room procedures
Sterilization and disinfection processes
Waste management systems

Environmental Preparation

All medical equipment, especially reusable equipment, should be sterilized or disinfected before use to prevent the transmission of infections.

Before admitting patients, ensure:

All surfaces are thoroughly cleaned and disinfected
Hand hygiene stations are strategically placed
Clean and soiled utility rooms are properly designated
Medical equipment is sterilized and ready for use
Linen management systems are in place
Sharps containers and waste bins are installed

Emergency Preparedness and Safety

Emergency Operations Plan

Emergency management includes four phases: mitigation, preparedness, response, and recovery, with details of activities and actions required captured in the Emergency Operations Plan.

Your emergency plan must address:

Natural disasters (earthquakes, floods, hurricanes)
Fire emergencies
Active shooter situations
Hazardous material incidents
Power outages
Infectious disease outbreaks
Mass casualty events

Required Drills and Exercises

Disaster exercises, particularly those using terrorism incident scenarios, are among the best ways to evaluate your hospital's emergency management plans, equipment, and systems.

Before opening, conduct:

Fire drills with all shifts
Code response drills (cardiac arrest, rapid response)
Evacuation procedures
Communication systems testing
Emergency generator testing
Mass casualty simulations

The Joint Commission Environment of Care standard requires hospitals to conduct regular, varied fire drills, and to routinely evaluate the effectiveness of the procedure, fire safety equipment, building features, and staff response.

Information Technology Systems

Electronic Health Records

Network cables must be spread in and around hospital vicinity to meet short term and long term eHealth system needs as all health institutions are moving toward eHealth based hospitals.

Your IT infrastructure commissioning should include:

Electronic health record system installation and testing
Network infrastructure verification
Cybersecurity measures implementation
Data backup and recovery systems
HIPAA-compliant data storage
Pharmacy information systems
Laboratory information systems
Radiology PACS systems

Communication Systems

Test all communication systems including:

Telephone systems
Paging systems
Nurse call systems
Code blue notification systems
Emergency notification systems
Staff communication devices

Supply Chain and Materials Management

Initial Inventory

Before opening, establish adequate inventory of:

Category	Essential Items
Pharmaceuticals	Emergency medications, commonly prescribed drugs, IV solutions, controlled substances
Medical Supplies	Gloves, masks, gowns, syringes, dressings, catheters, tubes
Surgical Supplies	Sterile instruments, drapes, sutures, implants, disposables
Laboratory Supplies	Reagents, test tubes, collection supplies, quality control materials
Linen	Bed sheets, blankets, patient gowns, surgical linens, towels
Food Services	Food inventory, kitchen supplies, patient meal supplies

Vendor Contracts

Establish contracts with:

Medical equipment maintenance providers
Pharmaceutical suppliers
Linen and laundry services
Waste disposal companies
Food service vendors
Biomedical equipment service providers

Policies and Procedures

Clinical Policies

Before admitting patients, finalize and distribute policies for:

Patient admission and discharge procedures
Clinical documentation requirements
Medication administration protocols
Surgical safety checklists
Blood transfusion procedures
Restraint and seclusion policies
End-of-life care guidelines

Administrative Policies

Required policies include patient rights and responsibilities policies, governing body policies, and medical staff policies including various committees.

Essential administrative policies include:

Patient rights and responsibilities
Privacy and confidentiality (HIPAA)
Billing and financial policies
Medical staff bylaws and credentials
Human resources policies
Safety and security procedures

Mock Operations and Dry Runs

Practice Patient Admissions

Before your official opening, conduct mock patient admissions to test:

Registration and admission processes
Patient flow through various departments
Electronic health record documentation
Laboratory and pharmacy order processing
Medication dispensing and administration
Patient transport procedures
Discharge planning processes

Department Simulations

Run simulations in critical areas:

Emergency department patient scenarios
Operating room procedures
Intensive care unit admissions
Labor and delivery simulations
Radiology workflow
Laboratory specimen processing

Financial and Business Operations

Revenue Cycle Management

Ensure your revenue cycle is ready by verifying:

Billing system is configured and tested
Payer contracts are in place
Claims submission processes are established
Charge capture systems are functioning
Financial policies are communicated to staff

Insurance Credentialing

Complete credentialing with:

Medicare certification
Medicaid enrollment
Commercial insurance networks
Managed care organizations
Workers' compensation programs

Quality and Performance Measures

Baseline Metrics

Establish systems to track:

Patient satisfaction scores
Clinical quality indicators
Safety event reporting
Infection rates
Patient outcomes
Staff satisfaction
Financial performance

Quality Improvement Structure

Create committees and teams for:

Quality improvement initiatives
Patient safety reviews
Mortality and morbidity reviews
Infection control oversight
Pharmacy and therapeutics
Medical staff peer review

Final Inspection Checklist

30 Days Before Opening

Complete all construction punch list items
Finalize state licensing and accreditation
Complete equipment commissioning
Finish staff hiring and orientation
Conduct emergency drills
Test all building systems

14 Days Before Opening

Conduct mock patient admissions
Verify all supplies are stocked
Test information systems end-to-end
Complete staff training
Conduct final safety walkthroughs
Verify vendor contracts are active

7 Days Before Opening

Hold all-staff readiness meetings
Test on-call schedules and coverage
Verify medical staff privileges are granted
Confirm payer contracts are effective
Complete final cleaning and disinfection
Test emergency contact systems

24 Hours Before Opening

Conduct final systems check
Verify all departments are ready
Confirm staffing for first shift
Review admission criteria and processes
Conduct leadership walkthrough
Brief all staff on opening day procedures

Conclusion

Commissioning a hospital before admitting the first patient is a complex but critical process that requires careful planning, systematic execution, and thorough verification. Success depends on attention to detail across multiple domains: facility infrastructure, equipment installation, staff preparation, regulatory compliance, and operational readiness.

By following this comprehensive checklist, you can ensure your hospital opens with confidence, knowing that every system has been tested, every staff member is trained, and every safety measure is in place. Remember that commissioning is not just about meeting regulatory requirements—it's about creating a safe, efficient environment where patients receive the highest quality care from day one.

The investment you make in thorough commissioning pays dividends in patient safety, staff satisfaction, and operational efficiency. While the process may seem overwhelming, breaking it down into manageable components and maintaining clear documentation throughout will help ensure nothing falls through the cracks.

Your opening day represents the culmination of months or years of planning and preparation. By completing each item on this checklist, you position your hospital for success from the very first patient admission.

Frequently Asked Questions

How long does the hospital commissioning process typically take?

The commissioning process typically takes 12-18 months from initial planning to opening day, though this can vary based on facility size and complexity. Major systems commissioning should begin as soon as construction allows, while staff recruitment often starts 6-12 months before opening. Final commissioning activities, including mock drills and dry runs, typically occur in the 60-90 days before admitting the first patient.

What happens if we find problems during commissioning?

Discovering problems during commissioning is actually the purpose of the process—it's far better to identify and fix issues before patients arrive. When problems are found, document them immediately, work with contractors or vendors to resolve them, and conduct retesting to verify the fix. Never compromise on safety or compliance issues; delay your opening if necessary to ensure everything functions properly.

Do we need to commission every piece of equipment individually?

Yes, every piece of medical equipment should undergo acceptance testing before clinical use. The Joint Commission requires hospitals to test all medical equipment for safety and performance before initial use. This includes both hospital-owned equipment and leased or rented items. A standardized commissioning checklist helps ensure consistency and completeness across all equipment types.

Can we open with partial commissioning and finish the rest later?

No, hospitals should not open until full commissioning is complete. State licensing requirements mandate that all systems be functional and tested before receiving your license to operate. Opening with incomplete commissioning creates significant patient safety risks and potential liability issues. If you're planning a phased opening, each phase must be fully commissioned before accepting patients.

How do we maintain commissioning documentation for regulatory purposes?

Create a comprehensive commissioning binder or electronic database that includes all test results, inspection reports, training records, certificates, and vendor documentation. Organize it by system or department for easy reference during surveys or inspections. Keep copies of state licenses, accreditation certificates, fire safety inspections, equipment commissioning reports, staff training records, and emergency drill documentation. This documentation proves compliance and helps identify baseline performance for future reference.