Relevant information presented by TJC (The Joint Commission) before 2017:
For the past several years, facilities management and hospital safety have been under a microscope during Joint Commission surveys, particularly since the addition of dedicated Life Safety Code surveyors whose sole responsibility is to review the physical environment for compliance with safety standards. Joint Commission surveys are no longer on a set schedule--while they are approximately triennial, surveyors can arrive unannounced and without warning at any time, requiring organizations to be in a state of continual readiness. Leadership needs to acknowledge that Joint Commission surveyors can arrive when they themselves are not present, and must make sure that their staff members, from the ground floor up to unit directors, are prepared for survey.
This is particularly challenging in the area of medical equipment and what the responsibilities are for staff from top to bottom. George Mills, MBA, FASHE, CEM, CHFM, director of the Department of Engineering at the Joint Commission, spoke recently at the Association for the Advancement of Medical Instrumentation (AAMI) conference on what the Joint Commission survey process is with inspection of medical instrumentation and what surveyors will be looking at.
To begin with, surveyors will examine the inventory, looking to see if the work has been done according to schedule and what the organization has determined for frequency of inspections.
Department leaders should be not only qualified, but must know how the inventory of devices was created. If organizations are using Alternate Equipment Management (AEM) processes, department leaders should understand and evaluate the monitoring process as well as its effectiveness. What is the organization’s criteria? What is the completion rate for the AEM processes?
Equipment maintainers must have a working understanding of the process and strategy of equipment maintenance, both according to manufacturer guidelines and AEM processes if used. They must be prepared to address the completion of scheduled work and how to address repeated work orders if asked by surveyors.
Equipment users must also be prepared to demonstrate a high level of knowledge. They should be able to address the reliability of the equipment, know what the response time is when the equipment fails, and have an understanding of the organization’s culture of safety.
Equipment users should be trained on equipment use, and be prepared to address customer satisfaction within the department.
Surveyors are going to look at policies and procedures, Mills said. Specifically, they will ask how equipment is evaluated to ensure there is no degradation of performance and how to identify and address if there are any mis-calibrations.
Policies and procedures should address how equipment is tested for calibration.
Surveyors will also look at errors and near misses. How are incidents investigated, according to your policies and procedures? Was an equipment failure preventable? Did the use of AEM processes contribute to the equipment failure? And how do your policies and procedures dictate how potentially unsafe equipment will be sequestered to avoid further potential harm?
Surveyors will want to know how an organization evaluates potential modifications to its medical device and equipment maintenance strategy.
They will also examine the accuracy of an organization’s inventory, with focus on evaluation of High Risk and Life Support equipment. How the organization indicates the use of AEM for specific equipment is a necessary requirement. Staff should be prepared to answer the question: is grouping of like equipment acceptable?
Lastly, when evaluating the organization’s inventory, the question should be addressed: are the imaging/radiological devices and medical laser devices exempt from AEM?
Surveyors will have a focus on High Risk equipment, and will expect that appropriate manuals are available. Documentation of inspections, tests, activities, and frequencies of use should be accurate and readily available--documentation issues have been one of the most-cited standards for 2013 and even earlier, a challenge which many organizations still struggle mightily with.
Staff should be prepared to discuss organizational strategies for equipment maintenance and explain how current policies are appropriate and effective in order ensure that medical equipment on site is reliable.
Lastly, Mills mentioned some of the most challenging standards for 2013, all of which organizations are still struggling with even as 2014 comes to a close. These include many physical environment issues, including corridor clutter, ventilation, fire barrier penetration, documentation of inspections and testing, smoke barrier penetration, maintenance of an 18” clearance from the ceiling, and unsafe environment standards.
Leadership would do well to maintain a firm understanding and keen eye on medical equipment policies, procedures, and processes as well as staff awareness and training in preparation for upcoming Joint Commission surveys.