By Rodgerick Williams
The best way to get through an inspection is by “Staying Survey Ready.” But for those of you who have recently taken over a HTM department or who are reading this article to understand how to manage the leadership of a HTM department, I will take you through the things to do to prepare an inspection as best as you can without being 100% confident.
Here’s the order of attack:
- Review the MEMP (Medical Equipment Management Plan).
- Round all areas that may be surveyed – walk through all departments and look for expired PM stickers or no PM stickers.
- Check the database for open PMs.
- Check the database for high risk/life support PMs – make sure these PMs have been completed at 100 percent.
- Check the database for vendor performed PMs – make sure these PMs have attachments with readings.
- Round looking for broken medical devices. Remove nursing tape and adhesive off everything and fix everything that is broken. Remove items with cracks or holes from service.
- Send emails to all clinical leaders asking them to round their areas looking for expired PM stickers and broken medical equipment.
- Check the database for open work orders and close what you cannot locate.
- Clean up the HTM shop. Make sure there are no boxes on the floor. Make sure nothing is within 18 inches of a sprinkler head.
- Check the lab.
- Verify output is recorded on PMs on electrosurgical units, defibs, anesthesia machines, ventilators, centrifuges, blanket warmers and blood warmers. Verify some output stickers on the devices and the PMs.
Review the MEMP
Verify there are approved policies in the MEMP. For a JC hospital, go to the Environment of Care section online and get all of the latest medical equipment policies and cater them to your facility. If you do not have any policies at all, look online at teaching hospitals for templates. HTM policies don’t change much that often. Verify with the regulatory body’s websites for minor current changes.
Rounding for PMs
The best way to round for PMs is to put general test equipment on a cart and go to each area that will be inspected. Perform a PM on each device with an expired PM sticker or no PM sticker. I like to have a PM sticker or a “No PM sticker” on all devices in the medical equipment management plan in an effort to reduce confusion between technicians and clinicians.
Checking the Database for Open General PMs
There may be some PMs that were performed, but not closed. For example, Alaris infusion pump PMs are performed with the Alaris service laptop using the Alaris System Maintenance Software. The Alaris System Maintenance software records what PMs were performed. Verify if the PMs were actually performed by checking the PM stickers on the devices and the database to be sure someone just didn’t close the PMs in the system. Now look for devices that did not have a PM for two consecutive years, or two PM cycles, or whatever your policy criteria is for removing a medical device from the inventory. You will find some devices are on the PM program that should not be in the active inventory. These devices can be removed from the inventory according to the policy and these PMs can be closed. HTM cannot perform a PM on devices that are lost or no longer in the facility. Send documentation to the CFO, CNO, Clinical Owner and Accounting regarding the devices being removed from the active inventory. Be sure to advise the owner of the device that the device will be placed back on the Medical Equipment Management Plan once it is found and a PM is performed. Export all remaining open PMs into Excel. Sort the open PMs by department and send a copy of the open PMs to the department leaders – copy the CNO, Director, Manager or Charge Nurse. Announce you need assistance finding devices that have open PMs during the safety huddle. Inform the facility of the PM sticker program. Reinforce the facility sticker program with emails with pictures of the stickers and explanations of what the stickers mean. I personally like to use a color for each year, so we can tell if a device is expired by looking at the sticker across the room. JC now says 100% of all PMs need to be performed, but I don’t think that’s possible. A continuous 100% PM completion makes me question a technician. No one will find every asset monthly. Clinicians will hide things, patients will take things. Housekeeping will throw things out with the linen. The ambulance will take IV pumps to other facilities. I still strive for 95% actually performed. I allow 5% to be unable to locate, but closed in 60 days or in accordance with the policy.
Check the Database for Imaging or High Risk/Life Support PMs
High Risk/Life Support PMs need to be completed at 100%. Verify vendor records for vendor performed PMs in an effort to cross reference if PMs were performed by outside vendors and not just left open in the database. These PMs should not be listed as unable to locate. We cannot lose an MRI, CT, or X-ray room and it’s very difficult to lose an anesthesia machine, or a ventilator. One thing we can misplace here is a defibrillator. We need to go by department and verify all defibrillators. Check every crash cart. This is one of the top things inspectors find. Also, while checking the defib PM sticker, verify the daily checks were performed by the nurses on the check sheet on the crash cart.
Check the Lab
The lab is different than all other areas minus radiology. The lab manages most of their service events. They have a book that keeps up with their PMs and service. Check their books because when they have an issue, they will still try and make it HTMs fault. In a perfect world, all devices on the Medical Equipment Management Plan will be managed by HTM, but since the world is not perfect, we have the lab. Most policies have a statement that says “All service events generated by HTM are the responsibility of HTM. Service events not generated by HTM are the responsibility of the person that generated the service event. Discuss responsibilities with lab leadership. Here are the things that are 100% the responsibility of HTM – centrifuges, blood bank refrigerators, ultralow freezer, blood warmers.
- Centrifuges – Make sure a tachometer test has been performed. Perform a stop watch verification of the timer. I like to use an output sticker on centrifuges where applicable.
- Blood Bank Refrigerators – Perform a fire and ice test of the alarm where you violated the high and low alarms with ice and warm fluid and verify the temperature with an external thermometer.
- Ultralow freezer – Get a thermometer that goes low enough to verify the operating temperature of the freezer. Verify facilities or an outside vendor has cleaned the coils/performed a mechanical PM on the devices. BMETs are not usually trained in refrigeration.
- Blood Bank Refrigerators – Look in ICU, anesthesia and surgery for these devices and make sure they are clean and have current PMs.
CHECKLIST
The document “Preparing for Joint Commission, CMMS, or DNV Inspection” provides a check list for Health Technology Management (HTM) departments to prepare for inspections. Here are the key points:
General Preparation Strategy
- Staying Survey Ready: Maintain ongoing readiness rather than preparing only before inspections.
- Leadership Transition: New HTM department leaders should familiarize themselves with the inspection preparation process.
Steps for Inspection Readiness
1. Review the Medical Equipment Management Plan (MEMP):
- Ensure MEMP has approved and up-to-date policies.
- Customize policies from reputable sources if necessary.
2. Round All Areas for Survey:
- Walk through departments to check for expired or missing PM stickers.
- Remove broken devices and repair as needed.
3. Database Checks:
- Verify completion of all PMs, especially high-risk/life support equipment.
- Ensure vendor-performed PMs have attached readings.
- Look for devices without PMs for two consecutive cycles and remove them from active inventory if appropriate.
4. Communication and Documentation:
- Email clinical leaders to check for expired PM stickers and broken equipment.
- Export open PMs into Excel, sort by department, and send to department leaders.
- Announce needs during safety huddles and reinforce sticker programs with visual aids.
5. Specific Checks:
- Imaging and High-Risk Equipment: Ensure 100% completion of PMs.
- Crash Carts: Verify defibrillators and daily checks.
- Lab Equipment: Check PM books, centrifuges, blood bank refrigerators, and ultralow thermometers for compliance and maintenance.
Detailed Actions for Specific Equipment
- Centrifuges: Perform tachometer tests and stopwatch verifications.
- Blood Bank Refrigerators: Conduct fire and ice tests, and ensure external temperature verification.
- Ultralow Thermometers: Verify operating temperatures with appropriate thermometers.
- Blood Bank Refrigerators in ICU, Anesthesia, and Surgery: Ensure cleanliness and current PMs.
This methodical approach ensures that HTM departments are well-prepared for inspections by addressing potential issues systematically and maintaining clear communication with clinical leaders.
