Q: What is your policy pertaining to vendors bringing in equipment? Do you just safety check it and document that it’s in your hospital? Is that enough? Are you sure it’s safe for a patient? How do you know?
A: We perform electrical safety and have the vendor show proof of a current PM before it is allowed for patient use.
A: We require the vendor to bring a copy of the current PM or manufacturer documentation stating no PM is required. We do a safety check as well.
A: It must be UL Listed or equivalent. It must have latest PM records available. We must perform an electrical safety test. It must be put into our database with a temporary asset number with a PM assigned 90 days out to check to see if item has left the hospital or, it’s due for factory PM.
A: We perform electrical safety, create a work order to document serial numbers (in case of an issue while at our hospital) and nothing comes in without a P.O. number from our purchasing department. We label non-hospital owned or trial and don’t assign an asset number because they never check out with us.
A: I just want to put out some information on the UL or equivalent rating for medical equipment (vendor or purchased) coming into the hospital. The insurance company insuring the facility will more than likely require this, you would need to check with them. For our hospital, it is required. This insures the power supplies in the medical equipment meet or exceed UL 60601-1, remember the power strips from last year? That also pertains to power supplies.
A: We require the vendor to provide the instructions for use to verify what needs to be checked during incoming inspection. We follow the manufacturer’s requirements and place a temporary equipment inventory sticker on the equipment for tracking. Most of the time the only thing required is electrical safety, but occasionally there are more requirements. We also see if regular maintenance is required and verify the vendor has been performing that maintenance. We recently had a piece of equipment come in that required annual PM but the sticker on the device had expired in 2013. There were numerous electrical safety stickers from various local facilities but no one had bothered to make sure the manufacturer was performing the required PMs. We obviously did not allow the rep to use the device. He came in the next day with a new unit from his company with updated inspections.
A: UL or equivalent is enforced by the Biomed shop which is backed up by the safety officer and Environment of Care committee. It’s common practice now for the sales rep to carry last PM info. The last two are through the Biomed shop. Any piece of equipment that does not go through the process and sneaks in, and we catch it, goes to the Director and Chief Nursing Officer, we don’t miss much if any!
Q: How many of you are going to completely overhaul your PM program to meet the new Joint Commission standards for 100 percent PM completion?
A: I am completely reviewing our standards in Colorado to meet the 100 percent completion goal. This hasn’t been the practice in most organizations for all medical devices in the past.
A: This is a Joint Commission recommendation/standard and not sanctioned by CMS. I think in most cases it would be wise to stick with the policy you have in place until such time where CMS actually reviews this and renders a response. We all remember the confusion with CMS and “predictive maintenance” years ago. The standard says 100 percent complete or your policy. Our policy will stick with the old guidelines until this settles down. Seems CMS and Joint Commission are in a contest lately and we, the techs in the field, are taking the blunt of the blows.
A: The 100 percent completion to my understanding is for “high risk” devices. We were already using a 100 percent performance requirement on anything we deem to be a life safety device. Should that requirement expand to include less critical devices, we are going to have a problem.
A: Agreed. As long as we are meeting the guidelines stated in our policy 100 percent of the time, we are in compliance. Our policy states that we will complete a minimum of 95 percent of scheduled preventive maintenance of non-high risk equipment each month. The 100 percent for high-risk equipment was already in place, so that hasn’t changed.
A: Unfortunately, that information is INCORRECT. I literally just completed a webinar with George Mills that was hosted by the ECRI Institute, my second webinar in the last couple of weeks with George. All medical devices that have a scheduled PM must be completed 100 percent for the month scheduled, unless the device is in use or cannot be found. In the case when a device is in use or cannot be found, you must document your activities to find that device, and have a plan when the device is discontinued on that patient or if the device is found.
A: Use to be 100 percent on life safety, 95 percent on everything else, changed to all 100 percent. I think all this will do in the long run is that it will create “could not locate” entries in the database.
A: That’s only explained half correctly. This is from The Joint Commission website:
“The critical access hospital identifies the activities and associated frequencies, in writing, for maintaining, inspecting, and testing all medical equipment on the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program. Note 1: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice, such as the American National Standards Institute/Association for the Advancement of Medical Instrumentation handbook ANSI/AAMI EQ56: 2013, Recommended Practice for a Medical Equipment Management Program. Note 2: Medical equipment with activities and associated frequencies in accordance with manufacturers’ recommendations must have a 100 percent completion rate. Note 3: Scheduled maintenance activities for high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100 percent completion rate. Scheduled maintenance activities for non-high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory may be deferred as defined by organization policy, provided the completion rate is not less than 90 percent.”
In other words, it has not changed for many years. One hundred percent life safety, ninety percent all others. To me it sounds like The Joint Commission is trying to set a new standard without going through CMS. I know all facilities in my area which have had a Joint Commission inspection within the last two years, CMS does a “follow up” survey within two weeks of The Joint Commission inspection. I was involved in one of those and the whole inspection was an inspection where CMS was inspecting The Joint Commission, not us. We will continue our process as it has been for years until we hear something from CMS.
A: I think the difference here is being 100 percent compliant as opposed to 100 percent complete with the non-high risk equipment. You should still set a minimum for completion, 95 percent for us, but for the items not completed you need to have documentation that you searched for the equipment or that it is not available for PM, making you 100 percent compliant with The Joint Commission standard. You can’t just get to the end of the month and say I met my 95 percent goal and not have attempted to find the other 5 percent. They want to see a documented effort to do everything that was scheduled. During the webinar with George and Steve it was also brought up that The Joint Commission wants to see that 100 percent of the manufacturer required PM steps were completed. Not sure how they are going to monitor that.
A: I would have to agree with you. The conversion to following manufacturer PM instructions has been easy enough. Over the course of the last year we simply review the manufacturer recommendations and adjust accordingly. On the rare occasions where we differed we either changed to their requirements or started an AEM. Generally we discovered that we were doing more tests, or testing more often.
If required to have a 100 percent work order completion, then it will simply create a “close out frenzy” at the end of each month. I don’t perceive a strategic benefit to the requirement.
A: George Mills explained in the last two webinars, one hosted by AAMI and one by ECRI, that The Joint Commission information went to publication in September with the data you are presenting. CMS disagreed with The Joint Commission point that non-high risk equipment was compliant as long as we met metrics at 90 percent completion or better of scheduled work. George redacted that printing on the last two webinars and communicated that CMS has no wiggle room from 100 percent completion of scheduled work unless NHR (non-high risk) devices are in use or cannot be found. In the case of NHR devices, you must document efforts to find the device or communicate with clinicians about the device and its scheduled maintenance. Devices in use and cannot locate devices will not count against completion rates as long as you document your efforts. You must also have a communicated plan as to what the process is when a device is found or the device is discontinued from use on the patient. I invite you to review the recent webinar information from the AAMI and ECRI hosted webinars with George.
A: I was on the ECRI webinar as well. I also have firsthand experience of an TJC auditor that was performing a mock inspection this year at one of my sites quoting the new standard of 100 percent completion relative to the non-high risk category. One point that George did highlight during his presentation was that equipment that was deemed found in use (common examples of this category would be ventilators on critical patients) or unable to locate (infusion pumps) will not be counted against the 100 percent as long as the facility P&P annotated the protocol for found in use and unable to locate clearly in their respective P&P.
A: I’m trying to understand this standard from a CMS point of view and I have not seen anything from CMS which dictates the new Joint Commission standard. If you have something please provide a link or website. I understand that George/AAMI is pushing this, and by all means, this is no disrespect to George but for us to change policy we have to have strict guidelines to present to our EOC Committee. The way we read it was to comply with this standard or your policy. That, my friend, is no guidance as far as we are concerned. That’s why we are looking for a concrete CMS response.
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