If you could reduce the number of maintenance checks and assessments required for your clinical devices then you would obviously save time, effort and the associated technician labor. Alternative Equipment Maintenance (AEM) schedules can make this possible and can drive considerable cost savings for Healthcare Technology Management (HTM) teams. But how do you make AEM scheduling a reality and get your modified maintenance schedules approved by The Joint Commission? Therein lies the rub. You need a smart, modernized CMMS solution to help you validate and manage the entire process, and to pass a TJC audit.
Following is an overview of the January 2020 medical equipment-related Joint Commission Elements of Performance (EP) and what your CMMS must be able to document and report in order to be compliant for your AEM schedules. It is also important that your policies and procedures are well documented and aligned.
#1 – EC.02.04.01 EP 4 – The hospital identifies the activities and associated frequencies, in writing, for maintaining, inspecting and testing all medical equipment in the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance program.
On the surface it might sound simple enough, however, when you dig into the details it requires a lot from your CMMS to document compliance and validate the AEM eligibility of specific clinical assets. The most basic requirement is that your CMMS must have a way to identify every device that is on an AEM schedule and run an AEM inventory report if requested by The Joint Commission. A modernized CMMS should also manage the following:
- Identify if the device type or model has been approved to be on an AEM.
- Assign the appropriate PM frequency and activities to the asset.
- Differentiate those devices that have their AEM eligibility set at the device-type level from those that are set at the model level and, as required in Per EC.02.04.01 EP 5, you need your CMMS to ensure the following types of equipment are not put on an AEM: lasers, imaging and radiologic devices and new equipment with insufficient maintenance history to support the use of an AEM.
While it is not completely spelled out, this first EP also requires that the strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice. The implication here is that you need a baseline of the equipment’s safety performance before you put it on an AEM and then the ability to measure changes in the equipment’s performance (KPI metrics) after it’s on an AEM.
Finally, EP 4 also dictates that all medical equipment must have 100% completion rate of the maintenance activities and frequencies of the written AEM schedules. Your CMMS should have the ability to generate different PM work orders, as well as track compliance, in order to validate their AEM authorization.
When this EP was first introduced, there was a huge outcry from the HTM community, because it is nearly impossible to have 100% PM completion due to devices that aren’t available for their PM. So the Joint Commission has allowed PM Grace Periods and two other exceptions to this rule: if the device cannot be located or is in use for its scheduled PM, and reasonable attempts have been made to find or gain access to the device, it will not count against the hospital. These exceptions introduce the concept of PM Compliance (not to be confused with PM Completion). Whereas your PM Completion % is the percent of PMs that actually were completed compared to the number of PMs that were due, PM Compliance removes the devices that could not be found or were in use from the denominator, so that they don’t count against your compliance rate and 100% compliance is achievable.
There are many more Joint Commission elements of performance that apply to medical equipment. The more your CMMS can simplify the data entry process for your technicians, and even automate it, the more accurate your data will be. As reported by one of our customers, Blake Collins (Clinical Engineering Director, Christiana Care, BioMed Engineering Management), “Nuvolo helps us successfully analyze and manage our AEM scheduling for clinical devices. Their solution enabled our planned ‘Digital Transformation’…”
For more information about the AEM management capabilities in Nuvolo, please reference our web page for clinical asset management: https://www.nuvolo.com/solutions/clinical.
