Hospitals are required to maintain facilities, supplies, and equipment to ensure an acceptable level of safety and quality for patients and to meet industry standards for inspection. In 2013, the Department of Health and Human Services updated the guidelines, and many hospitals struggled to meet the demands of the new requirements.
Joint Commission’s project REFRESH instated in Jan. 2017, further modified the standards by creating a comprehensive method of categorizing risk for all aspects pertaining to medical equipment maintenance. The “A” scoring category was previously used only for high risk, life-sustaining equipment, such as bypass machines and ventilators, and required Healthcare Technology Management (HTM) professionals to complete 100 percent of scheduled maintenance on such devices. Now, the recent law requires this same pass/fail standard to be applied to non-high risk equipment as well. The previously accepted 90 percent of scheduled maintenance is no longer acceptable.
Hospitals have tried to manage this by way of clinical engineers, but a gap in the system becomes quickly undeniable. Clinical engineers who are hired to maintain and repair equipment are expected to oversee risk management, but typically, there are not enough engineers and technicians in one hospital to meet the demand of this critical role. It leads to cutting corners for lack of time and relying on industry experience alone rather than precisely following state and federal regulations.
This approach has no chance at success, especially with rigorous requirements like the Centers for Medicare & Medicaid Services (CMS) that determine a hospital’s reimbursement status. Additionally, accreditation requirements, equipment recalls and alerts, and state department of health rules must all be assessed and maintained. The deadlines in and of themselves are challenging to keep track of and ideally require a full-time risk manager or safety officer who works closely with clinical engineering.
A risk manager must develop:
- An equipment maintenance plan
- A preventive maintenance schedule for every device in the hospital
The risk manager must know:
- When state surveys take place annually so that data is readily available
- When CMS occurs – every 15 months
- When Joint Commission occurs – every 18 months to 3 years
The repercussions of a lackadaisical approach to equipment maintenance can be costly and can put a hospital’s regulatory compliance at risk. To stay ahead of the curve, here are the steps to follow:
- Document inventory
Without proper inventory management, it is impossible to meet the compliance requirements. Often, the equipment listed in inventory is no longer on the market, or it is a duplicate listing. Worse, the machine may still be in use but not listed in the inventory.
- Document a preventive maintenance schedule
A preventive maintenance schedule should be kept for all medical devices regardless of whether the equipment is leased, rented, physician-owned, hospital-owned, or loaned. History of the device maintenance should be attained for older equipment the hospital acquires.
- Elect to develop an Alternate Equipment Management (AEM) program
As an alternative option, hospitals may elect to establish their own program for maintenance logging, which is referred to as an Alternate Equipment Management (AEM) program. For each specific piece of equipment, the hospital must either adhere completely to the manufacturer’s recommendation, or they must have the data to support the decision to deviate from it.
As stated in A-0724 regarding new equipment, “If a hospital later transitions the equipment to a risk-based maintenance regimen different than the manufacturers’ recommendations, the hospital must maintain evidence that it has first evaluated the maintenance track record, risks, and tested the alternate regimen.”
- Elect a Computerized Maintenance Management System (CMMS) Maintenance Log
Managing all of the stipulations for compliance can be overwhelming and nearly impossible. Electing a CMMS to organize the data and inventory and to remind you of the important deadlines takes all of the guesswork and stress out of the equation. MedTrainer’s system for equipment maintenance logs manages all of these tedious tasks as well as implement equipment manuals, manufacturer information, and equipment contacts . You can set reminders and assign certified users on staff to particular pieces of equipment with ease.