Q&A: Changes to Joint Commission maintenance standards and AEMs

Briefings on Accreditation and Quality, July 1, 2017

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Editor’s note: The following is an edited Q&A from the Association for the Advancement of Medical Instrumentation’s (AAMI) webinar, “Clarifying the Changes to Joint Commission and CMS Standards.” The webinar talked about the changes to The Joint Commission’s maintenance standards, which no longer differentiate between inspecting high-risk and non-high-risk devices for an alternative equipment management (AEM) program. The speakers for the event were George Mills, MBA, FASHE, CEM, CHFM, CHSP, Joint Commission director of engineering, and Stephen Grimes, FACCE, FAIMBE, FHIMSS, managing partner and principal consultant for Strategic Healthcare Technology Associations, LLC.

Q: With the changes to the standards, will equipment that’s not found or is in use count in favor of or against completion percentage?

Mills: We’ve always said that if you go to a unit to do the work on equipment for service maintenance and it’s on a patient and in use, we’ve never ever advocated taking it off a patient to see if it’s working OK.

But [say] you’re there on time, on the date you’re supposed to be doing the work, when the device is in use. At that point, we’d expect that you have some sort of policy to guide you as far as what the next steps are. Steve [Grimes] gave some good examples of what those next steps could be as far as letting nursing know that as soon as this patient no longer needs this device, to call somebody at your shop so they can send somebody up to do the work. But [since] you were there on time, you’re going to get 100% credit for that. So you wouldn’t consider yourself to be late servicing that equipment.

In a similar situation (with equipment not found), you’re in the unit the equipment is supposed to be in. You look for it and can’t find it. Again, being driven by a strong policy, you go to nursing and say, “I’m looking for X device.” They say, “Jeez, I haven’t seen this up here in a long time.”

At that point, you put out an alert saying that you’re looking for it. And you have maybe a three-step process where your first step was that you were on time, so you’re taking the 100% as far as your recordkeeping goes. Maybe your policy says that within five days you return to the unit and look for it again and post it in the nurses’ communications strategies asking nursing to help you find it.

Maybe the third step is that you still can’t find it, so you flag it as “deferred until found” or somehow indicate that it didn’t receive its preventive maintenance (PM) because it couldn’t be found. Ask nursing again to help you find it.

The key is that you are going to be taking 100% on your “on time” because you were on time, and you knew what it was. And the fact that you couldn’t complete it wasn’t your fault or a penalty to your shop. The key then becomes whether your policy is robust enough to still make sure that you capture that equipment when it does show up. If it doesn’t show up after a second cycle, do you then remove it from your inventory as “not being in the building?” Maybe it went out with a patient to a nursing home or something like that; you never know.

The point is that for your 100% compliance calculations, if you were there to do the work on time, take the credit for being there on time. Your policy steps in and gives you the next steps, gives you the evidence of what to do next, because you couldn’t service your equipment.

So a surveyor would be looking at your history and would say, “I see you are at 100%, but I see three things that were deferred because they were in use. What does your policy say?” Then if you can explain your policy back to the surveyor, everything should be fine because everything should be reconciled and driven by a written policy to get to that point.

Q: As an organization that supports multiple hospitals in several states, would one AEM program developed centrally be acceptable for all of our hospitals, or would each hospital require its own customized AEM program?

Grimes: Just having come from an organization that was an independent service organization servicing a large number of hospitals, I’ll at least start with the response to that and how we addressed it.

I think it’s a good idea if you’re an organization like [the International Organization for Standardization] servicing a large group of hospitals to come up with a template for the AEM program. However, given that each hospital is going to be different in terms of its size, service, staffing, or how it’s using the equipment, you need to take that template that you’ve got and do a risk assessment to ensure that the AEM program has the appropriate adjustments made to it to reflect the needs of that hospital.

I think it’s a good idea to design a master program, but in terms of the implementation you have to implement it at the local level. That means engaging the clinicians and risk management in the local hospital and tweaking [the AEM] to meet the specific needs of that organization. There will be a lot of things they have in common, so you can benefit from starting out with a template, but, rather than just coming up with a master solution, it needs to be tweaked. One size doesn’t fit all in this case.

Mills: I wouldn’t have a problem with the corporate [office] defining the activities to standardize. That way we’re servicing all the equipment of this population with these activities so that the activities from site to site are the same. AEM programs give you the ability to flex on your frequency.

 I think you can get guidance from your corporate level, and it’ll be up to corporate to decide to allow it or if the skill sets exist at the local levels to modify the frequencies. Again it’s really got to be driven by your corporate policies, how it’s implemented at the site level. But to Steve’s point, we want to make sure that when we’re at that site, the activities that are in place benefit the site. It’s fine for corporate to establish standardized operating procedures (SOP) and approaches, but there’s still going to be tune-up needed to those standardized approaches to fit the needs of the individual organizations and sites.

I got experience coming from a third-party firm that used to have SOPs on everything. But there were always those “what ifs” and unique situations. Somehow your policy has to be robust enough to capture unique situations based on the settings of individual sites as well, so we would survey to the outcome and how responsive you were to your process.

There’s nothing more frustrating than asking a [healthcare] program, “How do you know your program is effective?” and getting a blank stare or being told, “This is what corporate told us to do.” That doesn’t tell me if it’s effective at your site. While using your templates, you want to check to make sure it’s effective at the site level.

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