|Happy Holidays! Here’s a quick look back at the top five “Ask George” questions and answers from 2015. As always, you can submit your Joint Commission question for George Mills at this link.
Q) Can you recommend a policy structure for equipment management? Are there requirements for what has to approve management plans and policies? Can a hospital define its own approval process?
A) I would suggest you discuss with your organization’s risk manager regarding organizational policy, and follow your organizational policy. A hospital can define its own approval process, so long as it is following organizational policy.
Q) Have you found that hospitals have been establishing clinical alarm safety as a priority, as The Joint Commission had instructed them to do as part of National Patient Safety Goal 06.01.01
A) A study from late 2014 with 624 respondents indicated that 79% had established it as a priority. The most common examples of specifically how clinical alarm safety was established as a priority in those organizations included:
- Multidisciplinary committee established (80%)
- Evaluation of alarm usage, issues, and incidents across the organization (72%)
- Alarm safety improvement initiative started (71%)
Q) I understand that CMS is allowing a categorical waiver for power strips in some patient care areas. Can you expand upon that?
A) CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if you are in
compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions.
The organization must follow all requirements of the categorical waiver process. This includes identifying where they are located at the unit level. See details below about the categorical waiver process:
Categorical Waiver Process
If the organization decides to use this categorical waiver they must
1. Ensure full compliance with the appropriate code reference
2. Document the decision to adopt the categorical waiver
–Note: The Relocatable Power Tap is not a LSC issue but an Environment of Care issue
–Note: For Environment of Care items. document by Minutes in discussion at the Environment of Care Committee (or equivalent)
3. Declare the decision at the beginning of any survey.
Q) We have asked several of our vendors for the PM checklist and we are told that is proprietary. So we enter that into our database along with the copy of the service report. Any recommendations?
A) Definitely document that the vendor who is servicing your equipment is unable to share their activities based on the proprietary nature of the information. I am assuming this equipment is under a contract, so the Joint Commission would look at two things: is the equipment operating as designed without failure; and how your organization is managing the contract (see LD.04.03.09 where you define and monitor expectations).
If your intention is to reduce the contracts and bring it in-house you will need to have access to the manufacturers’ recommendations to evaluate how your activities will sync with those, or if you intend to deviate how you have ensured you alternative approach is safe and will not diminish the reliability of the equipment of impact patient safety.
Q) Regarding Otoscope Ophthalmoscopes: 1) Should these be included in our medical equipment inventory? 2) Should we be performing periodic electrical safety or inspections on these?
A) 1. For those organizations seeking accreditation for deemed status purposes, all medical equipment must be in the inventory, including Otoscope ophthalmoscopes. I would suggest a category in your inventory for items such as these that do not benefit from scheduled maintenance, are considered to be non-essential to patient care, carry little or no risk and actually are replaced as needed. For those organizations that are not seeking accreditation for deemed status purposes, Otoscope ophthalmoscopes need not be included in your equipment inventory if they have been judged by the organization to be non-essential to patient care and carry little or no risk. This would mean you are implementing a risk- based process that reduces the total number of inventoried devices, provides a defendable explanation for devices that are not on the inventory based on a lack of risk, and provides an accurate assessment of devices receiving service. However, if your program’s maintenance plan is to include all devices in your inventory, then they should be included in your inventory. 2. This would depend on your organization’s maintenance plan for these devices, based on history, risk-assessment, etc.
Director Healthcare Technology Management