Transcript
WSSHE 2017: Managing Medical Equipment in Today’s Regulatory Environment
Jeanette Thielen, CCE Manager of Clinical Engineering, Harborview Medical Center
My Background: BSE
in Biomedical Engineering, University of Iowa Certified Clinical Engineer Over 24 years in CLE industry Over 22 years in CLE Management 21 years in VA & over 3 years at Harborview Member of AAMI, ASHE, ACCE, & WSBA Multiple Successful Site Visits
Harborview Medical Center
Harborview Medical Center
Harborview Medical Center is owned by King County, governed by a county-appointed board of trustees & managed by the University of Washington to serve patients from all walks of life in world-class centers of emphasis & also serve a mission population for King County. Harborview is the only designated Level 1 adult & pediatric trauma & burn center in the state of Washington & serves as the regional trauma & burn referral center for Alaska, Montana & Idaho. Harborview is an entity of UW Medicine, & all staff working at Harborview are University of Washington employees. 2015 Statistics
Inpatient beds...........................................................413 Employees..............................................................4,476 Admissions...........................................................17,362 Clinic visits.........................................................247,615 Emergency Department visits.............................62,217
HMC Clinical Engineering Dept.
HMC Clinical Engineering Dept. Various
inspections & visits Staff of 22: 1 Manager, 1 Supervisor, 1 Program Assistant, 1 IT Specialist, 18 BMETS (including 2 vacancies)
4
teams: Bed, Respiratory, Imaging, Biomed Manage equipment concept to grave. 17,600 devices maintained worth over $128.5 M. Thousands of work orders/year. 100% on Critical Medical Equipment 96.6% on Non-Critical ME (2016) – 100% (2017)
DISCLAIMER These
are my opinions and interpretations of standards, regulations, etc.
Not
a reflection of HMC, UWM, or other regulatory bodies.
Objectives: Regulatory
standards CMS, TJC, & NFPA 99, 2012
TJC EOC Standards additions & subtractions. Most missing standards still apply. TJC set to inspect to CMS. TJC SAFER Model what does that mean? See it cite it. Life Safety Code 2012 & NPFA 99, 2012. RPTs & NFPA 99, 2012 or waiver, which applies? CMS 2013 Memo: Hospital Equipment Maintenance Requirements Planned Maintenance Inspections: OEM vs. AEM PMI Completion %s, what 100% means for you.
See it, Cite it, Score it.
What does this mean? See
it, Cite it. Unless you do everything perfectly, you will have findings. They will be based on risk of harm & how the finding impacts the patient, patients, or hospital as a whole. There is no 100% & 90% any more. It is all 100% or findings go on the matrix. This includes all PMI completion is 100%.
Where did all the TJC standards go? Many
standards are missing from EOC. Many are found in other chapters. Many are found in reference documents from NFPA, CMS, & others (SMDA law). Other standards have been added in detail to meet what CMS wants inspected, like radiology & radiation safety EOC requirements. Don’t assume because its not written in the EOC it won’t be required anymore.
One MEMP plan or more? Medical
Equipment Management Plan Radiology Safety Management Plan Patient Alarms Plan
Management Plan(s):
How program is designed to meet standards. Framework for MEMP, to minimize & manage risks & potential for harm. Identify an individual(s)
to manage risk, coordinate risk reduction activities in the physical environment, collect deficiency information, & disseminate summaries of actions & results.
Include scope & objectives, or risk assessments & management, describe responsibilities of individuals or groups, & time frames for specific activities identified in the plan. Risk assessments for key processes & issues. Annual review of program, plan, & risks.
Risk Assessments for Program(s) Identify
risk associated with programs & score: Injuries patients & staff Damage to property Medical or laboratory equipment management problems like failures, use errors, etc. Process issues Incidents User knowledge
Radiology Safety & Maintenance MRI
safety risks: anxiety, noise, metal implants & objects MRI security & access: zone enforcements, training, signage Radiation safety
Equipment testing & maintenance Image Quality Testing Competency of personnel testing CT, PET, MRI, Nuc Med, their monitors
Dosimeter
badging & monitoring Equipment room shield testing: pre-construction planning & post installation
Laser Safety Program Policy Inventory Training
programs
PPE Maintenance Etc.
Goal 6: Reduce the harm associated with clinical alarm systems Priority: Put together a Committee and keep it together. CALM Identify the most important alarm signals to manage include:
Input from the medical staff & clinical departments Risk to patients if the alarm signal is not attended to or if it malfunctions Whether specific alarm signals are needed or unnecessarily contribute to alarm noise & fatigue Potential for patient harm based on internal incident history Published best practices & guidelines
Establish policies & procedures for managing the alarms identified above & address the following:
Clinically appropriate settings for alarm signals When alarm signals can be disabled When alarm parameters can be changed Who in the organization has the authority to set alarm parameters Who in the organization has the authority to change alarm parameters Who in the organization has the authority to set alarm parameters to “off” Monitoring & responding to alarm signals Checking individual alarm signals for accurate settings, proper operation, & detectability
Educate staff & practitioners about the purpose & proper operation of alarm systems for which they are responsible.
MEMP Program:
MEMP Program requirements:
Management Plans & Risk Assessments Initial ME inspections Maintaining ME Inventories Establishing PMI procedures & following 100% (OEM/AEM) PM Completion as written & timely Written Contingency Procedures Monitoring & Action on ME Safety Issues Radiology Safety, Testing, & Maintenance LD: Resources provided to care for patients(Acquisition) IC: Infection Control & ME (sterilizers & dialysis & HLD) HR: Competency & Knowledge IM: Information Security & Integrity
Equipment Acquisition Leadership
No longer says operators & maintainers are required to be a part of it.
Look
should have a process
for potential problems
Recalls & events (MAUDE or ECRI) Patient alarms Cleaning needs Maintenance needs Availability of manuals & PMs Standardization issues
Initial Inspection Prior
to use on patient. No longer “regardless of ownership” (its in NFPA 99) Check
loan, rentals, & demos. Certification of vendors Safety,
operational, functional, (performance), & electrical safety. Electrical safety intervals: only initial, upgrade/modification, & repairs & per your policy. See new ES limits. Plus… check manuals (op, svc, PM); PM needs, AEM vs. OEM, High-risk; & inventory data.
Speaking of …NFPA 99, 2012 The
hospital meets all other HealthCare Facilities Code requirements; facilities code for electrical equipment in the patient care vicinity as related to NFPA 99-2012: Chapter 10.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes: the hospital meets the applicable provisions of the Life Safety Code Tentative Interim Amendment (TIA) 12-5.
NFPA has other standards about:
Testing Intervals – have a policy – only on initial, upgrade/modification, & repair. Protection of Patients with direct electrical pathways to the heart Adapters & extension cords Devices likely to be used during defibrillation System Demonstration Electrical equipment systems Applications not provided by the facility Service & Maintenance of equipment OEM documentation Use of OEM documentation for consideration in a maintenance program Administration of Oxygen Therapy Laboratory Record Keeping: Instruction manuals, service manuals, documentation, test logs. Qualifications & Training of Personnel
Type of equipment Fixed PCREE, prior to hard-wiring. Portable PCREE in a patient care vicinity, either as a single device or a singlepower corded assembly.
Isolated Lead Touch/Leakage Current
Chassis Touch/Leakage Current
Ground Resistance
NA
<=10 mAmps with all grounds lifted
NA
<=100 micro Amps with ground intact & <=500 micro Amps with ground open
<=100 micro Amps with ground intact & <=500 micro Amps with ground open >500 micro Amps need isolation transformer or policy approved method to reduce risks
<0.5 Ohms
Patient-owned personal NA electrical appliances in the patient-care vicinity. Appliances used in a NA diagnostic laboratory.
Other medical NA electrical equipment used outside the patient care vicinity.
Pass staff visual inspection, plus are NA either double-insulated, battery operated, or are PCREE that meet the portable standards above. <= 500 micro Amps limit is No standard recommended for lab, but is not required. >500 will have their touch current documented. No standard No standard
RPTs power strips status? CMS Memo for waiver & NFPA 99, 2012, which applies now? NPFA 99, 2012: 10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart- mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2) *The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4) *The electrical & mechanical integrity of the assembly is regularly verified & documented. (5) *Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.
TIA 12-5 1. Delete entire subsection 10.2.3.6(5). 2. Delete corresponding Annex A material A.10.2.3.6(5).
NFPA 99 Definitions
Patient Care Room (PCR) - Any area/room of a health care facility wherein patients are intended to be examined or treated.
Patient Care Vicinity (PCV) - A space, within a location intended for the examination and treatment of patients, extending 6 ft. beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination & treatment and extends vertically to 7 ft. 6 in. above the floor.
Patient-Care-Related Electrical Equipment (PCREE) Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity.
Patient Care Room: ICU Bed Location
Computer directly into the wall outlet.
Patient monitor plugged into mobile head wall. Head wall plugged into ceiling outlet.
Medical equipment systems with Medical-Grade strips on assemblies or device, Plugged directly into wall outlets.
6 ft.
Medical & non-medical equipment plugged into Hospital-Grade strip, plugged into the wall outlet.
Patient Care Vicinity
RPT Mgmt. Recommendations: Policy
– RPTs, ext. cords, adaptors.
Medical grade RPTs, permanently mounted to device assembly, for PCREE in the PCV. UL1363A or UL60601-1. LIMS. Device assembly as whole meets Electrical Safety limits. Check electrical & mechanical integrity & safety of RPT, initial & regularly (during PMs & repair). Medical-grade outlets covers on ME? Asset number, perhaps child to parent. Incoming inspection to document the testing. Outside PCV, in PCR, hospital-grade RPTs PCV. UL1363 with HG plugs. Outside PCR, use Hospital-Grade or consumer-grade RPTs. UL1363 or UL1449.
ME Inventory
100% accurate & 100% of ME on inventory regardless
Maintain How
of ownership (loans/rentals)
the inventory for accuracy.
equipment comes & goes.
Trade-ins,
Surplus programs
Lost/Stolen
ME Inventory 100%
accurate & 100% of ME on inventory
What
is Medical Equipment?
Classifying
Medical Equipment
High-Risk or Critical Medical Equipment
Non-High-Risk or Non-Critical Medical Equipment
Non-Medical Equipment
Other –Clinical Support Equipment?
ME Inventory “…medical
equipment, which are devices intended to be used for diagnostic, therapeutic or monitoring care provided to a patient by the hospital (e.g., IV infusion equipment, ventilators, laboratory equipment, surgical devices, etc.).” (CMS memo 14-07)
high-risk
medical equipment on the inventory for which there is a risk of serious injury or death to a patient or staff member should the equipment fail, includes life-support equipment.
ME Inventory 100%
accurate & 100% of ME on inventory
What
is Medical Equipment?
Classifying
Medical Equipment
High-Risk or Critical Medical Equipment
Non-High-Risk or Non-Critical Medical Equipment
Non-Medical Equipment
Other –Clinical Support Equipment?
ME Inventory What
else to add in your inventory
CMS Memo EPHI Networking data PM decisions Manual locations Ownership status Departments Etc.
Competency & Knowledge
Under HR, EOC, & NFPA standards.
Staff know how to identify & minimize risks, what
action to take when incident occurs, & how to report it.
Have written procedures to follow if ME fails,
including emergency clinical interventions & back up equipment.
High-risk ME (ventilators) & ME with high-risk failures
(telemetry)
Competency & Knowledge Medical
equipment operators still need to be trained &competent in their duties. Plus know their risks associated with use. Maintainers still need to be competent to do their job maintaining equipment. (NFPA 99) Know their failure ME plans. How to report failures & problems. Fire & safety training for ESUs, Lasers, fiberoptic devices. (NFPA 99)
Corrective Work Orders How
to report & document issues & actions.
Conduct
repair actions, note parts used, &
cause if known. May
have to do electrical safety testing again.
May
have to follow PM procedures if they are
stated to be completed as-needed or on-repair. Document Run
all actions taken & findings.
reports on CM WO to look for issues/trends.
Recalls Tracking & Actions Sources:
FDA, ECRI, internal, etc. Actions if you have a recall ME:
Pull from service change in instructions field correction or combination thereof
Document
in work order Document for Recall Office (don’t want to be the only repository of recall info).
Internal Events / Close Calls Internal
reporting system for patient harms Occupational injuries of staff or vendors. Work order that may hint at a problem or injury. Root Cause Analyses Work with Quality/Risk Management/Patient Safety to consider Common Use Error Trends Document in work orders for history (but without EPHI) or other reports to EOC, Risk Mgmt.
External Reporting of ME Harm Removal
If
of SMDA in TJC, but SMDA still the law.
Death or serious injury Ten working days to report once you are made aware of the incident or that it may be an SMDA reportable issue. Don’t forget annual reports due January 1st if you have mandatory reporting
SMDA reportable event, it may be reportable to DOH/CMS too. Work with Quality/Risk Management/Patient Safety for outside reporting forms & permissions.
Information Security Identify
medical equipment/systems that may have EPHI for HIPAA compliance.
Use inventory Yes/No, or other
BAA
& DSPA for servicing such ME with EPHI Method for remove data/drives for erasure/destruction prior to trade-in of ME Information security, more than cybersecurity Information Integrity, goes to the right patient record. Is it correct? Is it verified? Information & records mgmt. & retention
ME Infection Control Performance
testing & maintenance of all
sterilizers Performs equipment’s maintenance, as well as, chemical & biological testing of water for dialysis. Also consider high-level disinfection washers for scopes, etc.
OEM cleaning procedures Run cycles after repairs, filter changes, etc.
OEM vs. AEM PMIs
OEM vs. AEM PMIs CMS
& the Original Equipment Manufacturer
(OEM) PMI recommendations
Supersedes S&C 12-07 Hospital (OEM only)
CMS ref: S&C” 14-07 Hospital, 12-20-2013,
“Hospital Equipment Maintenance Requirements”,
The use of Alternate Equipment Maintenance (AEM) Inspections programs.
OEM vs. AEM PMIs
When must you follow OEM PMI recommendations?
Can you use OEM anyway?
Under what circumstances can you select an AEM PMI procedure/frequency?
Do you have to follow such procedures to the letter?
Do 100% of all PMs have to be completed on-time, or just High-Risk?
OEM PM Musts:
Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, & maintaining must be in accordance with the manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements.
Washington State – AEDs.
Medical laser devices Imaging & radiologic equipment (whether used for diagnostic or therapeutic purposes) (New) medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies.
OEM PMIs: Must
have an OEM PMI procedures to follow.
Copy
of PMI frequency & procedures recommendation for every ME device. Or have OEM conduct the PMIs. Must
follow all steps in the OEM PMIs.
Can’t
skip steps. Can you add steps? What if the OEM doesn’t even follow it? Must
follow on-time completion windows based on OEM frequency.
Timely PMs: by day or month? Good if in the same month What about TJC grace periods? IF AEM, can you expand timelines?
PM On-Time Schedule Days Early Scheduled Days Late Month Annual + - 30 days 30 days 30 days Semi-annual/4 months + - 20 days 20 days 20 days Quarterly PM + - 10 days 10 days 10 days Monthly within calendar month Weekly within calendar week
What About AEM? Alternate
Equipment Maintenance Program (TJC Alternative) (me – Adjusted) - AEM The AEM program must be based on generally accepted standards of practice for medical equipment maintenance. Use
OEM or other procedures (ASHE, ECRI) for starting point of procedures.
Qualified
personnel are making decisions Documentation of AEM decision process. The risk to patient health & safety that is considered in developing alternative maintenance strategies must be explained & documented in the AEM program.
AEM The
strategies of an AEM program must not reduce the safety of equipment & must be based on accepted standards of practice. How the equipment is used & the likely consequences of equipment failure or malfunction.
Seriousness of Harm How widespread the harm
Timely
availability of backups OEM or other PMI recommendation if no OEM.
Equipment PM Strategy:
OEM Must (Law/Rad/US/laser) OEM Plus OEM PM OEM 0: none/corrective AEM Frequency window AEM Frequency AEM Procedure AEM Procedure & frequency AEM Procedures & frequency window AEM None/check on repair
AEM
Maintenance requirements of the equipment:
Simple or complex? Can the hospital explain how & why it is modifying the manufacturer’s instructions? If the manufacturer’s instructions are not available in the hospital, how does the hospital assess if the AEM uses appropriate maintenance strategies? How readily can the hospital validate the effectiveness of AEM methods for particular equipment?
no reduction in the quality (and safety) of the performance of biomedical equipment subjected to alternate maintenance methods?
AEM Incident
history of identical or very similar equipment – is there documented evidence, based on the experience of the hospital (or its third party contractor), or on evidence publicly reported by credible sources outside the hospital, which: Provides
the number, frequency & nature of previous failures & service requests? Indicates use of an AEM strategy does not result in degraded performance of the equipment?
Evaluating Safety & Effectiveness of AEM Program
Ensure no degradation of performance, particularly for equipment where such degradation may not be readily apparent to staff using the equipment, e.g., mis-calibration. Incidents of equipment malfunction are investigated, including:
Whether or not the malfunction could have been prevented, & what steps will be taken to prevent future malfunctions. How a determination is made whether or not the malfunction resulted from the use of an AEM strategy.
The process for the removal from service of equipment determined to be unsafe or no longer suitable for its intended application. The use of performance data to determine if modifications in the AEM program procedures are required.
AEM Risk Assessments HMC
sample
David
M. Dickey, MS, CHC, CCE, FACHE
Corporate Director Clinical Engineering McLaren Health Care
AEM HMC Formula Sample A. Classification of equipment: (0-3)
3-Critical ME 2-ME (Non-critical) 1-Clinical Support Equipment 0-Non-ME
B. Equipment Availability
3-Unique, important, high-use, with no/little backup 2-Some backup available or low use 1-Moderate use & backups available 0-Many backups available based on use
F. Clinical Impact of Failures
3-Impact to multiple care units 2-impact to single care area but multiple patients 1-Impact to single patient 0-Little or no impact to patient/care
H. Equipment Safety (0-3)
3-Sever e-death, non-resuscitation, serious injury 2-Failure to alert to serious patient condition or treatable harm 1-Low risk or harm, misdiagnosis, or alert to condition 0-Little or no harm or misdiagnosis
AEM Formula Sample C. PM or CM history shows repair of PM preventable failures
3-History of hidden safety problems only findable on PMI 2-History of PMI preventable problems or repairs. 1-History of operator findable problems with PMs or repairs 0-None or few PMI preventable repair history.
D. OEM PM & Active Change of Materials
3-PM has proactive, technical change of materials 2-Actice change in materials for PM occasionally, not every PM 1-Material changes can be done by operator 0-No active change in materials
E. Performance Verification
3-PMI more than a technical performance verification that only BMETs can do 2- PMI is a technical performance verification only BMETs can do 1-PMI is a performance verification operators can do 0-Operaotor or equipment checks/verifies performance
AEM Formula Sample G. PM frequency Requirements
3-OEM recommends more than once a year 2-OEM recommends once a year 1-OEM recommends less than once a year or vague frequency 0-None or OEM recommends PM/PV only on equipment repairs.
I. Battery Changes
3-Proactive change during all PMs, once a year or more 2-Battery changes some PMs, less than once a year. 1-Betery changes during repair or after several years. 0-Battery changes by operator or no battery.
AEM Risk: (A+B+F+H)/4 + (C+D+E)/3 + (G+I)/2
Score 0-9, the lower than 4.5 would be available for AEM if safety is not compromised.
David M. Dickey, MS, CHC, CCE, FACHE McLaren Health Care Equipment Function (EF) Points Life Support Critical/High Risk Misc. Patient Care Device Non Patient Care Device
8 4 2 1
Potential Risk (due to typical device failure) (PR) Maintenance Requirements (MR) Device History (DH) Use/Environment (UE)
Equipment Score: ES = EF+PR+ MR+DH+UE
CATEGORY 1: ES>=x highest priority OEM 100%. CATEGORY 2: ES= y-z OEM or AEM PMI CATEGORY 3: ES = w-v AEM, periodic PV, sampling, etc. CATEGORY 4: ES <=u No PMI except on repair
How to record an AEM PMI
Need to be able to separate AEMs from OEMs as well as HRME & NHR ME In inventory &/or PM work orders. PMI procedural names starts with AEM or OEM. Scan in changes procedures (e.g.) Record the decision in the PMI procedure Note AEM frequencies or frequency windows (e.g. how to PMI over 400 beds) AEMs still 100% follow all steps in procedures.
PMI Completion OEM
Follow 100% of OEM activities in procedures OEM 100% of all PMIs completed by TJC timelines.
AEM
PMIs
PMIs
Follow 100% of AEM activities in procedures AEM 100% of all PMIs completed by ontime. Does this mean TJC timelines or can you expand these windows?
On-Time PMI Rates EC.02.04.01 The hospital manages medical equipment risks (cont.) Note 2: Medical equipment with activities & associated frequencies in accordance with manufacturers’ recommendations must have a 100% completion rate. Note 3: Scheduled maintenance activities for high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% 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%. *
100% because of SAFER MATRIX *
*Per George Mills, TJC, ECRI Webinar “Clarity to Avoid Confusion: Updates to The Joint Commission’s Requirement for Equipment Maintenance Programs (1/7/2017). CMS did not like the 90% & TJC couldn’t stop the 1/9/2017 standard publication. ECRI, AAMI, ACCE Plus 90% did not fit in with SAFER MATRIX strategy for findings.
On-Time PMI Rates EC.02.04.03 The hospital inspects, tests, & maintains medical equipment. EP 2: The hospital inspects, tests, & maintains all high-risk equipment. These activities are documented. (See also PC.02.01.11, EP 2)
Note 1: High-risk equipment includes medical equipment for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment. Note 2: Required activities & associated frequencies for maintaining, inspecting, & testing of medical equipment completed in accordance with manufacturers’ recommendations must have a 100% completion rate. Note 3: Scheduled maintenance activities for high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate.
EP 3: The hospital inspects, tests, & maintains non-high-risk equipment identified on the medical equipment inventory. These activities are documented.
Note: Scheduled maintenance activities for non-high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory are to be completed at 100%. AEM frequency is determined by the hospital’s AEM program.
100%? Complete
100% of all OEM activities in published OEM procedures Complete 100% of all written AEM activities in procedures 100% completed on-time for OEM 100% completed on-time for AEM 100% completed on-time for High-Risk ME 100% completed on-time for Non-HR ME
How Do 100%?
Pass Corrected Consider not counting the following against your 100% average when you can’t do PMs.
If in use, get device once patient is done with it, Delayed in use. Document! If equipment is pulled from service before the timeline, Delayed out of service. Document! If cannot locate after multiple searches, Delayed-lost, or Deferred as lost/stolen. Document!
Document all actions in any delays or deferrals. If you cannot complete due to time or resources & it is still being used, it will count against you.
Non-CME & C-Support OPEN D0 D1 D2 D3 D4 D5 C P PM WOs Delayed Completed Late C+P D0+OPEN+late D1+D2+D3+D4+D5
Jan-17 0 0 1 0 3 3 9 5 75 96 1 0 80 0 16
Feb-17 Mar-17 0 5 0 0 69 2 0 0 1 1 34 4 15 3 45 2 1706 131 1870 148 3 0 0 0 1751 133 0 5 119 10
Apr-17 May-17 415 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 25 0 442 0 0 0 0 0 25 0 415 0 2 0
Jun-17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jul-17 Aug-17 Sep-17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oct-17 Nov-17 Dec-17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Non-CME & C-Support ON-TIME PMs All PMs Completed All PMs for the Month Goal
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 100.0% 100.0% 96.4% 5.7% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 80 1751 133 25 0 0 0 0 0 0 0 0 80 1751 138 440 0 0 0 0 0 0 0 0 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
References:
David M. Dickey, “Using Your CMMS to Support CMS Equipment Management Program Compliance,” AAMI Conference Presentation, June 2015. David M. Dickey, “A Clinical Engineer’s Approach to CMS Compliance: Part Two, “Biomedical Instrumentation & Technology Nov/Dec 2015. Caroline Heskett, TJC, “Survey Analysis for Evaluating Risk (SAFER) Matrix, TJC Webinar, November 15, 2016. CMS Memo S&C 14-07-Hospital, “Hospital Equipment Maintenance Requirements,” December 20, 2013. CMS Memo S&C 14-46-LSC, “Categorical Waiver for Power Strips Use in Patient Care Areas,” September 26, 2014. TJC, Hospital: Environment of Care Standards, January 9, 2017. TJC National Patient Safety Goals Effective January 2017, Hospital Accreditation Program. NFPA 99, version 2012: Health Care Facilities Code, Chapter 10. George Mills, ECRI Webinar “Clarity to Avoid Confusion: Updates to The Joint Commission’s Requirement for Equipment Maintenance Programs, January 17, 2017 George Mills, “JCR Environment of Care Base Camp Training Handout”, Joint Commission Resources, July 2014 George Mills, “Ask George,” Biomedical Instrument & Technology Nov/Dec 2011 George Mills, “Ask George,” Biomedical Instrument & Technology Nov/Dec 2010 George Mills, “JC: Maintenance of Life-Support Equipment Must be 100% On Time,” Biomedical Instrument & Technology May/June 2007
Questions? Jeanette
A. Thielen
[email protected] 206-744-3496
