Equipment Management Standards

The April “CCE Prep” article in 24×7 reviewed The Joint Commission standard EC.9.10. This article will discuss the other Joint Commission standards that have an impact on the medical equipment management program.

The Environment of Care (EC) standard EC.9.20 applies to all seven EC programs and requires the hospital to analyze identified environmental issues and develop recommendations for resolving them. One of the elements of performance (EP) in this standard requires recommending one or more performance improvement (PI) activities annually to the hospital leaders, based on the ongoing performance monitoring of the EC programs. An example of a PI activity that crosses several EC programs could be, “How to handle contaminated medical equipment received for repair in the clinical engineering department.” The PI effort to address this problem would particularly involve safety, hazardous (infectious) materials, and medical equipment programs besides infection control, nursing, and other departments. The flowchart shown above—courtesy of Matthew F. Baretich, PE, PhD—demonstrates The Joint Commission Performance Improvement Cycle.

The Environment of Care standards require hospitals to analyze identified environmental issues and develop recommendations for resolving them.

The EC.9.30 standard requires the hospital to improve the environment. One of the EPs in this standard requires reporting the results of performance monitoring to those responsible for managing the patient safety program. Some of the medical equipment program activities that can have an impact on patient safety include “medical device incidents,” “equipment hazard notices and recalls,” and “user errors.”

Human Resources (HR) Standards

The HR standards address the requirements for all the hospital staff (including contracted employees) who provide care, treatment, and services. For the medical equipment management program, these standards apply to both clinical users and the biomedical/clinical engineering staff. HR.1.10 requires that the hospital provide an adequate number and mix of staff for various functions in the organization. An appropriate mix of biomedical staff is essential to handle the variety of medical equipment used in the hospital.

HR.1.20 requires that the qualifications of the staff members be consistent with their job responsibilities. This links with one of the main Joint Commission medical equipment standards—EC.6.10— that states that the equipment must be maintained appropriately by qualified individuals. The hospital needs to define the required competence and qualifications of the biomedical/clinical engineering staff. In addition, the education, experience, competence, applicable background check, and health screening requirements of the staff need to be verified.

For more on EC.6.10 see the January 2007 “CCE Prep“

The orientation, education, and training requirements are addressed in the standards HR.2.10, HR.2.20, and HR.2.30. The orientation should provide initial job training and information about the hospital. Orientation should include the mission and goals of the hospital, all policies and procedures specifically related to safety and infection control, and specific job duties and responsibilities. Ongoing education and training should occur when job responsibilities change and to keep up with changes in the profession, technology, and equipment. Competency assessment and performance evaluation requirements are addressed in the standards HR.3.10 and HR.3.20. They require that hospital conduct performance evaluations of staff be done periodically, at intervals determined by the hospital, but at a minimum of at least once in the 3-year accreditation cycle.

Infection Control (IC) Standards

Infections in hospitals occur due to many reasons, including poor hand hygiene and poorly cleaned equipment. IC.4.10 requires the hospital to plan and implement interventions to address priority infection control issues. It covers methods to reduce the risks of health care–related infections associated with the use of medical equipment. This includes developing appropriate policies and procedures for storage, cleaning, disinfection, sterilization, and discarding of equipment; and the appropriate use of personal protective equipment.

The biomedical/clinical engineering staff should be trained in infection control policies and procedures. They must be aware of the biological hazards in the hospital environment and on the surfaces of objects, particularly medical equipment.

Leadership (LD) Standards

The leadership standards apply to all individuals who are responsible for the overall governance of the hospital, such as the chairman/CEO, president, chief nursing/medical officer, and other senior leaders, as well as the departmental leaders—director of biomedical/clinical engineering, director of imaging, director of surgery, and others. LD.2.20 requires that each department have an effective leader who ensures that the program is managed properly and who holds the staff accountable for their responsibilities. LD.3.80 requires the leader to provide adequate space (for medical equipment service, for example); equipment, such as medical and test equipment; and other resources. LD.4.10 requires the leader to participate in the organizationwide performance improvement activities. LD.4.50 requires the leader to set performance improvement priorities and to adjust priorities in response to unusual events. LD.4.60 requires the leader to allocate adequate resources for measuring, assessing, and improving the hospital’s performance and safety. LD.4.70 requires the leader to measure and assess the effectiveness of performance improvement and safety.

Management of Information (IM) Standards

The provision of patient care and treatment and other support services in a hospital is a complex process extremely dependent on information. For the biomedical/clinical engineering staff, IM.2.30 mandates that the hospital have a procedure for maintaining the continuity of information. This requires determining the critical information in managing the medical equipment program. Examples include inventory, maintenance history, and patient data stored in the medical equipment. This also necessitates having plans for backing up data if the computer that houses the medical equipment program, or the data, fails. The data should be backed up appropriately, tested periodically, and the staff should be aware of how to recover data, if necessary. IM.2.20 requires maintenance of information security and data integrity. This requires taking adequate steps to secure protected health information. IM.4.10 requires the collection and aggregation of data and information to support service—clinical engineering, for example—delivery including issues like patient safety and performance improvement.

Improving Organization

Performance (PI) Standards Improving the performance of the organization through collection and analysis of data, monitoring progress, and improvement initiatives is the focus of the PI standards. PI standards will be reviewed in detail in a future article.

Arif Subhan, MS, CCE, is senior clinical engineer, Masterplan, Chatsworth, Calif; and chair, CCE Education Committee, ACCE. For more information, contact .