Joint Commission Promotes ‘Documentation’ as Solution to Common Survey Concerns


Posted June 4, 2018

Kenneth Monroe and George Mills
Kenneth Monroe (left) and George Mills (right) share a laugh during the final main stage presentation of AAMI 2018.

For the first time in recent memory, George Mills took to the main stage at the AAMI Annual Conference & Expo and did not deliver an update from The Joint Commission. Instead, the accreditation body's former director of engineering introduced his successor, Kenneth Monroe. 

“He’s a voice of reason. He’s honest, full of integrity, and a good individual,” Mills said of his longtime friend.

Monroe, who took over what is arguably one of the most high-profile positions in the world of healthcare technology management (HTM) in December, confessed to the audience that the HTM field isn’t “his wheelhouse” but that he had learned a lot during his time at the conference. 

“I came here to be a sponge, to soak up as much knowledge as I can,” Monroe said. “I didn’t come as a subject matter expert, a SME; I came as a subject matter learner (SML). And now, I’m going to turn back into a SME.”

Monroe, in tandem with Mills, then addressed some of the HTM field’s most pressing questions and lingering concerns. 

Alternative Equipment Management (AEM) Programs

According to The Joint Commission’s elements of performance (EPs), healthcare delivery organizations (HDOs) have two strategies for managing medical equipment: following the manufacturer’s recommendations or developing written criteria for an AEM program (except for equipment subject to federal or state law, imaging and radiologic equipment, medical device lasers, and new medical equipment, which always must follow the manufacturer’s recommendations). 

“The key part of understanding this EP is to ensure that you have things done and that they are documented, whether you are doing things according to manufacturer recommendations or whether you are doing them according to an AEM,” Monroe said. “You need to be able to prove—through some method—that you’ve got a good program in mind.”

Monroe also emphasized that while HTM departments must complete all scheduled maintenance activities for non–high-risk medical equipment in an AEM program at a 100% completion rate, it can be done “at a frequency that you’ve defined.” 

“You can figure out what the frequency is through your own research or from past experience, but just make sure that you have some solid ground for that,” Monroe advised.

Equipment that’s ‘In Use’ or ‘Unable to Locate’ 

When it comes to achieving the 100% completion rate, a number of HTM departments have reported that Joint Commission surveyors won’t let them remove equipment that cannot be located from their preventive maintenance (PM) completion percentage calculation.

“There is no requirement by The Joint Commission to interrupt the use of a piece of equipment that’s on a patient. The last thing we want to do is endanger the life of a patient because we’re doing a survey or you’re doing a PM,” Monroe said. “It also has to be a policy-driven process. Part of the documentation is to tell us what you are going to do if a piece of equipment is on a patient.” 

When to comes to equipment that can’t be found, “you can say you’ve done it, you’ve looked for it, and it’s not there,” according to Monroe. It still counts as being complete even if it’s still listed in your open work orders because “if it’s not there, it’s not there. You can’t PM it if you can’t find it.”

Relocatable Power Taps 

Based on EC.02.05.01 EP 23, “power strips in a patient care vicinity are only used for components of moveable electrical equipment used for patient care that have been assembled by qualified personnel.” These power strips must meet either the UL 1393A or UL 60601-1 standard.

Power strips used outside of a patient care vicinity, but in a patient care room, must meet UL 1363 requirements. In non–patient care rooms, power strips must meet other UL standards. 

“It’s important that you look for those UL labels,” Monroe said. “You can’t go to Menards and buy a $1.99 extension cord. This is a serious piece of work.”

Service Manual Library 

EC.01.01.01 EP 3 requires all HDOs to have a library of service manuals, instruction manuals, maintenance manuals, technical bulletins, and “specification information and other information for the inspection, testing, and maintenance of equipment and systems.” However, many HDOs are finding it difficult to acquire this information from manufacturers, despite a National Fire Protection Association requirement for manufacturers to provide it.

“The Joint Commission never really intended to make this a difficult issue for any of our customers. The idea was that we wanted to help give them a tool to be able to acquire these documents and have them in their resources,” Monroe said. 

To help meet this requirement, Monroe suggested bringing the issue to the Environment of Care Committee to discuss and identify three classes of documents:

  1. Those that are required to perform your work.
  2. Those that enhance understanding of an item or equipment.
  3. Those that are beneficial but are not required. 

“Then when the surveyors come around, you have the documentation of what actions you’ve actually taken,” Monroe added.