Importance of 'Defensible' Policies Key Theme of TJC Update

Posted June 9, 2019

Herman McKenzie and George Mills
Herman A. McKenzie, acting director of the TJC's Department of Engineering (left), and George Mills, director of healthcare technical operations at JL

A recurring theme emerging from an update by The Joint Commission (TJC) on Sunday during the AAMI Exchange in Cleveland, OH, was the importance of healthcare technology management (HTM) departments having documented, defensible evidence supporting their equipment management strategies.

The informational session saw Herman A. McKenzie, acting director of the TJC's Department of Engineering, joined on stage by George Mills, director of healthcare technical operations at JLL, where the two responded to a variety of questions and concerns voiced by TJC-accredited facilities. Mills, who recently was named an AAMI Fellow, formerly served as director of engineering for TJC.

For organizations looking to implement an alternative equipment maintenance (AEM) program, McKenzie recommended starting with EC.02.04.01 EP 6, which addresses how equipment is used, including the seriousness and prevalence of harm during normal use.

The likely consequences of equipment failure or malfunction need to be reviewed, including seriousness and prevalence of harm. Organizations, said McKenzie, need to determine whether their AEM program addresses those failure modes and impacts in a better way than simply what the original equipment manufacturer (OEM) has suggested—hence the “alternative" part of AEM.

He further noted other key considerations when devising an AEM program:

  • Availability of alternative or backup equipment in the event that equipment fails or malfunctions, or is dropped and breaks
  • Looking at incident history of identical or similar equipment
  • Considering other maintenance requirements of the equipment not identified by the OEM

Mills said that help is on the way for HTM departments looking to launch an AEM program: The AAMI Medical Equipment Management (EQ) Committee is working on an AEM standard that will feature a comprehensive flow chart walking users through the process of creating an AEM program.

He further pointed out that the standard will look to remedy confusion in how "AEM" is defined, as both "alternative equipment maintenance" and "alternative equipment management" have been used. Mills said that the forthcoming standard will define "AEMP" as "alternative equipment management program" and "AEM" as "alternative equipment maintenance."

Mills also said that HTM needs to dispel any misconceptions of AEM being a "work reduction tool" or a method a department might employ because they are short staffed. An AEM strategy is not a way of cutting corners, he said; it's a means for demonstrating the comprehensiveness and effectiveness of equipment management strategies.

"It's a way of creating a highly defensible program and showing the great work you're doing," said Mills.

"The biggest thing in surveys is: Have you thought about the repercussions?" he added—again stressing the importance of not only devising but also documenting policies so that they can be used in one's defense during surveys.

The session also saw McKenzie and Mills address a variety of other topics, including achieving "zero harm and high reliability," adopting a quality management system, cybersecurity, special-purpose relocatable power taps, TJC surveyor training, temperature in the operating room, blanket warmer temperature, cleaning of case carts, travel requirements for clean and dirty case carts, frequency of electrical safety inspections, and how "equipment not found or in use" factors into 100% PM completion.

As a resource for HTM departments, AAMI offers the AEM Program Guide: Alternative Strategies for PM Safety, available in the online AAMI Store.