With Changes on the Horizon, Mills Charts Path for Meeting TJC Maintenance Requirements

Posted June 12, 2017

George Mills' SessionMore changes are coming to Joint Commission requirements in January, the accreditation organization’s director of engineering announced Monday at the AAMI 2017 Conference & Expo. However, for those in attendance, the more immediate concern is ensuring their departments are meeting requirements for medical device maintenance that went into effect early this year.

Under the new elements of performance (EPs), hospitals are expected to complete all planned maintenance activities in line with manufacturer recommendations or an alternative equipment maintenance (AEM) program 100% of the time.

The commission’s George Mills provided the example of changing the oil in a motor. If there are nine steps in the process, then all nine steps need to be completed. The leeway comes in setting the frequency of the required maintenance activities.

“If there’s ever been a reason to go to an AEM program, [EC.02.04.01, EP 4] is the EP for it,” Mills said.

Mills illustrated, with the use of volunteers from the audience, how healthcare technology management (HTM) departments could implement a rolling “frequency window.” The goal would still be to complete all preventive maintenance (PM) activities within a year; however, the written policy could be written to provide the department with a two-year window in which to complete all PMs. That would give departments a little extra time to account for potential “slippage,” while still remaining in compliance. Once all of the PMs had been completed, the next two-year window would begin.

“With an alternative equipment management approach, you don’t have to put yourself in this little box. You can be thinking out of the box,” Mills said. “You can be creative with frequency and still come up with a safe and reasonable approach.”

For some in the audience, the idea of moving everything (minus imaging equipment, lasers, and other legally specified devices) into an AEM program didn’t sit well.

“I’m a little concerned that we’re using AEM as a workaround to justify the fact that most of us in here aren’t going to be at 100% with our PMs,” David Eck, director of health technology management at Boston Children’s Hospital, told Mills during the Q&A discussion. “While I appreciate the work that you’re doing and I understand the way we’re trying to kinda dance around this 100% thing, I think we’re still a little misguided using AEM to solve the problem. I mean, what in life is 100%?”

For Mills, while there is flexibility when it comes to the frequency of PM activities, the underlying constant is always patient safety.

“The AEM is not designed, nor is it intended, to be a replacement for staff. It is not a solution because you’re short-staffed or whatever. And there are many times when you’re doing AEM that you actually increase PM frequency based on your experience and what you’re finding,” Mills said. “Everything that we do goes back to patient care so that it’s a safe environment … without any fears, without any worries, without any harm coming to them.”

Mills also advised HTM professionals that more changes are coming.

“In January 2018, you’re going to see another large population of EPs coming into your standards and then we should be pretty stable for a while,” Mills said.

Two of these new EPs are:

  • EC.01.01.01, EP 3: The organization has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information.
  • EC.03.01.01, EP 1: Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training.

Mills said that he wrote these EPs not to add additional requirements but to “help out” HTM professionals by giving them stronger footing when making requests for needed tools and resources.

“I’m so tired of [hospital] leadership … saying: ‘We don’t have money to send your staff for training,’” Mills said. “This EP is solely designed to help you educate your staff … Don’t be afraid of this but truly embrace it, and it should be a way to get your staff to where you need to be.”