Ask George

Abstract

In this column, BI&T features questions and answers between AAMI members and Joint Commission expert George Mills. Become part of the discussion and ask questions about those subjects that matter to you the most.You can submit your Joint Commission question at this link: www.aami.org/htmcconnect/askgeorge.html. Or to join AAMI's Joint Commission e-forum, which is open to all AAMI members, visit www.aami.org/communities/discussion.html. Some of the questions and answers may have been edited for space, style, and clarity.My last Joint Commission inspector wanted me to rate all my medical devices for infection control risks. Is this specified in the standards? Are there some examples of this rating that I can use?Although inclusion of potential risk associated with infection control makes sense, this is not required in the Elements of Performance that address developing your medical equipment inventory (EC.02.04.01 EP 1 and EP2). EP 2 states: “The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorization by physical risk associated with use (including all life-support equipment) and equipment incident history.”The recent issues surrounding scopes make a good argument for including infection control in the categorization process, but, again, it is not required for medical equipment. Note: EC.02.05.01 EP 2 is similar for utilities systems and does include the line: “. . . utility systems based on risks for infection, occupant needs, and systems critical to patient care (including life-support equipment).”Is The Joint Commission's expectation that we track individual endoscopes or just keep a total number inventory? I'm hearing two different things. Also, how is “endoscope” being defined? Does this include all urology and laparoscopic scopes?The intent is to provide another concerned department with a look at the process that those responsible for cleaning and storing scopes use. I am not as concerned with serial numbers—although risk managers may be for tracking possible adverse events—as bringing another department to take a fresh look at the process to ensure handling and storing does not create opportunities for cross-contamination. Joint Commission surveyors have seen scopes that were cleaned and stored in cabinets that were too short, causing the end of the scope to actually rest and drain onto a towel that is shared with another scope.To answer the question, if you have five scopes on the inventory and one is sent out to the supplier and a different scope is provided, the inventory is still five. The risk manager or your own policies may require more detailed information.A surveyor just wrote up one of our facilities for having a piece of lifesupport equipment coded as “could not locate (CNL).” Of course, the preventive maintenance is overdue and the surveyor told the facility that CNL was no excuse and that life-support equipment must be inspected 100% of the time. Is this surveyor making an incorrect assumption or did the surveyor not understand that sometimes items go missing?This is hard to answer, as I was not there to hear the discussion. Generally, if you have a policy stating how you manage “could not locate” items as they affect life-support equipment and associated completion rates, and show that to the surveyor, the result should be acceptance of your process—unless the process is determined to be lacking. If the policy is not acceptable, ask the surveyor to explain why.Is it a department's responsibility to make its equipment available to biomedical equipment technicians (BMETs) for preventive maintenance inspection purposes? Or do BMETs have to search for the equipment due for scheduled inspection?This is driven by your policy. Ideally, users and maintainers should have a common goal of working together to ensure that scheduled activities can be done in a timely manner for the benefit of the patients.Is there a standard requiring that the expiration date on the refill cartridges of hand-sanitizer dispenser be visible through a wall dispenser window?Nothing to that effect in the Joint Commission requirements, but it sounds like a good practice to consider.