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/tmcconnect/askgeorge.html. Or to join AAMI's Joint Commission e-forum, which is open to all AAMI members, visit www.aami.org/tmcconnect/discussiongroups.html. Some of the questions and answers may have been edited for space, style, and clarity.Regarding risk factor calculations, there are many published formulas from which to choose. Presumably, someone could derive his/her own, new formula, too. This seems to be quite arbitrary. Do you have some recommendations? Are you concerned that different formulas will have different results for which equipment to include? Do you have a favorite formula?The potential “arbitrary” methods is one of the reasons that Joint Commission surveyors will begin to question how you set up your risk-based inventory, looking for indicators that the outcome of the process is continued equipment reliability. Generally the various published formulas and methods arrive at the same conclusions. I remember when the model developed years ago by Fennigkoh and Smith was introduced. It seemed to meet the needs of sorting equipment based on criteria and risk, was rational and my staff understood its intent, which helped in implementation. Others have created complex models that also seem to work well. In assessing the various models, you may want to try a few formulas on known devices to see how consistently they all score the same device out.There are apparently no new standards or elements of performance (EPs) for medical equipment management for 2011. However, can you tell us about any new areas or issues about which surveyors might ask?Joint Commission Life Safety Code surveyors received training specific to EC.02.04.01 EPs 1–4 at the beginning of the year. A theme I have been using is “Back to the Basics” as I go out and speak and write articles. The four EPs I mentioned really bring us back to our program roots. Many biomed managers inherited their medical equipment inventory when they started at their hospital and have never edited it. That might be a good place for a surveyor to start. You should be able to explain how the inventory was created, what maintenance strategies you use and examples, how you established preventive maintenance frequencies.When a hospital adopts a time-related shelf-life system, as stated in AAMI ST79, what formula or guidelines can be used to determine the expiration date of the sterilized items?In ST79, there is a recommendation about an event-related system. ST79 does not specify how to “operationalize” a time-related system, however. The Joint Commission would expect you to create guidance policies for your organization.Is it true that The Joint Commission will have biomed departments inventory the hospital rigid endoscopes? If so, is there any documentation coming from The Joint Commission describing this requirement?Both the Joint Commission and ECRI Institute have identified contamination issues related to scopes as a significant patient safety concern from information gathered from 2009 and before. The Joint Commission Environment of Care Handbook, 3rd Edition has included as a definition of medical equipment four categories: treatment, diagnostic, monitoring, and patient support. Endoscopes are listed under diagnostic. With the recent patient safety concerns, it is only reasonable to have scopes be included in the medical equipment inventory. This was discussed in AAMI News (August 2010) where I mentioned that other than the reporting relationship, the organization continues to have full control over the management of its scopes. There is nothing in the article about oversight of the endoscopic department and their process by clinical engineering (in fact, I made sure to allow the current practice to continue). The goal of The Joint Commission is to have a process that is functional and that raises the awareness of this issue to the organizations we accredit. Currently, this is considered best practice and is not a specific element of performance.