JCAHO Connection

Abstract

Editor's Note: AAMI and JCAHO are working together to provide AAMI members with more information about JCAHO initiatives and medical equipment standards. AAMI members can pose questions to JCAHO standards experts and obtain responses, which will be published in the Joint Commission Resources' Environment of Care News and in BI&T. AAMI members can pose their questions by e-mailing Steve Campbell at scampbell@aami.org. Questions will be answered by JCAHO's Standards Interpretation Group, the official interpreters of JCAHO standards language.Q: I am a certified biomedical equipment technician. Over the last several years, I have noticed a nationwide trend—hospitals hiring electronic technicians without medical training. In some cases an electronic tech is put in charge of the biomedical engineering department or is the only biomed tech for the hospital. Has the Joint Commission addressed this issue?A: The Joint Commission does not specify a particular qualification or background for individuals working with medical equipment. While EC.6.10 (rationale) says medical equipment should be maintained by “qualified individuals,” the standard leaves it to the organization to make a reasonable determination about what those qualifications are.Joint Commission leadership and human resources standards do require health care organizations to ensure staff are competent to perform their assigned work, and an understanding of physiology is clearly an important factor in the ability to handle biomedical engineering duties. This is not to say, however, that technicians without a physiology background cannot be employed in biomedical engineering departments. A health care organization may reasonably consider entry-level technicians qualified to work on equipment not used clinically on patients-for example, nurse call systems. Under HR.2.30, which requires organizations to offer ongoing education to improve staff competence, such technicians could be given opportunities to develop the knowledge base and expertise to work with medical equipment.Q. Is there a standard of practice for the nursing personnel charged with care of inpatient dialysis patients? Specifically, are we required to have ACLS-certified RN/LPN caregivers on site?A. Joint Commission standards do not specify a particular background or qualification for caregivers in charge of dialysis patients. However, the Joint Commission does regard patient type as one of the factors that go into assessing caregiver qualifications. When evaluating staff competence, health care organizations must consider the patient population (HR.3.10, EP1) and the complexity of required services (LD.3.70, rationale). The potential risks associated with dialysis are serious enough to warrant a careful look at caregiver qualifications in this area.Note: State laws or CMS regulations may require specific qualifications for inpatient dialysis nurses.Q. We were recently told by one of our customers that doctor's offices are not subject to the Joint Commission's preventive maintenance regulations. Is that correct? If so, why?A. It's correct only if the doctor's office is not accredited by the Joint Commission. If the office is accredited by the Joint Commission, then it must comply with Joint Commission standards on medical equipment, including preventive maintenance standards.The only exception would be if the office is a behavioral health care facility. The Joint Commission's medical equipment standards (EC.6.10 and EC.6.20) do not apply to behavioral health.Q. What is the difference between a “random unannounced survey” and an “unannounced accredited survey”?A. An unannounced accredited survey is simply a Joint Commission accreditation survey that has not been announced ahead of time to the surveyed organization. Starting January 1, 2006, all Joint Commission surveys will be unannounced.A random, unannounced survey is a one-day survey conducted several months after an organization's full accreditation survey. The purpose of this abbreviated visit is to validate the effectiveness of the full survey. Every year, 5% of surveyed organizations are randomly selected for a one-day validation survey.