By Binseng Wang, ScD, CCE
Recently, I’ve heard some colleagues say that the purpose of AEM is to save maintenance costs (while preserving equipment safety). Not only does this statement concern me, but so does this line of reasoning. Cost-saving is not the primary purpose of AEM—and it is a slippery slope that CE/HTM professionals must avoid at all costs.
Let’s first remind ourselves how AEM came about. Soon after gaining oversight authority over the Joint Commission (TJC) in 2008, the Centers for Medicare & Medicaid Services (CMS) discovered that TJC had accreditation standards that differed significantly from their requirements. To eliminate such discrepancies, in 2011 CMS issued a memorandum mandating that all equipment must be maintained per manufacturers’ recommendations. Realizing that this mandate was not only impractical to implement but would also seriously degrade patient safety, the CE/HTM community rallied behind George Mills—the TJC Director of Engineering at the time—to seek relief.
The industry provided CMS with extensive evidence showing that medical equipment has been properly maintained for several decades without strictly following manufacturers’ recommendations. Furthermore, to do so would divert CE/HTM professionals’ attention from other more critical patient-safety-related activities (e.g., equipment planning/selection, user training, CE-IT integration, cybersecurity, etc.). After reviewing the overwhelming evidence, CMS relented and issued another memorandum in 2013, which allowed AEM for most equipment.
Therefore, AEM was not granted for saving costs. Hospitals did not lay off staff or reduce service contracts by implementing it. Any “savings” were virtual (i.e., “cost avoidance”) by not hiring more staff to fully comply with the new CMS mandate. By alleging cost-savings, CE/HTM and outsourcing managers run the risk of being asked by their supervisors or contract administrators to reduce staff or contract prices.
Worse yet, lawyers could exploit the cost-saving justification for AEM in the event of an equipment-related patient injury. Imagine how a jury of laypersons would react to learning that the hospital reduced maintenance activities in order to “save costs.” At that point, it would not matter even if you could prove that the equipment failed in an unpredictable and unpreventable manner. It would be a dream come true for any ambulance-chasing lawyer.
So, what is the purpose of AEM? In my humble opinion, the purpose of AEM is to optimize the use of limited resources to better distribute attention to areas that most benefit patients and caregivers. This is not just sophism, but an honest answer and actually what good CE/HTM professionals have been doing all along.
Another concern that I have regarding recent AEM discussions is the recycling of the old “risk-based criteria” originally proposed by Dr. Larry Fennigkoh for equipment inclusion into a scheduled maintenance (SM) program. Despite George Mills repeatedly saying that, “Just because [a device is] high-risk doesn’t automatically mean it’s high PM,” many people still think that changing SM on high-risk equipment is taboo.
For example, ICU patient monitors are obviously critical for patient safety. However, nothing can be done to prevent their failures since they’re built with solid-state electronic components. Consequently, SM is completely useless if it cannot reduce the probability of failure by replacing wearable parts or sensors, or detecting failures hidden from the users or the machine itself (“self-test”). Please understand that I am not saying risk should be completely ignored—only that it should not be a primary parameter. A detailed discussion on AEM inclusion criteria is beyond this article.
Finally, one CMS requirement for implementing AEM that has been frequently overlooked is the need to evaluate its safety and effectiveness. A simplistic and erroneous evaluation method is to monitor the failure rate or mean time between failures. Unless those failures are related to SM planning, such data is meaningless. Therefore, the cause of the work-order failures should be determined so that indicative analyses can be performed.
Even if only patient incidents caused by maintenance-related equipment failures are monitored and analyzed, it’s important to remember that clinicians often take prompt actions when they notice something wrong. However, these “close calls” are seldom documented and much less investigated. So some AEM deficiencies could go unnoticed until someone is truly harmed.
Instead of just evaluating patient incidents, one should analyze all actual and potential failures found to be predictable and preventable, hidden from users, in progress, and induced by service. Any unusual surge of these failure causes should trigger a review of the respective AEM, even if OEM recommendations were followed. Actually, the evaluation may suggest increasing the SM frequency or adding SM tasks, proving again that AEM is not for saving costs.
The biggest challenge of AEM is the lack of data to support both initial planning and post-implementation evaluation, particularly for small CE/HTM teams. It would be highly desirable for regional and national HTM organizations and/or CMMS providers to collaborate by polling together data for statistical analyses that everyone can use.
Binseng Wang, ScD, CCE, is a principal consultant with health technology consulting firm BSI. Questions and comments can be directed to chief editor Keri Forsythe-Stephens at [email protected].
- While the Centers for Medicare & Medicaid Services (CMS) calls it the Alternate Equipment Management program, The Joint Commission (TJC) prefers the name Alternative Equipment Maintenance program. Information available at http://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_07.pdf and https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-07.pdf
- Fennigkoh L & Smith B. Clinical equipment management. JCAHO PTSM Series, 2:5-14, 1989.
- Lower J. Joint Commission’s Mills to AAMI: Use Common Sense for Alternative Equipment Maintenance Available at https://24x7mag.com/2015/06/joint-commission-mills-common-sense-alternative-equipment-maintenance-still-top-issue-for-biomeds/ Accessed Aug. 22, 2015.
- Wang B. Pinpointing the Root Cause of Equipment Failures. Available at https://24x7mag.com/2018/07/viewpoint-pinpointing-root-cause-equipment-failures/