When the Joint Commission surveyor comes calling, a concise, well-organized MEMP will put you ahead

As a clinical engineering consultant, I find myself reviewing healthcare technology management (HTM) programs from time to time, usually for hospitals or hospital systems. Often, the person who first contacts me is an administrator who says something like, “I don’t know a lot about our medical equipment management program, but I’m worried that it’s not going well. Can you come take a look and let me know what you find?”

To get the process started, I send the hospital a list of documents that I’d like to see before my site visit. I learn a lot from the documents I’m sent: Are the documents complete, up-to-date, and well-written? I also learn a lot from the documents that are not sent: they may be nonexistent, not locatable, or just in such bad condition the facility doesn’t want to share them.

The key document, the first thing I look at, is the medical equipment management plan (MEMP). For readers who are not familiar with it, the MEMP is a requirement under the Joint Commission accreditation standards for hospitals and similar healthcare organizations. This article focuses on standards of the Joint Commission, but other accrediting organizations have similar requirements and terminology.

It’s not surprising that many of us struggle to write a good MEMP. Most of us are doers rather than writers; we tend to let our work speak for itself. However, writing a good MEMP is something that needs to be done (and redone from time to time). Here are some things to think about that can make the process go more smoothly.

A Road Map for HTM

Before you start working on your MEMP, it’s important to understand why you’re writing it. The Joint Commission hospital standards manual has a chapter on what it calls the Environment of Care (EC). The EC chapter has sections that cover a variety of topics, from safety and security management to utility systems management. The MEMP requirement is part of the Medical Equipment Management section.

Within the Medical Equipment Management section, there are actually only two standards specific to medical equipment:

Standard EC.02.04.01: The hospital manages medical equipment risks.

Standard EC.02.04.03: The hospital inspects, tests, and maintains medical equipment.

Under each of these standards, there is a set of Elements of Performance (EPs). During a Joint Commission survey, the surveyor assesses and scores the hospital’s level of compliance with each EP. The survey team aggregates all EP scores from all chapters of the accreditation manual—ranging from Nursing and Medical Staff to Information Technology and Leadership—to reach a decision about whether or not the hospital will retain its accreditation. Compliance with EPs is the foundation of Joint Commission accreditation.

For example, under Standard EC.02.04.01, EP 1 says, “The hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment.” The surveyor will look for evidence that the hospital complies with this EP. Evidence might include a written policy, minutes from meetings of the committee responsible for carrying out the policy, records showing how recent medical equipment purchases were handled, and so on. The surveyor will also likely ask specifically about involvement by equipment operators (such as nurses) and equipment servicers, meaning HTM professionals.

The MEMP requirement is actually found under Standard EC.01.01.01—the hospital plans activities to minimize risks in the environment of care. Under that standard, EP 7 states, “The hospital has a written plan for managing the following: medical equipment.” The MEMP is our road map for HTM activities. Within the constraints of the Joint Commission requirements, we get to draw our own map. If we do a good job writing the MEMP, we’ll be less likely to get lost.

In my work as a consultant, I have seen a lot of really bad MEMPs: documents that are confusing, disorganized, out of date, incomplete, and downright painful to read. Some of the bad ones are boring enough to put me to sleep (which can be useful as a cure for insomnia), but the truly terrible ones lead to weeping and gnashing of teeth. It’s bad enough to do that to me or yourself, but don’t do that to your Joint Commission surveyor.

Write for Your Readers

Before setting pen to paper or fingers to keyboard, think about the purpose of the MEMP: to tell the reader exactly how the organization complies with every medical equipment-related standard and every associated element of performance. My experience is that most of us are doing a pretty good job of managing our medical equipment. We can think of the MEMP as an ideal way to communicate that important fact to our readers.

Who are our readers? The most important one is the Joint Commission surveyor who just arrived to scrutinize your medical equipment management program. The first opportunity for the surveyor to learn about your program is when he or she reads your MEMP on the first day of the survey. Only a few minutes are allocated for this step. We need to seize that opportunity and use it wisely. We want the surveyor to come away with an impression that we know what we’re doing. The last thing we want is for the surveyor to be confused and full of follow-up questions. We need to help the surveyor shift from inquisitor to educator, from someone looking for trouble to someone here to help.

Joint Commission surveyors are not the only people who will read our MEMP masterpieces. We should use it to communicate with the people to whom we report, to let them know clearly and succinctly what we do for them. We should use it to communicate with others in the organization, from Environment of Care (EOC) Committee members to new employees in the HTM department. And we should certainly use it to communicate with our future selves as HTM program managers who need to keep ourselves on track during the pressures of day-to-day responsibilities. Keep all these readers in mind as you write, and edit, and polish your MEMP.

An Assessment Tool

Figure 1

Figure 1. The Joint Commission Performance Improvement Cycle.

One more important way to use a well-written MEMP is as a guide for the annual evaluation of the HTM program, which is another Joint Commission requirement. Figure 1 shows the performance improvement process the Joint Commission wants to see. It starts with the MEMP, our road map for the year. Throughout the year we monitor our performance, perhaps on a monthly basis, and report it to the EOC Committee, perhaps quarterly.

At the end of the year, we do the annual evaluation of the MEMP’s objectives, scope, performance, and effectiveness (see Standard EC.04.01.01, EP 15). Ideally, this is—pardon the consultant jargon—a multidisciplinary, data-driven effort. One result of the evaluation process is a performance improvement activity to be undertaken over the following year (see Standard EC.04.01.03, EP 3). Equally important is feedback to the start of the process and revision of the MEMP to incorporate lessons learned.

To be useful for all these purposes, the MEMP needs to be concise. Readers of the MEMP are not going to spend a lot of time wading through an overly long document, so keep your golden prose on point. Instead of including all the particulars within the MEMP itself, provide references to further information for readers who want to know every detail.

Organization is also key. Our readers are not going to rummage through the document to find that one morsel of information they’re particularly interested in. That means we have to present the material logically and make it easy to navigate. We want the reader to quickly find what he or she is looking for.

Proofing Pointers

With these principles in mind, here are some specific suggestions as you craft your document. They are based on my discussions with Joint Commission surveyors and culled from years of reading all-star and no-star MEMPs.

It’s not about you. I’m sorry to break this to you, but the MEMP is not actually about your department; it’s about how your organization complies with Joint Commission standards. If your department fixes nonmedical equipment such as, say, office computers, that doesn’t need to be in the MEMP. On the other hand, if the radiology department in your hospital manages its own equipment, for example, make sure the MEMP describes how they do that. It’s not enough for the MEMP to simply say that maintenance of imaging equipment is someone else’s job; it’s the hospital’s job, and the MEMP is the place to describe how the hospital does it.

Stay in alignment. Arrange the material in the MEMP in the same order in which it appears in the Joint Commission standards manual. Not everyone agrees with this suggestion, so it’s OK with me if you decide to do something different. But keep your readers in mind and make it easy for them to find what they’re looking for. Imagine you’re a Joint Commission surveyor trying to figure out how the hospital handles a particular EP. How easy is it for him or her to find that nugget of information? Because the MEMP is fundamentally about standards compliance, aligning the document with the standards makes the most sense to me.

Spell it out. You should include the text of each standard and EP within your MEMP, but that’s not enough. You need to include a brief description, perhaps a moderately sized paragraph, about how your organization complies with each EP. You don’t want the Joint Commission surveyor, who already has the standards manual memorized, to be left wondering what you actually do on a day-to-day basis to achieve compliance. As part of the “how we do things here” description, be sure to state clearly what position in the organization is responsible for compliance, where the documentation resides, and what specific policy the reader should refer to for more detail.

One last bit of advice. When my clients are having trouble writing a description of how their organizations comply with a particular EP, I ask them to put the existing MEMP aside and just tell me in their own words how things work. If I ask, for example, how the hospital handles recall notices, they almost always respond easily with a few sentences that capture, in plain language, the essential elements of the process. Then I say, “Let’s write it down, exactly the way you just said it.” After that, with a little bit of light editing, you’re done.

As Mark Twain said, “Use plain, simple language, short words and brief sentences. That is the way to write English—it is the modern way and the best way. Stick to it.”

Matthew F. Baretich is president of Baretich Engineering Inc. For more information, contact Jenny Lower at [email protected]. 

Photo credit: © Andrei Krauchuk | Dreamstime.com