This article will review how to attain continuous compliance with two other Joint Commission medical equipment standards: EC.04.01.01 EP 10, the medical equipment program reporting to the environment of care (EC)/safety committee; and EC.04.01.01 EP 15, evaluation of the medical equipment management plan.
EC.04.01.01 EP 10
This elements of performance (EP) requires the hospital to report and investigate medical equipment management problems, failures, and use errors to the EC/safety committee. Tips for ensuring continuous readiness:
- Establish a schedule of how often biomedical/clinical engineering will report to the EC/safety committee. Make sure the schedule follows the one established by the hospital’s EC/safety committee. Usually these reports are submitted at monthly, bimonthly, or quarterly intervals.
- Follow the established reporting schedule and report regularly.
- If biomedical/clinical engineering cannot attend in person to present, submit the report to the committee and make sure that it gets recorded in the minutes of the committee meeting.
- Develop a standard format of reporting based on the hospital requirements.
- Make sure that the report covers the medical equipment problems, failures, and use errors. Other suggested items to report include, PM completion rate (overall completion rate and separate completion rates for life-support and non-life support equipment); repair calls (open and closed); recalls (completed and open); medical equipment-related incidents; cannot duplicate calls; and damaged equipment calls.
- The report should also state the progress made with respect to any performance improvement goals established for the medical equipment program.
EC.04.01.01 EP 15
This EP requires the hospital to evaluate the medical equipment management plan’s objectives, scope, performance, and effectiveness every 12 months. Tips for ensuring continuous readiness:
- The medical equipment plan evaluation should be divided into four sections—objective, scope, performance, and effectiveness. Be sure to include these four key words explicitly in the annual evaluations. It is reported that The Joint Commission surveyors look for these key words when they review this document during the survey.
- The annual evaluation is an important document that is reviewed by The Joint Commission surveyors. This EP has a scoring category of “A” and is assigned a criticality level of “3.” (For explanations of scoring categories and criticality levels, see reference 2.)
- The annual evaluation should report on the progress made with respect to the performance improvement goals established for the medical equipment program.
- New performance improvement goals for the next year should be established based on the evaluation of the performance of the medical equipment management plan.
Arif Subhan, MS, CCE, is the chief biomedical engineer, VA Nebraska-Western Iowa Health Care System, Omaha, Neb; adjunct assistant professor, biomedical engineering, University of Connecticut; and a member of 24×7’s editorial advisory board. The suggestions and views expressed in this article are of the author. They do not represent the views of the Department of Veterans Affairs or the University of Connecticut. For more information, contact .
- Subhan A. The EC.9.10 Standard. CCE Prep article, 24×7, May 2007. Accessed August 11, 2010.
- Baretich MF. The 2009 JC Standards, 24×7, April 2009. Accessed August 11, 2010.