Photo of John NoblittThis article will review the different accrediting agencies for healthcare facilities and some of the requirements that they may commonly look for during a survey. The Joint Commission is the most widely known accrediting agency for healthcare facilities, but there are others that are also certified through CMS to perform these accreditations.

Note that with the additional certifications now available for HTM professionals, the information presented in this article may be useful for any and all of the certification exams. However, it may lend itself best to the new CHTM, or certified healthcare technology manager, exam.

Accrediting Bodies

Rather than The Joint Commission, your facility could by accredited by the Healthcare Facilities Accreditation Program, the Center for Improvement in Healthcare Quality, or DNV GL Healthcare. Each of these organizations has certain requirements for accreditation and there are undoubtedly some minor differences in the survey process. They may even have different requirements for some of the basic elements of safety. But overall, the majority of the requirements for all these agencies are somewhat generic.

Where you could possibly see some differences is in the standards that are being used for safety. The Joint Commission has adopted the safety requirements in NFPA 99 2012 edition, so it would be looking at those standards for accreditation. However, some other organizations may use the International Electrotechnical Commission (IEC) document 60601-1, which has been adopted by the American National Standards Institute (ANSI) and the Association for the Advancement of Medical Instrumentation (AAMI).

I have never known a certification exam question to be specific about accrediting agencies, but I have heard of specific NFPA 99 standards being used on test questions. For this simple reason, I will keep most of this information tied to NFPA 99 2012 standards. There are several actions all hospitals are required to perform in order to receive accreditation. We will now look at a few of these requirements.

Safety Programs

Each facility must have a comprehensive electrical safety program that includes the electrical distribution system in the facility and the electrical medical equipment. This safety program must include patient care and non–patient care areas. Safety testing documents showing results must be kept on file.

New devices are required to pass appropriate standards before being used on a patient. The new device should be listed for its intended use and certified by a nationally recognized testing laboratory, or NRTL, such as Underwriters Laboratories (UL). The “appropriate” standard could be NFPA 99, or it could be the ANSI/AAMI standard. This may depend on which standards your accrediting body has adopted.

Each hospital must have in place a training program on electrical safety for staff, which is usually addressed by means of new-employee orientation. The facility must also incorporate in-service orientations that provide guidelines for specific safety concerns with certain types of equipment and that is attended by the staff who operate the equipment.

The facility must also have a mechanism to identify hazards and investigate safety incidents. Many facilities accomplish this with a monthly safety committee meeting. This committee must also have a system in place to be proactive in all areas of safety within the facility and to implement performance improvement activities so as to continually improve safety conditions in the hospital.

Each facility must also have a medical equipment management plan and a utility systems management plan that identifies who is responsible for each plan. These plans must include provisions to review codes and standards, and must identify what guidelines are applicable to the plan. The facility must also identify all accreditation and certification programs in which it participates, such as the standards of the College of American Pathology followed in the laboratory.

The governing body of the facility is charged with approving the classification of the various areas of the hospital, as different areas will have different safety concerns. The classification of areas will assist in implementing testing procedures, schedules, and required documentation.

These safety plans must also address procedures for procurement of new equipment, which should require that all equipment meet regulatory guidelines for safety standards. For instance, a new device must go through a procedure that ensures the device is meeting safety standards before being put into use.

Review Procedures

Last but certainly not least, the safety plans must have provisions to review parts of the plan, such as the facility orientation process that educates new employees in potential safety concerns like electrical safety. These education efforts need to be reviewed and updated on a regular basis to ensure their effectiveness. Along with the review of the safety education process, there should also be a review process for the safety committee. This review process must update the established program on incident investigation and reporting, which addresses electrical hazards. The review of the safety committee would likely go much further than just electrical hazards, as this committee typically addresses many other types of safety concerns.

I hope you find this information useful as you prepare for the certification process. Until next time, take care.

John Noblitt, MAEd, CBET, is the BMET program director at Caldwell Community College and Technical Institute, Hudson, NC. For more information, contact editorial director John Bethune at [email protected].

Review Questions

1) Which of the following organizations is an NRTL?
a) UL
b) Joint Commission
c) IEC

2) AAMI and ANSI have adopted, with minor changes, a safety document from which of the following?
a) FDA
b) 29CFR
c) IEC
d) NFPA 101

3) NFPA 99 2012 edition requires all healthcare facilities to have which of the following?
a) Helipad
b) Labor and delivery department
c) Medical equipment management plan
d) CCE on staff

4) To accredit a healthcare facility in the United States, the accrediting agency must be approved by which of the following?
a) CMS
b) FDA
c) DOT



Answers: 1—A, 2—C, 3—C, 4—A