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Compliance News: TJC Discusses Equipment Inventories

| David Stymiest

In a new Clarifications and Expectations article entitled “Revised Equipment Maintenance Standards for Hospitals” published in the September 2014 issues of Environment of Care News and TJC Perspectives, TJC Director of Engineering George Mills provided guidance regarding the enhanced TJC equipment maintenance requirements that took effect on July 2, 2014. We previously discussed the driving CMS 2014 Survey & Certification Letter S&C:14-07-Hospital and its enclosed Appendix A interpretive guidelines changes generally in our May 2014 article and then related TJC updates in our July 2014 article. The changes related to equipment inventories and equipment maintenance entail six new and revised EPs within the medical equipment standards; and eight new and revised EPs within the utilities standards.

In this article we will focus on the enhanced requirements for equipment inventories.

Since the new language for EC.02.05.01 EP2 states that hospitals must maintain “a written inventory of all operating components of utility systems” there is some concern within the field about how far downstream in a specific system one must go before individual pieces and parts no longer need to be considered operating components of that system for inventory purposes.

Using a heating system as an example, Mr. Mills explained that the inventory components include “performance-related” equipment that “delivers a measurable outcome.”   He also gave examples of smaller supporting components, which he called “subcomponents,” that would still be subject to a PM program but might not have to be individually listed on the inventory depending on the maintenance strategies employed.

EC.02.05.01 EP3 requires that hospital identify high-risk utility system operating components in its inventory. As Mr. Mills also stated, TJC’s use of the term high-risk equipment (defined for utilities as components “for which there is a risk of serious injury or death to a patient or staff member” if the component fails) is equivalent to the CMS term critical equipment. The CMS 2014 Survey & Certification Letter S&C:14-07-Hospital’s Appendix A – interpretive guidelines state “A hospital is expected to identify any equipment in its AEM program which is “critical equipment,” i.e., biomedical or physical plant equipment for which there is a risk of serious injury or death to a patient or staff person should the equipment fail….” It appears from both the CMS interpretive guidelines and the TJC requirements that all defined high risk equipment (critical equipment) must be inventoried. We suggest that hospitals use the definition of high risk equipment (or critical equipment for those who do not use TJC for deemed status accreditation) to review existing inventories and augment them as necessary to completely cover that equipment category.

Although TJC is hesitating to identify very specific inventory operating component criteria because of the multitude of utility system configurations, a document recently posted in the ASHE Listserv drop box sheds a little more light on utility equipment inventory issues. ASHE members may want to avail themselves of that information as well.

Although they have been discussed during TJC presentations relating to utility systems for the past several years, fire alarm and fire suppression systems were specifically added in 2014 to the list of defined utility systems within TJC’s Comprehensive Accreditation Manual glossary. (A copy of that glossary definition was included within a sidebar to Mr. Mills’ article.) We should also note that the TJC glossary definition of utility systems has included “communication systems, including data exchange systems” for several years. Therefore it appears that the enhanced utility equipment inventory requirements and maintenance standards may also affect the management of fire alarm and suppression systems as well as the management of communication and data exchange systems. It may be wise for organizations to compare their management of those systems with the other traditional utility management requirements found in the standards as well.

We will discuss the Alternate Equipment Management (AEM) program in a future article. Hospital facilities personnel should acquire and review a copy of the September 2014 issue of either Environment of Care News or TJC Perspectives soon since these new requirements took effect on July 2, 2014 and are being scored during surveys according to reports from hospitals.