Joint Commission Updates Equipment Maintenance Rules for Critical Access Hospitals

The Association for the Advancement of Medical Instrumentation (AAMI) is reporting that the Joint Commission (TJC) has updated its standards to align with new federal requirements that allow critical access hospitals to deviate from manufacturers’ maintenance recommendations in certain circumstances.

The move comes in the wake of an August memo from the Centers for Medicare & Medicaid Services (CMS) in which the agency announced that critical access hospitals, or CAHs, would enjoy greater latitude in their medical equipment maintenance programs. The August memo follows an earlier one from CMS in December 2013 in which the agency announced a similar policy for hospitals in general. CAHs are a special category of hospitals under federal regulations. Among their characteristics, they are smaller and located in rural areas.

Starting Jan. 1, 2015, critical access hospitals accredited by TJC will need to identify high-risk medical equipment in their inventories that can cause serious injury or death if failure were to occur.  They also must identify in writing the activities and associated frequencies for maintaining, inspecting, and testing equipment, regardless of whether they adhere to manufacturers’ recommendations or an alternative equipment maintenance (AEM) program.

The TJC document points to ANSI/AAMI EQ 56:1999/(R) 2008, Recommended Practice for a Medical Equipment Management Program as having an example of standards for a medical equipment program.

While they may have AEM programs, critical access hospitals may not deviate from a manufacturer’s maintenance recommendations when:
•Federal or state laws, or hospital conditions of participation, require adherence to manufacturer’s recommendations and/or set specific requirements.
•The equipment is imaging/radiologic or a medical laser device.
•New equipment without a sufficient amount of maintenance history has been acquired.

Source: AAMI