Is Your CMMS Joint Commission-Compliant?

Healthcare maintenance teams need to ensure their facilities maintain compliance with all regulations related to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

It’s a challenging task, as these regulations are numerous. If that wasn’t enough, they also change relatively frequently.

What is JCAHO and Why Is it Important?

The Joint Commission developed JCAHO standards to help healthcare organizations measure, assess, and improve performance. The standards focus on important patient, individual, or resident care, as well as organizational functions that are essential to providing safe, high quality care.

All healthcare personnel play a role in patient safety. JCAHO compliance affects each role. For the maintenance team, that includes requirements for joint commission equipment maintenance, as well as other policy and procedure requirements.

How Can CMMS Software Help Meet JCAHO Medical Equipment Standards?

CMMS provides a reliable central repository for your healthcare equipment maintenance and safety data. With a properly implemented CMMS solution optimized for the healthcare industry, your organization can more easily adhere to the changing JCAHO requirements. And you won’t have to scramble at the last minute to set things in order.

For the Joint Commission, if it’s not documented, it didn’t happen. With CMMS, you have a traceable history of completed maintenance tasks and documented policies. As a result, you can prove that you’re acting in accordance with JCHCO regulations. Best of all, the documentation takes care of itself with CMMS.

Here’s how.

Inventory Management

If your organization is using the Joint Commission accreditation process for deemed status purposes, then all medical equipment is required to be included in the written inventory.

For organizations that do not use the Joint Commission accreditation process for deemed status purposes, then you may maintain a written inventory of either all medical equipment, or an inventory of selected equipment categorized by physical risk that includes all life-support equipment.

In this case, new equipment is evaluated prior to initial use to determine if it will be included in the inventory. While hospitals may have equipment that is maintained or owned by a vendor or the manufacturer, JCAHO compliance requirements state the hospital is still responsible for listing this medical equipment on the written inventory.

CMMS software offers asset management tools to purchase, operate, maintain, upgrade, or dispose of medical equipment in the most cost-effective manner. It also includes the ability to document storage locations and supplier information.

High-Risk Medical Equipment Maintenance

The written inventory also identifies high-risk devices. High-risk medical equipment includes all life support equipment and any other device for which there is a risk of serious injury or death to a patient or staff member should it fail. The term high-risk equipment is equivalent in scope and nature to the term critical equipment.

Maintenance activities and frequencies should follow manufacturers’ instructions and recommendations for maintaining, inspecting, and testing all medical equipment in the inventory.  These maintenance activities and frequencies—including an alternative equipment maintenance (AEM) strategy—are documented in writing.

CMMS reporting features also can help you quickly produce reports and documents giving details or summaries of medical equipment, high-risk devices, maintenance work and more to meet Joint Commission equipment maintenance requirements.

Alternative Equipment Maintenance Strategy

With some exceptions, an AEM program allows a healthcare facility to “adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel” (CMS 2013). This may include reduced or altered maintenance tasks, relaxed frequencies of maintenance, and run-to-fail strategies.

However, the Joint Commission states that the “strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice” (Joint Commission 2014). For example, an accepted standard of practice could be the American National Standards Institute/Association for the Advancement of Medical Instrumentation handbook ANSI/AAMI EQ56: 2013, Recommended Practice for a Medical Equipment Management Program.

You may not use AEM for…

  • Equipment subject to federal or state law or Medicare Conditions of Participation
  • Imaging and radiologic equipment (diagnostic or therapeutic)
  • Medical LASER devices
  • New medical equipment with insufficient maintenance history to support the use of an AEM strategy

Maintenance, Inspection, and Testing Documentation

Regulatory bodies like the Joint Commission are requiring increasingly complex recordkeeping. With CMMS, you also have a traceable history of completed maintenance tasks and documented policies. Therefore, you can prove to external agencies that you’re acting in accordance with their regulations.

CMMS helps maintenance teams stay organized and in compliance by…

  • Tracking employee health and safety information
  • Documenting work procedures
  • Ensuring all safety inspections and tests are done properly and on schedule
  • Determining when it’s time to repair or replace malfunctioning equipment
  • Documenting preventive maintenance on key assets
  • Creating reports for audits
  • Archiving work history
  • Storing employee trainings and certifications
  • Tracking incidents

Additionally, this documentation takes care of itself with CMMS.

Have more questions about how CMMS software can help you with Joint Commission policy and procedure requirements? Contact us. We’re here for you.