August 19, 2014 | | Comments 0
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May you live in interesting times…no duh!

Well, now that we are well and truly ensconced in the post-July 2014 world, perhaps things will quiet down a bit on the updated standards front. It’s been a very busy first half of 2014 relative to The Joint Commission’s ongoing alignment with the CMS Conditions of Participation and perhaps they’ll allow the smoke to clear a bit so we can get down to figuring out how much impact the changes to the standards will have in the medical equipment and utility systems management pursuits. Kind of makes you wonder what’s left to update/align, but let’s hold that card for another day.

So, the last salvo in June saw some fairly interesting edits of (to? you be the judge) the medical equipment and utility systems management standards and performance elements (visit here for details). As near as I can tell, the most eventful changes relate to the change of the life support and non-life support equipment categories to a somewhat more expansive (or at least it seems that way to me) categorization of high-risk (which includes life support medical and utility systems equipment) and non-high-risk (which includes pretty much everything else). To be honest, most (probably all, but I don’t want to use too big a blanket for this) of the programs I’ve had the privilege to review/evaluate have moved to the high-medium-low-no risk strategy for assigning preventive maintenance activities and frequencies, so I’m not sure that this will require any fundamental changes to how folks are administering their programs. But (and there’s always, always, always one of those when there is an official change in the standards), I am curious to see how these changes will be applied during accreditation surveys. I expect the life safety surveyors to have a good grasp on the practical impact of the changes, but what about the rest of the survey team as they wander around the corridors of healthcare organizations across the country. It’s not unheard of for standards changes to “drive” an increase in findings in those particular areas as surveyor knowledge expands/contracts/evolves/mutates so it will be interesting to see what types of findings may fall out of the changes.

I guess my best advice at the moment is to do a careful assessment of where your program is relative to the “new” standards, particularly if you have adopted an “alternative equipment maintenance” (AEM) program (this must be that alternative lifestyle I keep hearing about…). I suspect we are all going to need to be prepared to make full use of the post-survey process (especially the clarification process) to demonstrate the “compliance-ness” of our programs. As I tell folks at virtually every stop on my never-ending tour of hospitals, there will always be surveyors that will disagree with programmatic decisions that you’ve made. Your task/responsibility is to have a very clear understanding of how your program meets the intent and the spirit of the standards, regardless of how something might “look” to a surveyor. At the end of the day, it’s about supplying to our customers safe and reliable medical and utility systems equipment—and as long as we can demonstrate that within the confines of the standards –then we have fully honored that obligation. And that, my friends, is what compliance-ness is all about.

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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