The Joint Commission (TJC) is the oldest medical standards regulatory agency in the United States making and maintaining accreditation by TJC highly esteemed and sought after by healthcare organizations. To maintain accreditation, healthcare facilities are inspected at least once every three years to ensure that TJC standards are continuously being met.
This article will discuss:
- The Joint Commission Standards for Medical Equipment
- A Checklist of Equipment Upgrades, Replacements, and Additions for Joint Commission Inspections
Joint Commission Standards for Medical Equipment
There are more than 250 Joint Commission standards for medical equipment. TJC sets these standards to ensure the safety, functionality, and proper management of the equipment in the healthcare environment.
It is important to note that the types of standards mentioned in this article are not an exhaustive list. Standards may vary by facility and the services offered by the facility.
While compliance with standards set by The Joint Commission is voluntary, healthcare organizations must comply with local, state, and federal regulations for medical equipment and patient safety.
Here are four areas of Joint Commission standards related to medical equipment.
Equipment Management
The Environment of Care (EC) standard focuses on the effectiveness and safety of medical equipment. It sets requirements for the management and maintenance of equipment. Facilities must have processes in place to ensure medical equipment:
- remains in good working condition,
- is regularly inspected,
- cleaned, and
- properly stored.
Here are some sample requirements.
- written inventory of all medical equipment used for diagnoses and treatment.
- inspects, tests, and maintains equipment to ensure safe and reliable operation.
- identify medical equipment safety risks and takes appropriate actions to mitigate those risks.
In addition to processes related to physical equipment, TJC has EC requirements for documentation and staff training.
- document the clinical use and maintenance of medical equipment.
- staff members responsible for operating and maintaining medical equipment receive appropriate training and education.
Medical Equipment Associated with Medication Delivery
The Medication Management (MM) standard is focused on ensuring the safe and effective use of medications. To this end, it includes requirements for medication storage, handling, and administration.
Medication carts for example must have secure locking systems, well labeled drawers and contents, and documentation proving drug expiration dates are checked at least monthly.
Here are two samples of the types of standards for other medical equipment associated with the delivery of medication.
- ensures that medical equipment used for medication delivery such as infusion pumps, is properly maintained, calibrated, tested, and inspected.
- follows safe practices for the use of infusion pumps and other medical equipment used in the administration of medication.
Sterilization and Infection Control
The Infection Prevention and Control (IC) standard focuses on reducing the risk of healthcare-associated infections. Facilities must have robust infection prevention and control protocols in place and enforced. These may include proper cleaning and disinfection procedures for medical equipment.
Here are two more examples of Joint Commission type IC regulations.
- follow sterilization and disinfection practices for reusable medical equipment to prevent the spread of infection.
- inspect, maintain, and test equipment used for sterilization and disinfection.
Because of its impact on HAIs, The Joint Commission has set a hard line on the presence of rust on medical equipment. It is a best practice to inspect for rust frequently and immediately take remediation steps for even the smallest speck.
Emergency Medical Equipment and Supplies
Emergency Medical Equipment and Supplies (EM) standards focus on ensuring life saving medical equipment is immediately accessible and in working order to respond to emergencies quickly and appropriately.
Sample EM type standards related to medical equipment are to
- identify and maintain emergency medical equipment and supplies needed for patient care during emergencies.
- test and inspect emergency medical equipment and supplies to ensure their functionality and readiness.
These broad samples and examples are presented to show the kinds of things TJC looks for when inspecting medical equipment. To learn more about the specific standards for hospital accreditation, visit The Joint Commission Resources®. Print and electronic accreditation and certification standards manuals are available for purchase.
Checklist of Equipment Upgrades, Replacements, and Additions for Joint Commission Inspections
The Joint Commission requires all, 100%, medical equipment in an accredited organization receive documented annual preventative maintenance (PM). Setting up a scheduled preventative maintenance plan can help eliminate the risk of medical equipment functioning poorly or not functioning at all when it is needed for patient care. Additionally, PM can help prevent the hassle of preparing an Alternative Equipment Maintenance Plan (AEM) to explain breaks in documented equipment maintenance.
CME Biomedical Technicians can supplement hospital systems biomedical departments by performing required testing, calibration, and general maintenance to fulfill hospital accreditation compliance requirements.
Comprehensive preventative maintenance can also lay the foundation for medical equipment to pass formal TJC hospital accreditation inspections.
Here is a checklist of “standard” equipment upgrades, replacements, and additions to consider implementing during PM checks to ensure the medical equipment passes inspection down the road.
- Storage Solutions
- Additional storage units, replacing ones that are rusted.
- New cart covers to replace damaged ones.
- Scope Storage Cabinets
- New scope cabinets that have HEPA air filtration systems
- Chrome Shelving
- Replace damaged items, add shelf inlays, make sure nothing is stored on the ground.
- Stainless Steel Equipment
- Replace any equipment showing rust or pitting.
- Refrigerators/freezers
- Need to have monitoring systems to insure consistent temperatures.
- Carts
- Biohazard wheels for OR case carts, replacement wheels for any carts, new cart covers.
- IV Poles
- Replace broken or rusty equipment, replace wheels.
- Wall-Mounted Items
- AED cabinets in hallways, PPE dispensers and computer mounts less than 4” Deep in hallways.
- Replacement of Furniture
- Anything that has torn upholstery like exam tables, recliners, phlebotomy chairs and stretcher pads.
- ADA Compliant Equipment
- Cubicle Curtains
Splash guards and dividers arrived with the pandemic and are here to stay. If medical equipment is stored on a counter within 36” of a sink, look for and confirm the presence of splash guards during preventative maintenance checks.
As the only equipment-focused medical equipment distributor in the United States, CME can help you source replacement medical equipment. We have built relationships over the last forty plus years with the leading medical equipment manufacturers and can help you find the equipment you need and help you stay on budget.
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CME Corp Biomedical Services Help Ensure Compliance with Joint Commission Standards
Healthcare organizations are experiencing staffing shortages these days, including biomedical equipment technicians (BMET). Satellite or off campus Ambulatory Surgical Centers and Urgent Care Clinics are popping up everywhere, making the BMET shortage more acute.
The short version of this complex challenge is that biomedical departments are stretched thin and can benefit from outside support.
CME Corp biomedical services can be a much-needed extension of your biomed team. Our biomedical equipment technicians can support biomedical departments by performing annual preventative maintenance as well as medical equipment repairs.
CME BMETs perform on-site preventative maintenance checks, calibration service, and repair for a broad range of medical equipment including vital signs monitors, AEDs, Defibrillators, Autoclaves, Infusion Pumps, Suction Units, Ventilators, IT workstations, Beds, Stretchers, wheelchairs, and patient lifts. Our asset management system and inspection stickers help ensure nothing slips through the proverbial cracks and is found later by a Joint Commission inspector.
Contact CME Biomedical Services to start a conversation about setting up a preventative maintenance schedule for all your medical equipment. Call 833-447-1013 or email repair@cmecorp.com.
About CME: With two corporate offices and 35+ service centers, CME Corp is the nation’s only equipment focused medical equipment distributer. We are the premier source for more than 2 million healthcare equipment products, from more than 2,000 manufacturers.
Our Turnkey logistics and biomedical services allow us to help healthcare facilities nationwide reduce the cost of the equipment they purchase, make their equipment selection, and schedule delivery, installation, and maintenance without impacting patient care. From medical equipment purchases to renovations and new facility construction CME Corp is your partner for seamless capital medical equipment purchases, delivered on time and in budget.
