TJC Requirements for Medical Equipment for Ambulatory Care Centers:

Standard EC.02.04.01

The organization manages medical equipment risks.

Elements of Performance for EC.02.04.01

1. The organization has a systematic approach to selecting and acquiring medical equipment.

2. The organization maintains either a written inventory of all medical equipment or a written inventory of selected categorized by physical risk associated with use (including all life-support equipment) and equipment incident history. The organization evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (See also EC.02.04.03, EP’s 1 and 3)

3. The organization identifies the activities for maintaining, inspecting, and testing for all medical equipment on the inventory. (See also EC.02.04.03, EP’s 2 and 3)

NOTE: Organizations may not use different maintenance strategies based on the type of equipment. Strategies must include defined intervals for inspecting, testing, and maintaining equipment on the inventory. Defined intervals are based on criteria such as manufacturers’ recommendations, risk levels, and current organization experience. In addition, predictive maintenance, reliability-centered maintenance, interval based inspections, corrective maintenance, or metered maintenance may be selected to ensure reliable performance.

4. The organization identifies frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturer’s recommendations, risk levels, or current organization experience. (See also EC.02.04.03, EP’s 2 and 3)

5. The organization monitors and reports all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990.

6. The organization has written procedures to follow when medical equipment fails, including using emergency clinical interventions and backup equipment.

7. For organizations that provide the technical component of advanced diagnostic imaging and elect to use The Joint Commission CMS imaging supplier accreditation option: The organization identifies activities and frequencies to maintain the reliability, clarity, and accuracy of the technical quality of diagnostic images produced. (See also EC.02.04.03, EP 15)

 

Standard EC.02.04.03

The organization inspects, tests, and maintains medical equipment.

Elements of Performance for EC.02.04.03

1. Before initial use of medical equipment on the medical equipment inventory, the organization performs safety, operational, and functional checks. (See also EC.02.04.01, EP 2)

2. The organization inspects, tests, and maintains all life-support equipment. These activities are documented. (See also EC.02.04.01, EP’s 3 and 4)

3. The organization inspects, tests, and maintains non-life support equipment identified on the medical equipment inventory. These activities are documented. (See also EC.02.04.01, EP’s 3-4)

4. The organization conducts performance testing of and maintains all sterilizers. These activities are documented. (See also IC.02.02.01, EP 2)

5. The organization performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented.

15. For organizations that provide the technical component of advanced diagnostic imaging and elect to use the Joint Commission CMS imaging supplier accreditation option: The organization maintains reliability, clarity and accuracy of the technical quality of diagnostic images produced. (See also EC.02.04.01, EP 7)

17. For organization in California that provide computed tomography (CT) services: A qualified medical physicist measures the actual radiation dose produced by each diagnostic CT imaging system at least annually and verifies that the radiation dose displayed on the system for standard adult brain, adult abdomen, and pediatric brain protocols is within 20 percent of the actual amount of radiation dose delivered. The dates of these verifications are documented.

Notes: This element of performance is applicable only for systems capable of calculating and displaying radiation doses.

18. For ambulatory surgical centers that elect to use The Joint Commission deemed status option: Emergency equipment is maintained by qualified staff.