The Joint Commission evaluates and accredits nearly 17,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care. Since 1951, JCAHO has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks.

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JCAHO Year 2003

Standard EC.1.6
The hospital plans for managing medical equipment.

Intent of EC.1.6
The hospital identifies how it will establish and maintain an equipment management program to promote the safe and effective use of equipment. Equipment planning includes identifying processes for

1. selecting and acquiring equipment;
2. establishing risk criteria for identifying, evaluating, and taking inventory of equipment to be included in the management program before the equipment is used. These criteria address
   1. equipment function (diagnosis, care, treatment, and monitoring),
   2. physical risks associated with use, and
   3. equipment incident history;

   Note: All equipment may be included in the program rather than a limited selection based on risk criteria.

3. monitoring and acting on equipment hazard notices and recalls;
4. monitoring and reporting incidents in which a medical device is connected to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990; and
5. reporting and investigating equipment management problems, failures, and user errors.

   In addition, the medical equipment management plan establishes

6. maintenance strategies for all equipment on the inventory;

   Note: The hospital may use different maintenance strategies as appropriate (for example, predictive maintenance, interval-based inspections, corrective maintenance, metered maintenance, and so forth.)

7. intervals for inspecting, testing, and maintaining appropriate equipment on the inventory (that is, those pieces of equipment on the inventory benefiting from scheduled activities to minimize the clinical and physical risks) that are based on criteria such as manufacturers' recommendations, risk levels, and current organization experience;
8. how an annual evaluation of the equipment-management plan's objectives, scope, performance, and effectiveness will occur;
9. an equipment orientation and education program for maintainers of equipment; and
10. emergency procedures that address
    1. specific procedures in the event of equipment disruption or failure,
    2. when and how to perform emergency clinical interventions when medical equipment fails,
    3. availability of backup equipment, and
    4. how to obtain repair services.

    In addition, equipment planning establishes

11. an equipment orientation and education program for users of equipment;
12. ongoing monitoring of performance regarding actual or potential risks related to one or more of the following:
    • Staff knowledge and skills,
    • Level of staff participation,
    • Monitoring and inspection activities,
    • Emergency and incident reporting, and
    • Inspection, preventive maintenance, and testing of equipment.

    A management plan describes all the processes required for equipment management planning.

Examples of Evidence of Performance for EC.1.6

• Staff interviews
• Management plans for the issue(s) addressed in the standard
• Performance improvement standards for the issue(s) addressed in the standard
• Emergency procedures for the issue(s) addressed in the standard