what does ep4 stand for in joint commission regulation to hospital medical records
On March 31, 2014, the Joint Commission added a new element of functioning (EP 24) to the master medical equipment standard EC.02.04.03 for "deemed condition" hospitals. This requirement was intended to become into issue on July 1, 2014.1 This additional requirement was in response to the Centers for Medicare and Medicaid Services (CMS) memo dated December twenty, 2013 (S&C 14-07-Hospitals), which had relaxed some of the restrictive policies on preventive maintenance of medical equipment.2-4 The term deemed condition is described in a previous CCE prep article.4
According to the Articulation Committee, however, the CMS was of the opinion that this additional EP did non bring the Joint Commission standards in line with the CMS requirements for accounted status hospitals. Consequently, the Joint Committee has expanded and added EPs in the two main Articulation Commission standards EC.02.04.01 and EC.02.04.03. The previously approved EC.02.04.03, EP 24, has been removed. These updated requirements went into effect on July 2, 2014.5
EC.02.04.01 EP 1
This EP is unchanged. Information technology requires the hospital to seek input from individuals who operate equipment (clinicians and nurses) and those who service equipment (biomedical/clinical engineering) when the hospital chooses and purchases medical equipment.6
EC.02.04.01 EP 2
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Key Articulation Committee Definitions
Medical equipment: "Fixed and portable equipment used for the diagnosis, treatment, monitoring, and direct intendance of individuals."
High-chance equipment: "Whatever device or components of edifice utility systems for which there is a risk of serious injury or death to a patient or staff member if the device or component fails. High-hazard equipment includes life-support equipment."
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This EP was inverse. It formerly required the hospital to maintain either a written inventory of all medical equipment or a written inventory of selected equipment which would be classified by physical risk associated with its use and equipment incident history. This requirement was retained for the hospitals that do not use Joint Commission accreditation for "deemed condition" purposes.
However, "deemed status" hospitals must now include all medical equipment in their inventory. This new dominion will crave these hospitals to reassess their current medical equipment inventory based on the definitions of the term medical equipment, which can be constitute in the glossary of the Articulation Commission standards.5,6 (Run into box for a summary of the definitions.)
EC.02.04.01 EP 3
This is a new EP. Information technology requires the hospital to identify "loftier-risk" medical equipment in the inventory. This category of equipment includes items for which there is a risk of serious injury or decease to a patient or staff if the equipment fails. The high-take chances medical equipment encompasses life-support equipment, including items such as a robotic surgical arrangement. The term loftier-take chances is new to Joint Commission medical equipment standards and is considered comparable to the CMS term critical equipment. The term high-take chances is defined in the glossary of the Joint Commission standards.5,6
EC.02.04.01 EP four
This new, revised EP combines the concepts of maintenance activities and frequencies of the earlier EP 3 and EP 4. Information technology now requires the hospital to place the activities and associated frequencies, in writing, for maintaining, inspecting, and testing all medical equipment in the inventory.
In order to determine the frequencies of maintenance and testing, hospitals must follow manufacturers' recommendations or develop strategies of an alternative equipment maintenance (AEM) program. This AEM program must not reduce the safety of equipment, and must be based on accepted standards of practice. For medical equipment, suggested accustomed standards are the American National Standards Establish/Association for the Advancement of Medical Instrumentation handbook, ANSI/AAMI EQ56: 2013, Recommended Practice for a Medical Equipment Direction Programme.five,6
EC.02.04.01, EP 5
This is a new EP for "accounted condition" hospitals. It requires the hospital to use manufacturer'south recommendations for maintenance activities and frequencies for the post-obit types of equipment:
- Medical laser devices;
- Imaging and radiologic equipment (whether used for diagnostic or therapeutic purposes);
- Medical equipment that is field of study to federal or state law or Medicare Weather of Participation. It should exist tested and maintained according to manufacturer'due south recommendations or an arroyo that establishes more stringent maintenance requirements;
- New medical equipment that usually does not have adequate maintenance history to support the use of AEM strategies. The maintenance history must include records provided past the infirmary's contractors, information fabricated public past nationally recognized sources, and records of the hospital'due south experience over time.five,6
The adjacent CCE Prep cavalcade will discuss other changes to the Articulation Commission medical equipment standards.
Review Questions
(Answers at end of article)
1. The following chemical element of operation (EP), which requires the hospital to solicit input from individuals who apply and service equipment when information technology chooses and purchases medical equipment, was not role of the recent revision of the Articulation Commission medical equipment standards.
a) EC.02.04.01 EP i
b) EC.02.04.01 EP 2
c) EC.02.04.01 EP 3
d) EC.02.04.01 EP iv
2. The Joint Commission defines "medical equipment" as ________.
a) Fixed and portable equipment used for the diagnosis, treatment, and monitoring of individuals
b) Fixed and portable equipment used for the diagnosis, treatment, and straight care of individuals
c) Stock-still and portable equipment used for the diagnosis, handling, monitoring, and direct care of individuals
d) Fixed and portable equipment used for the treatment, monitoring, and direct care of individuals
3. The Joint Commission defines "high-gamble" equipment as _________.
a) Any device for which there is a take a chance of serious injury or death to a patient or staff member if the device fails
b)Any device for which there is a risk of serious injury to a patient or staff fellow member if the device fails
c) Any device for which there is a adventure of death to a patient or staff fellow member if the device fails
d) Any device for which at that place is a take chances of serious injury or decease to a patient if the device fails
4. Co-ordinate to the Joint Commission, the accepted standard for medical equipment is _______.
a) NFPA 99, 2015 Edition
b) ANSI/AAMI EQ56: 2013
c) NFPA 70, 2014 Edition
d) January 1, 2015
5. Co-ordinate to the Articulation Commission "high-risk" equipment includes _____.
a) life-support equipment
b) non-life support equipment
c) all devices that are included in the Preventive Maintenance programme
d) none of the to a higher place
Arif Subhan, MS, CCE, FACCE, is the chief biomedical engineer at VA Greater Los Angeles Healthcare System and a member of 24×7's editorial informational lath. The suggestions and views expressed in this article are of the author. They do not correspond the views of the Section of Veterans Diplomacy. For more information, contact jbethune@allied360.com.
References
1. Revised Requirements for the Surroundings of Care (EC) Chapter. Available at: http://www.jointcommission.org/assets/1/18/EC_PrepubReport_HAPandCAH_July2014release_20140304.pdf. Accessed Oct xi, 2014.
2. Biomeds Cheer CMS Change of Mind on Maintenance, December 27, 2013. Bachelor at: https://24x7mag.com/2013/12/biomeds-cheer-cms-change-of-mind-on-maintenance/. Accessed October 11, 2014.
3. Hospital Equipment Maintenance Requirements, CMS Memo dated December twenty, 2013. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-07.pdf. Accessed October 11, 2014.
4. Subhan A. New Articulation Commission requirement for medical equipment. 24×vii. 2014;nineteen(5):26.
5. Joint Commission. EC News. 2014;17(9).
6. 2014 Joint Committee Comprehensive Accreditation Transmission. Available at: http://www.jcrinc.com/2014-comprehensive-accreditation-manuals. Accessed Oct 17, 2014.
Answers:
one—A; 2—C; 3—A; iv—B; 5—A
Source: https://24x7mag.com/standards/regulations/joint-commission-regulations/revised-joint-commission-standards-medical-equipment/