Action plan for utility inventory and maintenance compliance

The following potential action plan may be a useful starting point for those hospitals that do not yet have a handle on the required inventory and alternative equipment management (AEM) changes. Initial compliance activities include the following steps:

• Obtain the American Society for Healthcare Engineering (ASHE) 2009 book, Maintenance Management for Health Care Facilities (a Centers for Medicare & Medicaid Services-approved, generally accepted standard of practice).
• Update the utility management plan to reflect new inventory and high-level AEM requirements.
• Prioritize inventory expansion to all equipment.
• Use the ASHE book to establish an inventory-expansion approach.
• Apply the critical/high-risk category to both existing and new inventory items.
• Create an AEM policy/procedure.
• Determine whether to consider AEM for critical/high-risk components.
• Set up an AEM risk assessment protocol and process.

Based on the utility management plan updates, facilities professionals should obtain the manufacturer’s inspection, testing and maintenance (ITM) recommendations (both activities and frequencies) for all equipment; and expand inventory to reflect new requirements and make full use of the ASHE book’s inventory approaches. Previously required inventories should not be reduced.

Finally, based on the new AEM policy, facilities professionals should obtain records on qualifications; follow manufacturer-recommended ITM practices where mandated; compare existing ITM processes with the manufacturer’s recommendations; do AEM risk assessments where AEM is desired; identify where AEM is being used for ITM; decide whether to split ITM into separate maintenance management system subcategories because sometimes inspection and testing are mandated by codes and standards, whereas maintenance is not; justify ITM choices; review the use of test equipment and calibration; monitor AEM program effectiveness; examine environment of care/safety committee reports; conduct an annual report on AEM effectiveness; conduct additional training of maintainers; discuss the policy with contractors/service companies; and test compliance with tracer-like tests.