How accreditation groups address AEM requirements

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Conducting AEM assessments

The Centers for Medicare & Medicaid Services (CMS)-issued Survey & Certification (S&C) Letter S&C:14-07-Hospital (titled “Hospital Equipment Maintenance Requirements”) dated Dec. 12, 2013, includes requirements and state agency survey guidelines.

Most of the accrediting organizations copy the CMS S&C letter AEM inclusion-risk assessments verbatim within their physical environment standards. These requirements appear to apply only to hospitals based on both the title and content of the original CMS S&C letter as well as the content of the related authorities having jurisdiction standards.

However, The Joint Commission paraphrased many of the CMS AEM inclusion risk-assessment requirements. The Joint Commission’s Standard EC.02.05.01, EP-6 first appeared in July 2014 and includes the following:

• “How the equipment is used, including the seriousness and prevalence of harm during normal use”
• “Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm”
• “Availability of alternative or backup equipment in the event the equipment fails or malfunctions”
• “Incident history of identical or similar equipment”
• “Maintenance requirements of the equipment”

The Joint Commission requirements are similar but not identical to the CMS requirements, as illustrated in the table below.

Source: David L. Stymiest