Understanding the expectations of the Joint Commission (TJC) can be a challenging task.
Understanding the impact of the TJC updates and how they affect your department activities can be even more challenging, but it is possible.
With the new updates, there are critical key changes:
- “Available” devices categorized as high risk and non-high risk, whether adhering manufacturer’s recommendations or on an Alternative Equipment Maintenance Program (AEM) program, must now follow all established maintenance activities and completion rates of 100%. Unable to Locate (UTL) or “In Use” devices do not have to be included in the 100% calculation.
- Although UTL’s and “In-Use” devices do not have to be included in the new rigors of maintenance standards, you must still have a policy that addresses these devices. The UTL policy may include declaring equipment permanently gone and archiving inventory after a reasonable number of missed intervals, but you will need to have a process for attempting to locate and documenting your efforts. The “In Use” policy could include how to educate users on the processes for informing Healthcare Technology Management when the equipment becomes available.
When it comes to the Joint Commission, surveyors are always looking to answer these 3 key questions:
- Do you have procedures in place?
- Did you follow these procedures?
- Did you follow the prescribed frequencies in accordance with your policies?
If you can answer these questions with confidence, you are on the right track. Building a strong foundation of best practices and guidelines can help ease the burden of remaining TJC compliant and consistently hitting those 100% targets.