2/20/01

MEDICAL EQUIPMENT MANAGEMENT PLAN

I            PURPOSE 

The purpose of the Medical Equipment Management Plan is to provide a programmatic framework to reduce the risk to the New York State Psychiatric Institute.  The plan includes processes that are designed to evaluate risks that may adversely affect the life of health of patients, staff, and visitors. 

The New York State Psychiatric Institute is committed to providing a safe, secure, and therapeutic environment at its main facility and off-facility program sites for all patients, staff and visitors.  The medical equipment program is designed to support safe, effective patient care by providing reliable information that allows facility management and staff to make better medical equipment decisions and to evaluate key issues and opportunities for improvement of medical equipment performance. 

Consistent with this mission, The New York State Psychiatric Institute has established and provides ongoing support for the medical equipment program described in this plan. 

II            SCOPE 

The New York State Psychiatric Institute has an Environment of Care Committee (EOCC) consisting of a cross representation of the facility’s staff.  The EOCC monitors training and competence of staff and assesses conditions of physical plant, grounds, and equipment through building inspections, environmental rounds, medical equipment inspections, and various performance improvement initiatives.  Through review of reliable information, management is able to make the best decisions regarding medical equipment concerns and to evaluate equipment performance related to key issues with opportunities for improvement.  The EOCC monitors and evaluates all medical equipment areas.  It takes actions and makes recommendations to the facility leadership, including the Executive Director, who is a member of the Governing Body.  The EOCC may issue assignments to committee members and non-committee staff for follow-up actions/improvements and completing of reports.

III             FUNDAMENTALS

A.        The medical equipment management program addresses equipment used in the treatment of patients, including diagnosis, care, and monitoring.

B.         Selection of new and replacement medical equipment and technology is researched and reviewed.

C.        Medical equipment operators are expected to possess and develop an understanding of medical equipment limitations, safe operating conditions, safe work practices, and emergency clinical interventions during equipment failures

D.        Medical equipment users of the following types of equipment are required to demonstrate competency prior to use and at least annually: glucometers, defibrillators, suction machines, pulse oximeters.

E.         The medical equipment management program establishes processes for managing those aspects of medical equipment that have a potential to harm patients of staff and negatively affect the reputation of the facility.

IV            GOALS

A.                Comply with accepted standards of medical equipment safety.

B.                 Provide a safe, secure, and therapeutic environment for patients, staff, and visitors.

C.                Integrate medical equipment management into daily operations.

D.                Identify opportunities to improve performance.

V            ORGANIZATION AND RESPONSIBILITY

A.        The Executive Director receives reports on activities of the medical equipment program from the EOCC.  The Executive Director reviews reports and, as appropriate, communicates medical equipment related concerns about identified issues and regulatory compliance.

B.         The Executive Director reviews reports and is, as necessary, communicates concerns about key issues and regulatory compliance to appropriate departments, services, and staff.  The administration collaborates with appropriate departments, services, and staff to establish operating and capital budgets for the medical equipment program.

C.        The Clinical Director has overall responsibility for identification of medical equipment management program deficiencies, development of plans for improvement, accident and injury prevention and investigation, and emergency response.  Training of staff and volunteers is facilitated by the responsible department.

D.        The Executive Director or designee authorizes key staff to take immediate and appropriate action in the event of an emergency.  An emergency is a situation that poses a threat to life, personal injury, or damage to property.

E.             Department, program and site managers are responsible for orienting new staff members to the department/programs and to job-specific medical equipment procedures.  Specific training needs and expertise can be requested by the department /program/site mangers in concert with the Education and Training Department.

F.            Individual staff members are responsible for learning and following job and task specific procedures for safe operations.  Individual staff members are also responsible for learning and using reporting procedures.

VI        PROCESSES OF THE MEDICAL EQUIPMENT MANAGEMENT PROGRAM

A.                Selection and Acquisition

Each department, program and site manager is responsible for the request of equipment based on need.  Criteria used may include for example:  performance, recall history, training and maintenance requirements, Central office requirement, availability for funding, frequency of repair history, and utility availability.  The Clinical Director or designee is responsible for the approval of the purchase. 

B.                 Criteria and inventory 

Medical equipment is included in the medical equipment program inventory based on criteria established by Clinical Director or designee and approved by EOCC.  Criteria for inclusion in the program may include the equipment function (diagnosis, care, treatment, monitoring), physical risks associated with use, maintenance requirements, and equipment incident history.  The Clinical Director maintains an inventory of medical equipment. 

C.                Inspection, Testing and Maintenance 

The Clinical Director has overall responsibility for the inspection, testing, and maintenance of the equipment in the medical equipment program.  The equipment maintenance schedule is assessed to minimize risks and is based on recommendations of the Clinical Director with the approval of the EOCC.  All medical equipment included in the program is inspected before initial use and at least annually thereafter. 

An outside contractor (R-Wave Company, tel. 516-218-8888) is used for inspection, testing, and maintenance of selected medical equipment. 

D.                Hazard Notices and Recalls 

The Risk Manager is responsible for managing the medical equipment hazard notice and recall process. 

Medical equipment safety alerts, product recall notices, and hazard notices are received and are routed to the Clinical Director. 

When conditions warrant, equipment is removed and replaced. 

The Clinical Director reports to the EOCC on any equipment notices or recalls. 

E.         Safe Medical Devices Act. (SMDA)   

The Chairman of the EOCC and the Clinical Director are responsible for managing the Safe Medical Devices Act reporting process.  If a sentinel event is involved using a piece of medical equipment the EOCC will receive a summary report of the SDMA notification and summary information of the event. 

F.                 Reporting and investigating 

The medical equipment management program uses a variety of reporting methods to document activities.  The Chairman of the EOCC and Clinical Director share responsibilities for managing, reporting and investigating. 

Medical equipment management problems, failures, and user errors are reported to the Clinical Director or designee. 

Reports of staff, patient and visitor medical equipment incidents/accidents are made using the appropriate report forms.  This information is reviewed by appropriate committees such as Incident Review, EOCC, Risk Management, and Infection Control. This information is reviewed by the EOCC through the ICES. 

One of the goals of the reporting process is for the responsible manager to receive facility incident and accident reports as soon as practical after an occurrence.  This goal is intended to allow appropriate and timely reporting and follow-up activities as needed. 

G.                Orientation and Education   

The facility Education and Training Department has overall responsibility for organizing the orientation and education program for each of the seven functions associated with Management of the Environment of Care.  Department, program, and site managers are responsible for assuring the medical equipment management program orientation and education is implemented. 

Every new staff member participates in a general orientation program.  The facility Education and Training Department is responsible for conducting the general orientation program with current information on general safety processes to new staff members as soon as possible, but within 30 days of employment.  The Education and Training Department records attendance for each new staff member who completes the general orientation program.  Attendance records are maintained in the Education and Training Department.  

Staff members also receive department-specific orientation to the department to which they are assigned.  Each department, program, and site manager is responsible for providing their new staff members with department-specific orientation to the medical equipment management program.  The goal of the department orientation program is to teach staff members about their department, and if indicated to provide new staff members with current medical equipment program information including area of job specific medical equipment issues and hazards specific to the department. 

H.                Performance Improvement Monitoring  

The EOCC Chairperson through the EOCC has overall responsibility for coordinating the ongoing performance monitoring and the performance improvement monitoring for each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson and the Clinical Director are responsible for all monitoring associated with the medical equipment management program.  

The intent of establishing performance monitoring is to improve the medical equipment management program through objective measures of demonstrated performance.  Performance improvement is an important aspect of the Medical Equipment Management Plan.  Ongoing performance monitoring serves as an indicator of continued effectiveness of the medical equipment management program and is a mechanism to identify performance improvement opportunities.

I.                   Emergency Procedures    

The EMSS Coordinator, Director of Nursing, and the Clinical Director have overall responsibility for coordinating activities related to establishing and maintaining emergency procedures for the medical equipment repair service.  

Emergency procedures contain specific procedures in the event of a medical equipment failure, clinical interventions, backup equipment, and how to obtain medical equipment repair service. 

The emergency medical equipment procedures are reviewed by the EOCC and approved by the Medical Staff Organization. 

J.                   Annual Evaluation   

The EOCC Chairperson has overall responsibility for coordinating the annual evaluation of each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson and Clinical Director are responsible for completing the annual evaluation of the medical equipment management program.  An evaluation of Medical Equipment Plan objectives, scope, performance, and effectiveness is included in each annual evaluation.  

In the completion of the annual evaluation, the EOCC Chairperson and the  Clinical Director utilize a variety of source documents such as policy review and evaluation, incident report summaries, risk assessment activities, meeting minutes, and statistical information summaries.  In addition, other relevant sources of information are used for the annual evaluation, such as results of monitoring studies, reports from accrediting and certification agencies, and goals and objectives.  The annual evaluation of the medical equipment management program is used to further develop educational programs, policies, and performance monitoring and performance improvement.   

The annual evaluation is reviewed and approved by the EOCC.  The annual evaluation is then presented to the Medical Staff Executive Committee, the Executive Director, and the Governing Body.  Approved minutes or other means of communications are received and reviewed from the Governing Body by the EOCC and recommendations are acted upon.

Page Updated 02/23/01