Section:UTILITY SYSTEMSEC.02.05.01 EP2Reviewed Date:

Subject:Policy on Utility SystemsInventory

Approval Date:Page 1 of 4

POLICY

The <Facility Name> maintains either a written inventory of all operating components of the utility systems or an inventory of selected operating components of utility systemsfor conducting maintenance, testing, and inspection activities. All new operating components of utility systems will be evaluated before initial use to determine whether to include this system in the inventory.

INVENTORY

Systems requiring planned maintenance are listed as part of an inventory. The list includes systems maintained by the <Engineering Department> as well as systems maintained by vendors. Utility systems in clinics of the <Facility Name> will be evaluated to for the inventory as well.

The clinical manager and <Engineering Director> will evaluate orientation and training requirements when appropriate. Detailed orientation for operators and <Engineering Staff> will be provided as necessary. The <EngineeringDepartment> evaluates new types of systems before initial use to determine whether to include this system in the inventory

RISK CRITERIA

Written criteria are used to identify risks associated with each operating component of the utility systems. The risks include:

  • Infection
  • Occupants needs
  • Systems critical to patient care
  • All life support systems

The risks identified are used to assist in determining the strategies for maintenance, testing, and inspection of utility systems. In addition, the identified risks are used to guide the development of training and education programs for staff that use or maintain systems.

PROCEDURE

The Engineering Department> maintains either a written inventory of all utility systems or an inventory of selected utility systems. The utility systems, including all life support systems, are categorized by physical risk associated with use and systems incident history. The Risk Factor, determined from the evaluation based on the criteria, will be used to determine the inspection, testing, and maintenance activities.
Based on the Risk Factor Threshold, <Engineering Director> will determine to include or exclude the systems from the inventory. The Risk Factor, along with information from manufacturers and resources, will also be used to determine the frequency of these activities. An initial test is required on all utility systems before initial use on patients.

All new and existing operating components that are part of the utility systems inventory program are assigned a permanent systems identification control number. This identification number will remain with the systems for the duration of the systems use in the facilities. This number will be retired and removed when the component has been replaced. Systems rented or borrowed, such as electrical generator or boiler, will be assigned a temporary unique identifier, which is used while that system is used by the organization.

The identification number will also be the preventive maintenance file number for the hard copy records. All new and existing systems are assigned relevant preventive maintenance task code or codes.

  1. Criteria :

The <Engineering Director> and other managers will evaluate each operating component of the utility system and assign a numerical score in each of five categories

  • Utility Function (Table 1)
  • Physical Risk (Table 2)
  • Maintenance Requirements (Table 3)
  • Incident History (Table 4)
  • Communication (Table 5)

The most appropriate value from each of the attached five tables (Table 15) will be selected and entered into the Risk Summary Score (Table 6), and the Risk Factor (RF) is calculated.

  1. Scoring:

Criteria for determining inclusion on the utility systems inventory will be developed by the Engineering Director>. Information from manufactures recommendations and other authorities on utility systems will be used. The scoring is based on the following:

Utility Function (Table1) / Risk Value
Life Support / 10
Infection Control / 9
Environmental Support / 7
Equipment Support / 5
Communication / 4
Physical Risk (Table 2) / Risk Value
Patient or Staff Death or Serious Injury / 4
Patient or staff injury / 3
Minor Injury / 2
Slight inconvenience / 1
No risk or inconvenience / 0
Maintenance Requirements (Table 3) / Risk Value
Extensive (daily or weekly) / 3
Average (quarterly, semiannual) / 2
Minimal (annual or longer) / 1
Incident History (Table 4) / Risk Value
Extensive Problems – Recent / 3
Some Problem, or Problems in the past / 2
Minimal Problems / 1
Communication (Table 5) / Risk Value
Significant impact / 3
Little or no impact / 1
Risk Summary (Tables 6) / Score
Utility Function Risk Value
Physical Risk Value
Maintenance Requirement Risk Value
Incident History Risk Value
Communication Risk Value
Total Score (Risk Factor)

Each operating component of utility systems will be evaluate by the above criteria and added to the inventory if appropriate. The values for each characteristic are added to arrive at the RF number. Only those devices calculated to have an RF number equal to or greater than <eleven [>11]> are included in the inventory, unless the <Facility Name> has elected to include all components.

Components determined not to be in the inventory will require an initial safety inspection and be released for use. Repairs will be performed as necessary.

The Risk Factor will also be used to determine the inspection, testing, and maintenance activities. The Risk Factor, along with information from manufacturers and resources, will also be used to determine the frequency of these activities. Based on the Risk Factor Threshold, <Engineering Director> will determine to include or exclude the equipment from the inventory.

  1. Including Devices

The <Facility Name> may wish to include all utility systems components in the inventory or exclude some components based on the risk score. System components included in the utility program are assigned an individual control number to which all work orders and preventive maintenance forms are referenced. Preventive maintenance inspections are handled in one of the following ways:

Depending on maintenance requirements and rating, devices will receive a Preventive Maintenance (PM) inspection weekly, monthly, bimonthly, quarterly or annually. The area in which the devices are located schedules virtually all PM’s.

  1. Non-included Devices

Generally, system components determined not to be in the utility management program [RF number less than eleven (<11)] will have this noted in the "other" section of the device record. Control numbers may be assigned to non-included devices for tracking, maintenance history, or other service information when ever appropriate.

E.Leased Systems

Leased systems will be evaluated utilizing the utility systems inventory system and included into the inventory program as appropriate. If the lease includes preventive maintenance and service, the leasing department will inform the <Engineering Director when any maintenance has been performed or the systems is returned. The leasing department will be responsible for administering the manufacturer or leasing agent’s maintenance documentation on site through the term of the lease.

  1. Random Evaluation

Utility systems will be randomly evaluated during periodic Environmental Tours and adverse findings will be reported to biomedical engineering and the Environment of Care® (EC) Committee.

EC.02.05.01 EP2 Policy on Utility Systems Inventory.doc