Seattle Cancer Care Alliance

Environment of Care Management Plan

Title: Medical Equipment Management Plan

Manager:Pam Gregory

MISSION:

SCCA’s Purpose

  • Provide state-of-the-art, patient and family centered care.
  • Support the conduct of cancer clinical research and education.
  • Enhance access to improved cancer interventions and advance the standard of cancer care, regionally and beyond.

SCCA’s Vision

To lead the world in translating scientific discovery into the prevention, diagnosis, treatment and cure of cancer.

SCOPE

The Medical EquipmentManagement Plan establishes the parameters within which a safe environment of care is established, maintained and improved for all licensed SCCA sites of practice except UWMC. Responsibilities include:

  1. Managing medical equipment risks.
  2. Inspecting, testing and maintaining medical equipment.

The hospital maintains the quality of the diagnostic computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), and nuclear medicine (NM) images produced. SCCA has quality control procedures in place and maintenance activities to maintain the quality of the diagnostic CT, PET, MRI and NM images produced. Documentation is maintained within each modality.

OBJECTIVE

The objective of this Medical Equipment Management Plan is to provide a safeenvironment and manage the risks associated with medical equipment. The plan identifies SCCA’spolicies, procedures and methodology as it applies to Medical Equipment. The first duty of SCCA is to ensure patient, employee and staff safety at all times. This management plan has been established to ensure all patient related medical equipment regardless of ownership is monitored and kept in optimal operational status.

AUTHORITY

The Chief Financial Officer appoints the Director of Facilities and Patient Access as the Environment of Care (EOC) Committee Chair.The EOC Chair appoints the Assoc. Director Materials Management and Purchasing as the Medical Equipment Plan Manager. This individual is responsible for Medical Equipment Management Plan oversight and implementation.

DEFINITIONS

Medical Equipment: Equipment intended for use in treatment, diagnosis, monitoring and life sustaining or resuscitating functions. Examples are: patient monitors, infusion devices, patient diagnostic equipment and beds.

High-Risk: This equipment category includes all life-support devices, key resuscitation devices, and other devices whose failure or misuse is reasonably likely to result in serious injury to patients or staff. Any device that has been associated with serious injury in the past (either repeatedly or by nature of its design, but not simply because of an isolated incident) should be included unless a modified device design has greatly reduced the risk. Many of the items in this category are therapeutic equipment capable of delivering substantial energy.

Asset Management System: Mainspring, an asset management and work order System, a software program used by the Materials Management Department to track existing equipment inventory, new equipment, loaner equipment, service equipment, demonstration and research relatedequipment. The system is used to generate reports on preventative maintenance schedules and status, recall / hazard events, trends and equipment obsolescence. The System also tracks equipment inspections, testing and maintenance.

Procedure

  1. Managing Medical Equipment Risks when Selecting and Acquiring Medical Equipment
  2. All requests for new types of Medical Equipment are initiated by the staff that operate the equipment and are approved by the department Managers/Directors and/or Senior Leadership.
  3. Orientation, training and monitoring of staff knowledge and participation in the use of Medical Equipment is the responsibility of each department manager.
  4. Inspecting, Testing and Maintaining Medical Equipment
  5. SCCA maintains a written inventory of all Medical Equipment, using the Asset Management System.
  6. SCCA identifies High-Risk Medical Equipment on the inventory, using the Asset Management System.
  7. Medical Equipment on the inventory will be monitored, inventoried and identified by physical risk associated with use, using the Asset Management System., as noted by risk score.
  8. SCCA documents activities and associated frequencies, in writing, for maintaining, inspecting, and testing all Medical Equipment on the inventory, using the Asset Management System.
  9. The activities and associated preventative maintenance frequencies are in accordance with manufacturer’s recommendations and documented with in the Asset Management System.SCCA currently does not have any alternative equipment maintenance programs in place.
  10. The Medical Equipment Coordinator is responsible for documenting in writing, the inspection, maintenance, performance and safety testing of all Medical Equipment.
  11. Before initial use and after major repairs or upgrades atSCCA licensed sites of practice (except UWMC), all Medical Equipment covered by this policy will be inspected whereupon sufficient safety, operational and functional checks will be performed and documented within the Asset Management Systemto ensure that said equipment is safe for its intended use.
  12. Scheduled maintenance for High-Risk equipment is monitored and reported separately from Non High-Risk equipment. The goal for scheduled maintenance on this type of equipment is 100% completed on time. Scheduled maintenance for all other Medical Equipment is monitored and reported separately from High-Risk equipment. The goal for scheduled maintenance on Non-High-Risk equipment is better than 95% completed on time when averaged over the previous 12 months.
  13. SCCA conducts performance testing of sterilizers. Performance testing is performed and documented by sterile processing staff. Scheduled maintenance is performed on all sterilizers and documented within the Asset Management System. Compliance is monitored monthly by the Sterilization Supervisor and Medical Equipment Coordinator and reported quarterly to the EOC Committee.
  14. Qualified diagnostic medical physicist complete a performance evaluation, inspect, test, and calibrate all CT, PET, MRI, Xray, Mammography, Fluoroscopy, Nuclear Medicine and Ultrasound equipment annually. The evaluation results, along with recommendations for correcting any problems identified, are documentedwithin the Asset Management System.
  1. Hazards, Recalls & Incidents
  2. Any incident in which a medical device is suspected or attributed to the death, serious injury or serious illness of any individual that relates to existing covered equipment is to be reported to the Medical Equipment Coordinator for inclusion into the Asset Management System including notifications as required by the Safe Medical Devices Act of 1990. Additional notification should be made to the Director of Risk Management, 206-288-1056 see policy, Medical Device Related Incident/Accident Reporting and management. In addition, any SCCA, or Medical Staff member who is aware of an unsafe condition or event involving a patient or visitor, shall report the event or unsafe condition in Patient Safety Net (PSN) on the day of the event occurring (if at all possible) – see Event and Near Miss Reporting in Patient Safety Net (PSN)
  3. The Medical EquipmentCoordinator reviews weekly postings of ECRI medical devices alerts against the current inventory of Medical Equipment and, if necessary, take appropriate action to quarantine, remove from service, or other as specified, any equipment identified therein.
  1. Equipment Failure
  2. When Medical Equipment fails, staff use emergency clinical intervention (if necessary), remove/disconnect patient from equipment (if necessary), unplug equipment from power source (if necessary), remove equipment to a safe location (if necessary), and callthe Medical Equipment Coordinatorat 206-288-6722 to repair equipment.
  3. Staff consult Medical Equipment Coordinator for availability of backup equipment.
  1. Regulatory
  2. SCCA has formally elected to use the Categorical Waiver for Power Strips Use in Patient Care Areas. SCCA will conform to the requirements identified for the categorical waiver elected.
  3. The receptacles are permanently attached to the equipment assembly.
  4. The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles.
  5. The ampacity of the flexible cord is suitable in accordance with the current edition of NFPA 70, National Electric Code.
  6. The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.

RISK ASSESSMENTS

SCCA proactively performs risk assessments to evaluate the impact of proposed changes to new or existing areas of the organization. The goal of performing risk assessments is to reduce the likelihood of future incidents or other negative experiences that have the potential to result in injury, accident, or other loss to patients, employees, or hospital assets.

The Medical EquipmentManagement Plan specifically uses the following sources to identify risks:

  1. Medical Equipment Coordinator monthly audits
  2. Patient Safety Net reports
  3. Annual staff knowledge assessment report findings
  4. Bi-annual environmental tour findings
  5. ECRI Recalls and Hazard Alerts

PERFORMANCE MONITORING

The EOC Committee Chair oversees the performance measurement and improvement process for allfunctions associated with the management of the environment of care. The Assoc. Director Materials Management and Purchasing is responsible for preparing quarterly reports which include ongoing measurement of performance, a summary of the hazards and problems identified during audits, and summary reports of incident trends and patterns. TheAssoc. Director Materials Management and Purchasing establishes performance indicators to objectively measure the effectiveness of the Medical Equipment Management Plan. Performance indicatorshavebeen established to measure at least one important aspect of the Medical EquipmentPlan. The current performance indicators are:

  1. Number and type of hazard alerts and recalls identified during the quarter.
  2. Number and type of equipment fault counts or repairsidentified during the quarter.
  3. 100% on time scheduled maintenance for all High-Risk equipment.
  4. 95% or better on time scheduled maintenance for all other types of Medical Equipment, when averaged over the previous 12 months.
  5. Number and type of Medical Equipment and medical supply PSN’s reported during the quarter.
  6. Monthly monitoring results
  7. Sterilization equipment maintenance results
  8. Sterilization monitoring results
  9. Humidity monitoring results

2017 Goals

  1. Implement wireless medical equipment inventory system-iTrackkit
  2. Manufacturer recommendations documentation included in Asset Management system
  3. Upgrade Nurse Call System
  4. Implement Care Boards throughout the clinic

REFERENCES/SOURCES OF INFORMATION

  1. Safe Clinical Alarm Management
  2. Event and Near Miss Reporting Patient Safety Net (PSN)
  3. Cleaning Disinfection andSterilization Patient Care Equipment
  4. Product Recall and Product Warnings
  5. The 2016 Joint Commission Hospital Standards
  6. Safe Medical Device Act

ATTACHMENTS

Process Improvement 2016

APPROVAL

Director: / Kristie Logan / Approval Date:
(this version) / 11/14/2016
Process Owner: / Pam Gregory / Next Review Due: / 11/09/2016
Revision/Review Dates: / 11/09/2015, 11/12/14, 12/10/13,12/10/12,12/12/11,1/10/11,12/30/09,12/30/08,11/19/07, 01/24/07, 11/30/06, 11/14/05, 02/04/04, 12/15/03, 12/31/02, 10/01/01
Original Approval Date: / 10/01/01

This version reviewed and approved by specialty committee or specialty individual:

Reviewer / Date Reviewed
EOC Committee / 05/09/2016

Annual Review of 2016 Management Plan

ANNUAL EVALUATION

The Assoc. Director Materials Management and Purchasing has overall responsibility for coordinating the annual evaluation process in which the scope, objectives, performance, and effectiveness of the Medical Equipment Management Plan are reviewed.

The annual evaluation is presented to the EOC Committee by the end of the first quarter of each calendar year. The EOC Committee reviews and approves the report and the deliberations, actions, and recommendations of the committee are documented in the minutes. Strengths are noted and deficiencies are evaluated to set goals for next year. This finalizes the evaluation process.

2016GOALS (Medical Equipment Management Plan) and STATUS

  1. Complete-Consolidate sterilization duties to the Materials Management Department 100%, Radiation Oncology final step
  2. Complete-AED addition in outlying buildings and training or staff.

Management Plan: First Aid Kit Management Plan

2016 Process Improvement Title: First Aid Kits

Identify:

 What risk was identified and how?

  • During the 2016 CAP Inspection, a deficiency was noted: first aid kits contained expired items and the first aid kits were not appropriately stocked.
  • We found that certain items in the first aid kit are not identified as expiring by their outside packaging.
  • First aid kit locations were not all properly documented throughout SCCA.
  • Departments were not following the procedure of calling the number listed on the box once an item is used or missing.
  • Inventory was not properly completed by Materials Management staff.
  • Process for inventorying the kits was not properly documented by Inventory Control Manager.

 What process improvement was identified to respond this risk?

  • First understand current requirements, obtained a copy of the WAC laws regarding first aid kit items.
  • Set up a maintainable process for inventorying and auditing first aid kits. Which includes a properly documenting the process.
  • Ensure expiring items are clearly labeled with large expiration date on outside of package.
  • Complete an accurate first aid kit location inventory.

Implement:

 What steps were taken in order to manage this risk?

  • MM completed an inventory in each room and building to identify the locations of all first aid kits.
  • MM pulled all expired items and restocked the kits as they were identified.
  • MM digitized a map of each floor, illustrating locations and presented to the Pam Gregory for review.
  • Pam Gregory presented to EOC, suggested standardizing kit placement which included removal of some existing kits.
  • Security and Materials Management met to discuss how Security might help monitoring the first aid kits.
  • Security will audit bi-annually and Materials Management (MM) will inventory bi-annually

 Who was responsible for the steps listed above?

  • Daniel Miller
  • Jarrod Blaesing
  • Pam Gregory

Evaluate:

 What method(s) of data collection were used to track the process improvement and assess effectiveness?

  • Documenting all first aid kit locations
  • Security bi-annual audit.
  • Inventory Control clerks bi-annual inventory.
  • Monthly audits performed by the Inventory manager.

Communicate:

How did you communicate or train staff on this process improvement?

  • Meet with staff to discuss new process, roles and expectations.
  • Email sent to all staff outlining the new procedure, roles and expectations.
  • New procedure written and available to staff as reference.
  • Leadership presentation.

Improve:

How will you continue to monitor the risk over time?

  • Inventory Control Manager will complete random audits of first aid kits monthly to ensure kits are inventoried appropriately.
  • Security will alert MM when if they find expired items or items missing.
  • Inventory staff will audit their floor’s kits bi-annually to ensure outdates have been removed and the kits are stocked to par.
  • Report to EOC once a year as part of a PDCA

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