Two workers inspect medical scanning equipment

Building Your AEM Program

By Ernest Oates and Jeffery Niederhausen

One of the biggest things we have been hearing about in our industry centers around the Alternate Equipment Maintenance (AEM) program. For many facilities, this program can be a struggle to build. Trying to figure out where to start is even worse. In our program, we have tackled this head on and have made great strides to complete the task of creating an AEM program that is effective.

The first step in this process is making sure there is a good understanding of what is allowed under an AEM program. Although there’s been a handful of articles written, the best source document is CMS’ S&C:14-07-Hospital. This document states, “Under certain circumstances, it also may be consistent with the regulatory requirements for a hospital to use maintenance activities or frequency of facility or medical equipment which may not be the same as those recommended by the manufacturer.” It goes on to give some exceptions for types of equipment that can be placed in an AEM program and some factors that should be addressed in the course of the AEM risk assessment.

The second step in creating an AEM program is coming up with an AEM eligibility risk assessment that is easy to understand and can be applied to any and all of the hospitals you currently serve. One way is to use a method similar to the way biomed currently calculates the risk associated with a piece of medical equipment (High Risk or Non-High Risk). The five scoring criteria are:

  1. equipment function
  2. potential risk due to a device failure (extent of harm)
  3. current maintenance requirements
  4. the maintenance history of the device (including a look at any past patient incidents involving that equipment)
  5. the use/environment of the medical equipment.

The first factor: equipment function, requires an additional risk assessment to determine if the equipment is used for life support, is High Risk/Non-High Risk, or if it’s a non-patient care device. It’s something to think about if you need to apply an additional risk assessment for the equipment that aligns more closely to The Joint Commission’s SAFER Matrix.

From that you can develop a “Severity x Probability” risk assessment. For the probability component, you could use a calculation of the Mean Time Between Failure (MTBF) for each device type. It is important to define what types of corrective maintenance would go into that calculation as the MTBF would also be used as part of the annual assessment of the program’s effectiveness. Consider removing any work orders related to device recalls, incoming inspections, and configuration changes as those work orders don’t give an accurate depiction of an equipment failure. Once you have the MTBF for each device type, definitions can be created for what counts as probable, occasional, remote and improbable for the risk scoring process. An unexpected benefit of performing an additional risk assessment will be to validate if your device risk scoring process was accurate or not.

Once a risk assessment has been applied to all the device types, we created four categories that the equipment fit into, based on their AEM risk assessment score. The categories ranged from adherence to manufacturers’ recommended activities and frequencies, to no preventive maintenance being performed at all (run to fail). Knowing there will be special circumstances you may not be aware of within a particular facility, the updated medical equipment inventories that now list the addition of AEM categories should be reviewed by each director (for programs that cover multiple facilities) for review, and allow them the opportunity to exclude individual assets from the AEM program.

The final step in creating an AEM program is coming up with a way to assess its effectiveness. One way is to use the MTBF to be your litmus test for whether or not a change in the preventive maintenance program resulted in a decrease in that equipment’s reliability. We calculated the standard deviation to show the variance in MTBF year-over-year for a device type, and if a given year’s MTBF falls outside the baseline MTBF (plus/minus the standard deviation), then a risk assessment would be performed to determine whether it’s acceptable to leave that device type in the AEM program. The biggest indicator for that risk assessment is determining whether or not the corrective repair would have been prevented if the OEM’s preventive maintenance recommendations would have been performed.

The biggest difficulty in creating a company-wide AEM program could be the lack of a standard in the community. One way to resolve this is to reach out to other organizations that have begun planning for an AEM program, and use them as a sounding board for the ideas you may have about your program. There are a few articles written by Stephen Grimes that can help shape your AEM risk assessment process.

Another difficulty you might face is getting the needed changes made to your CMMS software. There could be limitations in what is possible and some challenges in getting the changes made within the time frame for implementing the program.

It is expected that one of your difficulties to implementing this program could be pushback from the leadership within the hospitals you serve. If you are going to work on building this program, it is important to have open communication with hospital leadership. Be open with them about what is going to happen and how certain types of equipment will be serviced. Explaining to leadership how the program works, and having them understand how the program will allow you to put more focus on equipment with a higher associated risk and improve the turnaround time for corrective repairs should help get the support you are looking for from leadership.

Ernest Oates is a Director of Biomedical Engineering at Tech Knowledge Associates, and was formerly a Director at the Children’s Hospital of Orange County.

Jeffery Niederhausen is the Chief Financial Officer of Tech Knowledge Associates, a clinical technology management provider that was formed to bring unique value to its clients by guaranteeing savings, capping their expenses and protecting them from catastrophic failures.

For more information, contact TKA at info@ii-techknow.com or visit ii-techknow.com.