POLICY: Medical Equipment Management Plan Policy # SHM /02/14

Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 1 of 10

Medical Equipment Management Plan

I EXECUTIVE SUMMARY

Hospital strives to create a safe, secure and positive healing environment to support the
delivery of exemplary healthcare to all patients, staff and visitors. Each environment of
care poses unique risks to the patients served, the employees and medical staff who use
and manage it, and to others who enter the environment. The medical equipment
management program (MEMP) is designed to identify and manage the risks of the
medical equipment at Hospital. The specific risks of each environment are identified by
conducting and maintaining a proactive risk assessment. The identified risks are tracked
and mitigated through the EAC. The MEMP is based on applicable laws, regulations,
and accreditation standards and is designed to manage the specific risks identified for
medical equipment at Hospital.

The MEMP describes the risk, safety, and management activities that Hospital has put
in place to reduce the potential for adverse impact on the safety and health of patients,
staff, and other people, coming to the organization’s facilities.

This plan includes equipment used for the diagnosis, treatment, monitoring, which
meets the criteria for inventory, within Hospital and its clinics.

II PRINCIPLES

A. Selection of appropriate equipment to support the services of Hospital is an

essential part of assuring that safe effective care and treatment are rendered to
persons receiving services.
B. Orientation, education, and training of operators of medical equipment are
essential parts of assuring that safe effective care and treatment are rendered
to persons receiving services.
C. Assessment of needs for continuing technical support of medical equipment
and design of appropriate calibration, inspection, maintenance, and repair
services is an essential part of assuring that medical equipment is safe and
reliable.

III OBJECTIVES

The purpose of the Medical Equipment Management Plan is to promote quality patient care
services performed within the hospital and its clinics. The director of Biomedical Engineering
will manage and facilitate the program to accomplish the following:
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 2 of 10

A. Promote safe and effective use of Hospital medical equipment by staff and
physicians.
B. Ensure that medical equipment used to care for patients, at the hospital,
performs within accepted medical equipment standards.
C. Ensure medical equipment used within the hospital is maintained within
specifications to ensure its safe operation and readiness for use when needed.
D. Protect patients, visitors, employees and physicians in the use of medical
equipment.

IV PROGRAM MANAGEMENT STRUCTURE

A. The Board of Hospital receives annualy reports of the activities of the MEMP
from the Equipment Audit Committee. The Board reviews the reports and, as
appropriate, communicates concerns about identified issues back to the
Equipment Audit Committee.
B. Biomedical Engineering assures that an appropriate medical equipment
maintenance program is implemented.
C. Biomedical Engineering schedules and/or completes all calibration,
inspection, and maintenance activities required to assure safe reliable
performance of medical equipment in a timely manner.
D. Individual staff members are responsible for being familiar with the risks
inherent in their work and present in their work environment. They are also
responsible for implementing the appropriate organizational, departmental,
and job related procedures and controls required to minimize the potential of
adverse outcomes of care and workplace accidents.

V ELEMENTS OF THE MEDICAL EQUIPMENT PROGRAM

MEP.01 – Medical Equipment Management Plan

The Medical Equipment Management Program is described in this management

plan. The MEMP describes the procedures and controls in place to minimize the
potential harm that any patients, staff, and other people coming to the facilities of
Hospital might experience.

MEP.02 - Selection and Acquisition of Equipment

Biomedical Engineering assists, advises, and/or coordinates ad-hoc advisory

group activities for product selection and standardization. This includes the pre-
purchase evaluation of medical equipment involving nursing, technical and
administrative personnel that helps in choosing safe, effective and serviceable
medical equipment. Training requirements are identified at this time. The
department is responsible for the coordination of all training of their staff.
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 3 of 10

MEP.03 - Criteria and Inventory

The HOD of the Biomedical Engineering department is responsible for the

development of criteria used to identify risks associated with medical equipment.

The criteria are used to evaluate risks related to the function of medical
equipment, physical risks related to the use of equipment, and any history of
patient safety issues related to the use of the equipment.

The HOD of the Biomedical Engineering Department is responsible for assuring

that all medical equipment is screened at the time of commissioning. The
screening procedure is applied, as appropriate, to loaner equipment,
demonstration equipment, and equipment owned by hospital as part of the care or
treatment of a patient in any service of Hospital.

MEP.04 - Maintenance Strategies

The HOD of the Biomedical Technology Services uses manufacturer

recommendations, applicable codes and standards, accreditation requirements,
and local or hospital experience to determine the appropriates maintenance
strategy for assuring safety and maximizing equipment availability and service
life. The strategies may include predictive maintenance, reliability-centered
maintenance, interval-based inspections, corrective maintenance, or metered
maintenance to ensure reliable performance.
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 4 of 10

MEP.05 - Inspection, Calibration, and Maintenance Intervals

1- IINSPECTION AND PREVENTIVE MAINTENANCE (IPM)

2- CORRECTIVE OR BREAK DOWN MAINTENANCE (CM)

01- IPM includes all scheduled activities that ensure equipment

Functionality and prevent breakdowns or failures. Performance and safety
inspections are straightforward procedures that verify proper functionality
and safe use of a device. Preventive maintenance (PM) refers to scheduled
activities performed to extend the life of a device
and prevent failure (i.e. by calibration, part replacement, lubrication,
cleaning, etc). Inspection can be conducted as a stand-alone activity and
in conjunction. with PM to ensure functionality; this is important as PM can be fairly
invasive in that components are removed, cleaned or replaced. PM will be done after
every SIX month of all Equipment.

02- Breakdown Maintenance is a task performed to identify, isolate, and rectify a fault
so that the out of order equipment, machine, or system can be restored to an operational
condition.
All medical equipment in use should be free from any fault or defect and all repair
work should be carried out to accepted standards by competent person(s).

MEP.06 - Emergency Procedures

The Biomedical Technology Services staff and appropriate clinical care givers
collaborate to identify the appropriate amount of back-up equipment during the
evaluation/selection process of choosing the medical equipment. In the event of
a medical equipment failure:

A. The clinical department personnel will take appropriate clinical

intervention until replacement equipment is available or the medical
equipment is repaired.
B. The clinical department will contact Biomedical Technology Services to
see if back-up equipment is available. If equipment is not available,
contact Supply Chain Management for help.
C. The clinical department will contact Biomedical Technology Services at
0321-4049099 for repair of medical equipment.
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 5 of 10

MEP.07 - Equipment Inventory and Initial Testing

Biomedical Technology Services maintains a current, accurate, and separate

inventory of all equipment included in a program of planned inspection or
maintenance. The inventory includes equipment owned by Hospital used for the
diagnosis, treatment, and monitoring of patient care needs.

The HOD of Biomedical Technology Services assures effective implementation

of the program of planned inspection and maintenance. All equipment in the
program is tested for safety, operation and function prior to use on patients.

MEP.08 - Testing of Life Support Equipment & Non-Life Support

Equipment

The HOD of Biomedical Technology Services assures that scheduled testing of

all life support equipment & non-life support equipment is performed in a
timely manner. Reports of the completion rate of scheduled inspection and
maintenance are presented to the Equipment

MEDICAL EQUIPMENT MAINTENANCE:

POLICY:

Will provide broad logical framework of decision to be taken for

guiding certain actions that are useful in prolonging the active life of
equipment so that the equipment provides accurate results in diagnosing,
monitoring and treating our IPs, staff & beneficiaries. The equipment may
be useful for medical education and research.

MISSION OF THE POLICY:

 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 6 of 10

To maintain all medical equipments to the appropriate standards as

prescribed by equipment manufacturer, so as to ensure that all medical
equipments to be used to provide the best health care services to patients should
be safe, efficient, effective, reliable and long lasting.

OBJECTIVES OF THE POLICY:

This Policy is intended for the maintenance of medical equipment that

ensures:

a. Maximum availability and reliability of equipments

b. Minimum downtime and Maximum Uptime
c. Maximum return on investment
d. Prevention of wastage of consumables and spares
e. Extended useful life of equipments
f. Readiness of the equipment for emergency use whenever required

MAINTENANCE PLAN OF THE EQUIPMENT:

Proper maintenance of medical equipment is essential to obtain sustained

benefits and to preserve capital investment. Medical equipment must be
maintained in working order and periodically calibrated for effectiveness and
accuracy of the results.

The Maintenance consists of:

3- INSPECTION AND PREVENTIVE MAINTENANCE (IPM)

4- CORRECTIVE OR BREAK DOWN MAINTENANCE (CM)

 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 7 of 10

01- IPM includes all scheduled activities that ensure equipment

Functionality and prevent breakdowns or failures. Performance and safety inspections are
straightforward procedures that verify proper functionality and safe use of a device.
Preventive maintenance (PM) refers to scheduled activities performed to extend the life
of a device
and prevent failure (i.e. by calibration, part replacement, lubrication, cleaning, etc).
Inspection can be conducted as a stand-alone activity and in conjunction. with PM to
ensure functionality; this is important as PM can be fairly invasive in that components are
removed, cleaned or replaced. And finally write down in Log Books and Tag equipment.

The Biomedical Department uses manufacturer recommendations, risk levels, and

hospital experience to determine the appropriate maintenance intervals for assuring safety
and maximizing equipment availability and service life.

A computerized maintenance management system is used to schedule and track timely

completion of scheduled maintenance and service activities.

The Biomedical Department is responsible for assuring that the rate of timely completion
of scheduled maintenance and other service activities meets regulatory and accreditation
requirements.

The Biomedical Department assures that scheduled testing of all life support equipment
& non-life support equipment is performed in a timely manner. Reports of the completion
rate of scheduled inspection and maintenance are presented to the Equipment

02- Breakdown Maintenance is a task performed to identify, isolate, and rectify a

fault so that the out of order equipment, machine, or system can be restored to an
operational condition.
All medical equipment in use should be free from any fault or defect and all repair
work should be carried out to accepted standards by competent person(s).

The Biomedical Department staff and appropriate clinical care givers

collaborate to identify the appropriate amount of back-up equipment during the
evaluation/selection process of choosing the medical equipment. In the event of
a medical equipment failure:

A. The clinical department personnel will take appropriate clinical

intervention until replacement equipment is available or the medical
equipment is repaired.
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 8 of 10

B. The clinical department will contact Biomedical Technology Services to

see if back-up equipment is available. If equipment is not available,
contact Supply Chain Management for help.
The clinical department will contact Biomedical Technology Services at 0321-
4049099 for repair of medical equipment.Services staff and appropriate clinical
care givers collaborate to identify the appropriate amount of back-up equipment
during the evaluation/selection process of choosing the medical equipment. In
the event of a medical equipment failure:

A. The clinical department personnel will take appropriate clinical

intervention until replacement equipment is available or the medical
equipment is repaired.
B. The clinical department will contact Biomedical Technology Services to
see if back-up equipment is available. If equipment is not available,
contact Supply Chain Management for help.
The clinical department will contact Biomedical Technology Services at 0321-4049099
for repair of medical equipment.

Equipment Audit:

Equipment audit is a periodic evaluation system to measure the quality of

performance of the medical equipments.
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 9 of 10

At any given point of time, a substantial number of equipment in the hospital may be
non-functional. The reasons for the same could be:

1. Want of Minor repairs

2. Lack of Preventive Maintenance
3. Lack of corrective Maintenance
4. Lack of essential Spares
5. Electrical Faults
6. Unfavorable environmental conditions
7. Mishandling of equipment by untrained and unskilled manpower
8. Purchase of equipment without justifiable demand etc.
9. False Reporting, Willful Damage and Overuse than rated

Equipment Audit Committee:

Health Facility Incharge

User HOD

HOD Bio- Medical Workshop

Nursing Matron

Focus of the Audit is to:

1. Check the current status of the medical equipment

2. Analysis of the records such as Breakdown Register, Preventive maintenance Register
3. Questioning the user about the usage and performance of the equipment.
4. Suggesting measures to optimally utilize the equipment for quality health services.

Advantages of the equipment audit are to:

● Evaluate the performance and utilization of the equipment

● Provide an objective method for planning of equipment procurement in future
● Analyze various inadequacies (including downtime) in the utilization of an equipment
and recommendation of remedial measures (including training to the users) so as to
 POLICY: Medical Equipment Management Plan Policy # SHM /02/14
Department: Bio-Medical
Subject Category: The Joint Commission – Equipment Audit Committee
Policy Manual:
Effective date: 01-06-14 Revised date: Review date:
Approved by: CCO Page 10 of 10

maximize the efficiency and effectiveness of the equipment.