Acme Medical Center WAN Project Part I

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Acme Medical Center Classification of Medical Equipment

ACME MEDICAL CENTER

POLICIES AND PROCEDURES

Facilities Administration

Classification of Medical Equipment

Policy

All equipment used in the hospital is to be evaluated by Facilities and included in the

Hospital Equipment Management Program.

Purpose

� To provide a procedure for the inspection of all electrical and mechanical

equipment brought into the hospital

� To ensure that all electrical and mechanical equipment is cataloged and

added to the hospital’s asset inventory

� To assess all risks associated with the use of a particular piece of equipment and

to design and implement training and maintenance protocols based upon the

equipment’s risks

� To comply with all local, state and national regulations and accreditations

Procedure

1. Hospital Equipment Management Program

a. The Hospital Equipment Management Program shall be administered by

the Director of Plant Operations with assistance as may be required, from

time to time, by all other departments of the Acme Medical Center.

b. Each hospital department shall be responsible for the costs of

procurement, training and maintenance of all electrical and mechanical

equipment within its scope of control.

c. Records of equipment procurement, training and maintenance will be

maintained by the Hospital Equipment Management Program.

2. Receipt of Equipment

a. The Director of Plant Operations or his designee is to be notified of all

planned acquisitions of new electrical or mechanical equipment.

b. If possible, all deliveries of equipment for the Hospital should be at the

Hospital’s main loading dock. In the event that a particular piece of

equipment must be delivered and/or installed at another location within

the hospital, the Director of Plant Operations is to be notified in advance

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Acme Medical Center Classification of Medical Equipment

of the delivery installation and the Director of Plant Operations or his

designee is to be in attendance at the delivery installation.

c. Upon the receipt of a new piece of equipment, the Director of Plant

Operations or his designee shall do the following:

i. Coordinate with the department purchasing or leasing the

equipment to ensure that the correct equipment has been

received and that all ordered equipment has been received.

ii. Ensure that the equipment is in proper working order.

iii. Record the equipment’s description, make, model number and

serial number.

iv. Affix an Acme Medical Center asset identification tag to the

equipment.

v. Provide the Chief Financial Officer with a record of the asset

identification tag number and the equipment’s identifying

information. A separate copy of this information is also to be

maintained by the Director of Plant Operations.

vi. Coordinate with the department purchasing or leasing the

equipment and the office of the Chief Financial Officer to file any

necessary documents in order to comply with the requirements of

any applicable warranties or guarantees associated with the

equipment.

vii. Coordinate with the department purchasing or leasing the

equipment to file any necessary documents in order to comply with

the requirements of any local, state or national regulatory bodies

and/or any accrediting bodies that provide accreditation to Acme

Medical Center.

viii. Acquire at least two (2) copies of all training, maintenance and

user’s materials that are provided by the manufacturer and/or

seller of the equipment.

1. One (1) copy of the materials will be maintained by the

hospital department that is purchasing or leasing the

equipment.

2. One (1) copy of the materials will be maintained in a central

library by the Director of Plant Operations or his designee.

ix. Classify the equipment for inclusion in the Hospital Equipment

Management Program.

3. Equipment Classification

a. All electrical or mechanical equipment owned or leased by the Hospital

or any of its departments shall be classified into one of the categories

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Acme Medical Center Classification of Medical Equipment

utilized by the Hospital Equipment Management Program and

summarized by the table appended to this document.

b. The hospital’s equipment classifications will be reviewed every three years

by the Director of Plant Operations, the Chief Operations Officer or his

designee, the Chief Financial Officer or his designee and the Chief

Compliance Officer or his designee.

4. Training

a. The Director of Plant Operations shall be responsible for providing training

to hospital employees on the use of hospital equipment. Each hospital

department will coordinate with the Director of Plant Operations to ensure

that all of the department’s employees receive the training required

pursuant to this policy.

b. The Director of Plant Operations shall maintain records of the training

received by all hospital personnel. A copy of such training records shall

also be maintained by the employee’s hospital department.

c. When a new employee begins working for a hospital department, the

department director or his designee shall determine what equipment the

employee will need to operate as part of their job duties and present that

information, along with the employee’s identifying information, to the

Director of Plant Operations. This procedure is also to be followed in the

event that an existing hospital employee transfers to a new department

within the hospital.

d. Class A Equipment:

i. No employee shall operate any item of Class A equipment until

they have completed a training course on the operation of the

equipment and been certified by the Director of Plant Operations

as qualified to operate the equipment.

ii. Each department shall ensure that on any floor where it has Class A

equipment, there shall always be at least one person on duty on

the floor who has been certified by the Director of Plant Operations

to operate the equipment.

iii. Employees who operate Class A equipment must be recertified by

the Director of Plant Operations annually.

e. Class B Equipment:

i. No employee shall operate any item of Class B equipment until

they have completed a training course on the operation of the

equipment and been certified by the Director of Plant Operations

as qualified to operate the equipment.

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Acme Medical Center Classification of Medical Equipment

ii. Each department shall ensure that on any floor where it has Class B

equipment, there shall always be at least one person on duty on

the floor who has been certified by the Director of Plant Operations

to operate the equipment.

iii. Employees who operate Class B equipment must be recertified by

the Director of Plant Operations on the operation of a particular

type of Class B equipment any time the equipment is replaced with

new or different equipment and the model of the equipment or the

manufacturer of the type of equipment changes.

f. Class C Equipment:

i. Each department shall ensure that, as part of a new employee’s

orientation, the employee receives training in the use of all Class C

equipment the employee is expected to use in performance of

their job duties.

ii. Each department shall be responsible for providing training to its

employees when new Class C equipment is obtained.

5. Maintenance

a. Maintenance records for all hospital equipment shall be maintained by

the Director of Plant Operations.

b. Requests for equipment maintenance or repairs shall be directed to the

Director of Plant Operations. The Director of Plant Operations shall

determine whether required maintenance or repairs are to be performed

by hospital personnel or by outside contractors.

c. The Director of Plant Operations shall manage the maintenance and

repair of hospital equipment so as to minimize costs and maintain

equipment guarantees and warranties in force.

d. Class A Equipment:

i. Class A equipment shall be maintained and repaired only by

persons that have been certified by the manufacturer of the

equipment as qualified to perform said maintenance or repairs.

ii. All items of Class A equipment shall be inspected annually to

ensure that the equipment is in good condition and to perform any

maintenance suggested by the equipment’s manufacturer.

e. Class B Equipment:

i. Class B equipment shall be maintained and repaired only by

persons that have been certified by the manufacturer of the

equipment as qualified to perform said maintenance or repairs.

ii. Items of Class B equipment that had an acquisition cost in excess of

$10,000 or which are being leased, but have a replacement value

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Acme Medical Center Classification of Medical Equipment

in excess of $10,000, shall be inspected annually to ensure that the

equipment is in good condition and to perform any maintenance

suggested by the equipment’s manufacturer.

iii. The Director of Plant Operations shall make a list, updated

annually, of all other items of Class B equipment. In January of

each year, the Director of Plant Operations shall use such list to

take a statistical sampling of 10% of the items and schedule them

for inspection and maintenance during the year.

f. Class C Equipment:

i. Items of Class C equipment that had an acquisition cost in excess

of $10,000 or which are being leased, but have a replacement

value in excess of $10,000, shall be inspected annually to ensure

that the equipment is in good condition and to perform any

maintenance suggested by the equipment’s manufacturer.

ii. The Director of Plant Operations shall make a list, updated

annually, of all other items of Class C equipment. In January of

each year, the Director of Plant Operations shall use such list to

take a statistical sampling of 5% of the items and schedule them for

inspection and maintenance during the year.

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Acme Medical Center Classification of Medical Equipment

CATEGORY DESCRIPTION

A Life support / Life safety equipment and

systems

Equipment that delivers substantial

energy or radiation to persons such as radiation machines used in oncology treatment or defibrillators

Oxygen delivery systems

Fire control equipment

Emergency communication and lighting equipment

Invasive surgical equipment

B X-ray equipment

Dialysis equipment

Equipment for regulating and maintaining oxygen or pressure environments such as incubators or

hyperbolic chambers

Patient monitoring equipment

Drug delivery systems

Noninvasive surgical equipment

Invasive diagnostic equipment

Laser equipment

Motorized patient transportation

equipment

Patient care computer equipment

C

Non-patient care computer equipment

Office equipment

Copiers

Fans

Noninvasive diagnostic equipment

Laboratory equipment

Non-motorized patient transportation equipment

Televisions

Telephones / paging system

Hospital beds

Rehabilitation equipment

All other equipment not classified above

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