JCAHO INSPECTION-2004 STANDARDS

I would like to share with other BMET'S the latest method utilized by JCAHO, under the new 04 standards. We were inspected January 7th-9th. I found this inspection quite different in the following ways:

Inspector focused on nursing staff being able to understand our PM sticker system for medium and high risk equipment. We use the "UAL" color coded stickers with due date month in large print. Make sure the nursing staff understands your sticker coding system, if applicable. Inspector also recommended that all stickers be applied to the front of units, when possible. No equipment files were reviewed or mentioned.

Time for Biomed Director discussion was reduced to 30 minutes. (1.5 hour total for Eng., Security, Biomed and Safety Committee review). Much more focus placed on tracing the patient through the entire process. Eleven tracer activities were conducted. Much less time spent on building tour. 1.5 hours now.

Questions asked of me were :
1. Explain what I had done about the new alarm initiative-Inspector was not real picky about this.
2. Identify main thresholds. When were my thresholds established and have they been changed any since established? If so, why? He wants to see these updated routinely.
3. Explain my policy for the "unable to locate" and "equipment in use" PM's.
4. Is the nursing staff notified of PM's not actually done? How?
5. No reference to HIPAA was made.
6. PM completion rate for past 12 months
7. Dates of last two equipment plan evaluations

In summary, the gentleman was very knowledgeable, polite and asked good questions and allowed me time to answer. He spoke mostly about the PM stickers. When doing the building tour they still focus on Defibrillators, and mobile equipment. He asked our chairman of the Safety Committee how the committee interfaces with the Patient Safety Committee.

Overall, my department and the hospital did well. This was one of our best ever inspections. Easier for Biomed, but much more intense for nursing, with fewer Director interviews. The Inspector's name was Wendel Schmitt

by:
Virgil Smoot
Director, Biomedical Services
CHKD, Norfolk, VA.