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HTM ModelDoc 1

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(This document was last revised on 7-13-18)

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Policy number:
Effective date:
Document title: Alternate Equipment Management (AEM) Program

Scope: The hospital maintains an Alternate Equipment Management (AEM) Program that is consistent with the requirements contained in the memorandum titled “Hospital Equipment Maintenance Requirements” (Ref S&C: 14-07-Hospital) that was distributed to State Survey Agency Directors by the Director of the Survey and Certification Group of the Centers of Medicare & Medicaid Services (CMS) on December 20, 2013.

Policy: All equipment included in the facility’s medical equipment management program will be subjected to the maintenance activities recommended by the equipment manufacturer unless it is identified for inclusion in the facility’s AEM program. Determination of which devices are included in the AEM program is made by the Environment of Care Committee following the conclusions of a risk assessment conducted by qualified personnel based on information derived from the facility’s own equipment maintenance records and from information made public by nationally recognized sources.

As a minimum, the following devices will be subjected to the maintenance activities recommended by the equipment manufacturer.

  • Equipment subject to Federal or state law or hospital Conditions of Participation (CoPs) in which inspecting, testing, and maintaining must be in accordance with the manufacturer’s recommendations, or otherwise establishes more stringent requirements. For example, all imaging/radiologic equipment must be maintained per manufacturer’s recommendations; or
  • The equipment is a medical laser device; or
  • Imaging and radiological equipment (whether used for diagnostic or therapeutic purposes); or
  • New medical equipment without a sufficient amount of maintenance history to support the use of alternative maintenance strategies.

Selection of devices included in the AEM program: With the exception of devices that are specifically excluded by the current CMS regulation (see preceding section above), all device types other than those listed in Table 4 of the Healthcare Technology Management Community's database website (http://htmcommunitydb.org/wiki/index.php?title=Main_Page ) as having a PM Failure Severity Level (column 5) of A = Highest combined LOS through D = Moderate-Lowest combined LOS are considered to be eligible for inclusion in the program. These are device types that meet the criterion that they do not create the possibility of causing serious injury or death to a patient or staff member if they should fail.

Assurance about the levels of safety of the patients and medical staff: As explained in Section 16.8 of HTM ComDoc 16., maintaining the selected devices using the selected strategies will not result in a greater level of risk to patients or staff. (We will have to monitor Table 5 to confirm that the PM-related reliability documented at longer PM intervals - or in RTF mode - is no greater than it is at the manufacturer-recommended interval)

Periodic evaluation of the AEM Program: The AEM Program will be evaluated at 12-month intervals for scope, performance and effectiveness. Any changes in the scope of the program will be addressed in the annual update, and any changes deemed necessary following the review will be incorporated into the plan. This information will be reported to the governing body through the routine reporting channels.


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