Policies & Procedures

Facilities Administration

PATTON - FULLER COMMUNITY HOSPITAL POLICIES & 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
    1. 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 Patton-Fuller Community Hospital.
    2. 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.
    3. Records of equipment procurement, training and maintenance will be maintained by the Hospital Equipment Management Program.
  2. Receipt of Equipment
    1. The Director of Plant Operations or his designee is to be notified of all planned acquisitions of new electrical or mechanical equipment.
    2. 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 of the delivery/installation and the Director of Plant Operations or his designee is to be in attendance at the delivery/installation.
    3. Upon the receipt of a new piece of equipment, the Director of Plant Operations or his designee shall do the following:
      • 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.
      • Ensure that the equipment is in proper working order.
      • Record the equipment�s description, make, model number and serial number.
      • Affix a Patton-Fuller Community Hospital asset identification tag to the equipment.
      • 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.
      • 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.
      • 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 Patton-Fuller Community Hospital.
      • 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.
        • One (1) copy of the materials will be maintained by the hospital department that is purchasing or leasing the equipment.
        • One (1) copy of the materials will be maintained in a central library by the Director of Plant Operations or his designee.
      • Classify the equipment for inclusion in the Hospital Equipment Management Program.
  3. Equipment Classification
    1. All electrical or mechanical equipment owned or leased by the Hospital or any of its departments shall be classified into one of the categories utilized by the Hospital Equipment Management Program and summarized by the table appended to this document.
    2. 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
    1. 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.
    2. 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.
    3. 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.
    4. Class A Equipment:
      • 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.
      • 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.
      • Employees who operate Class A equipment must be recertified by the Director of Plant Operations annually.
    5. Class B Equipment:
      • 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.
      • 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.
      • 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.
    6. Class C Equipment:
      • 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.
      • Each department shall be responsible for providing training to its employees when new Class C equipment is obtained.
  5. Maintenance
    1. Maintenance records for all hospital equipment shall be maintained by the Director of Plant Operations.
    2. 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.
    3. 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.
    4. Class A Equipment:
      • 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.
      • 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.
    5. Class B Equipment:
      • 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.
      • 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 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.
      • 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.
    6. Class C Equipment:
      • 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.
      • 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.
 
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.
Non-invasive 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
Non-invasive diagnostic equipment.
Laboratory equipment.
Non-motorized patient transportation equipment.
Televisions
Telephones / Paging System
Hospital beds.
Rehabilitation equipment.
All other equipment not classified above.