The sterile supply and equipment spaces in our ambulatory surgery center (ASC) currently are experiencing growing pains due to our success. We do not have enough space for the extra sterile supplies or equipment we acquired in the last two years. Therefore, we are looking into extra space in our office building for storing equipment, extra custom packs, and medical supplies. This space will be dedicated for storage and will not be in the ASC footprint; therefore, it mainly will be a warehouse area. Do any concerns exist for keeping product off site?

As long as the organization meets the design requirements of the local authority and maintains the proper ventilation requirements for sterile storage, they will be considered compliant.

What is required to be presented regarding X-ray equipment during a TJC survey?

Typically, on day one of the survey, the surveyor will provide a list documents for review. Be sure to respond exactly as requested. Your medical equipment management plan, equipment inventory, and maintenance history records should always be ready for review. Because most records are now electronic, be sure that more than one person can run all your management reports. You want to avoid a citation for lack of documentation due to one person being unavailable.

For several reasons, alternative equipment maintenance (AEM) is not being accepted at our facility to the extent that it should. For example, legal said “no way” because they are hesitant to depart from manufacturers' recommendations. This is not a valid or quantifiable reason. Some third-party companies see AEM as revenue reduction. What are your suggestions for changing this?

A successful AEM program requires acceptance and “buy-in” from your key stakeholders. A data-driven proposal, including a risk assessment based on your historical services records or from another credible source, may help to support your argument. Your AEM strategy must not reduce safety and must be based on accepted practice standards. Your challenge is to prove this to key stakeholders with a defensible program.

Why do TJC surveyors not follow the tracer methodology when end users report to a surveyor that “a device is broken and healthcare technology management (HTM) hasn't fixed it”? We have had several surveys where TJC surveyors are told a device is “broken” and that “it has been broken for a long time”; however, no surveyor has taken down the HTM control number for the device and either requested the repair history records or gone to the HTM department to ask questions specific to the repair of that device (e.g., Was a work request submitted? Was a work order created? What was the resolution?). Usually, the report is returned to leadership with a “finding” noted and a description along the lines of “the infusion pump in inpatient was reported as broken and not being repaired,” with no reference as to which one of the hundreds of portable infusion pumps was allegedly at issue. This prohibits HTM staff from appropriately researching and responding to the alleged problems and/or providing documentation regarding the allegation that the device is not being maintained/repaired.

The tracer methodology is the process used during the on-site survey to analyze an organization's systems or processes for delivering safe, high-quality care by following an individual patient or resident through the organization's care process in the sequence experienced by each individual. Feedback received from staff is recorded as an observation of finding. Depending on the severity of the comment, the surveyor may or may not choose to investigate further. During the course of a survey, organizations may address the circumstances surrounding the discovery of an item that is out for repair.

In this department, The Joint Commission (TJC) answers questions posed by AAMI members. Become part of the discussion by visiting and joining AAMI's Joint Commission Discussion Group, which is open to all AAMI members. Some of the questions and answers may have been edited for space, style, and clarity.