TechNation | Tech Knowledge: Building Your AEM Program

By Ernest Oates and Jeff Niederhausen

One of the biggest things we have been hearing about in our industry centers around the Alternate Equipment Maintenance (AEM) program. For many facilities, this program can be a struggle to build. Trying to figure out where to start is even worse. In our program, we have tackled this head on and have made great strides to complete the task of creating an AEM program that is effective.


The first step in this process is making sure there is a good understanding of what is allowed under an AEM program. Although there’s been a handful of articles written, the best source document is CMS’ S&C:14-07-Hospital. This document states, “Under certain circumstances, it also may be consistent with the regulatory requirements for a hospital to use maintenance activities or frequency of facility or medical equipment which may not be the same as those recommended by the manufacturer.” It goes on to give some exceptions for types of equipment that can be placed in an AEM program and some factors that should be addressed in the course of the AEM risk assessment.

The second step in creating an AEM program is coming up with an AEM eligibility risk assessment that is easy to understand and can be applied to any and all of the hospitals you currently serve. One way is to use a method similar to the way biomed currently calculates the risk associated with a piece of medical equipment (High Risk or Non-High Risk). The five scoring criteria are:

  1. equipment function
  2. potential risk due to a device failure (extent of harm)
  3. current maintenance requirements
  4. the maintenance history of the device (including a look at any past patient incidents involving that equipment)
  5. the use/environment of the medical equipment.

The first factor: equipment function, requires an additional risk assessment to determine if the equipment is used for life support, is High Risk/Non-High Risk, or if it’s a non-patient care device. It’s something to think about if you need to apply an additional risk assessment for the equipment that aligns more closely to The Joint Commission’s SAFER Matrix.

From that you can develop a “Severity x Probability” risk assessment. For the probability component, you could use a calculation of the Mean Time Between Failure (MTBF) for each device type. It is important to define what types of corrective maintenance would go into that calculation as the MTBF would also be used as part of the annual assessment of the program’s effectiveness. Consider removing any work orders related to device recalls, incoming inspections, and configuration changes as those work orders don’t give an accurate depiction of an equipment failure. Once you have the MTBF for each device type, definitions can be created for what counts as probable, occasional, remote and improbable for the risk scoring process. An unexpected benefit of performing an additional risk assessment will be to validate if your device risk scoring process was accurate or not.  More…