ROP SELF ASSESSMENT AND ACTION PLAN

ACCREDITATION CANADA
CLIENT SAFETY AREA: Worklife
ROP #4: The organization’s leaders implement an effective preventive maintenance program for medical
devices, equipment, and technology.
VP Champion: Dan Germain Team Members:
Don Caswell, Amandeep Waraich, Eric Card, France Champoux,
Leaders: Kevin Marshall Monica Stanton, Ralph Nicoletti, Jeff Richer, Linda Campeua

Guidelines for Compliance:

An effective preventive maintenance program helps the organization ensure medical devices, equipment, and
technology are in safe and functional order. It also helps identify and address potential problems with medical
devices, equipment, or technology that may result in injury to staff or clients.

Tests for Compliance (per Accreditation Canada):

There is a preventive maintenance (PM) program in place for all medical devices, equipment, and technology.
There are documented PM reports.
The organization’s leaders have a process to evaluate the effectiveness of the organization’s PM program.
There is documented follow-up related to investigating incidents and problems involving medical devices,
equipment, and technology.

ROP Assessment (as of November 2010)

Status of ROP Evidence
Partial Compliance Computerized preventative maintenance systems are in place for all
medical devices equipment and technology. Programs include Angus
Anywhere, Asset Plus and ISIS Pro. Risk Pro is used to document any
failures of all equipment including medical.

Does not meet tests for Partial Meets tests for

compliance compliance compliance

Accreditation Milestone Dates:

 Establish Team, Self Assessment Completed, ROP Draft Action Plan to Accreditation Team: Nov 26th

 V.P. Review of Draft Action Plan: Dec 10th

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 ROP SELF ASSESSMENT AND ACTION PLAN
ACCREDITATION CANADA

ROP Action Plan

WRH Action Plan Timelines MRP Completed

Date:

Nov 10 Review current policies regarding preventative maintenance and March 2011 Kevin
repair of medical equipments. Eric

Nov 10 Draft new policy and procedure to expedite and simplify the March 2011 Monica
repair of medical equipment. Linda C.

Nov 10 Review Risk Monitor Pro’s to evaluate effectiveness of March 2011 Kevin
incidents involving medical devices.

Indicators:
Reduction in number of Risk Monitor Pros related to medical devices.

Monitoring Tools and Instruments:

Records from computer programs listed above.
Documentation of preventive maintenance schedules

VP Review and approval of Action Plans: ___________________________________ Date: ________________

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