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Summary of Joint Commission Genset Testing Requirements

The Joint Commission is a not-for-profit organization that evaluates healthcare organizations and programs in the United States. To promote safe and effective care, it issues standards that are used to audit and accredit healthcare practices and facilities.

To obtain and maintain accreditation, the Joint Commission and its authorized agents audit hospitals against its guidance, including guidance for the management and testing of backup power systems. Poor audit performance, including audits of power testing records, can lead to loss of accreditation. Payors may require accreditation as a condition of payment for patient services. This is one reason why it is important to perform the necessary testing and document its results.

Organization of Joint Commission Standards

The Joint Commission’s Hospital Accreditation Standards set forth criteria for the management and testing of emergency power systems together with an underlying rationale. Each criterium is followed by Elements of Performance that can be audited to demonstrate compliance with that criterium, which must be done to obtain or maintain Joint Commission accreditation. Many Elements of Performance direct users to requirements outlined in the NFPA standards for additional information. Actions required to comply with Joint Commission standards are similar to those required to comply with the NFPA standards.

For example, criteria affecting backup power systems are presented in the second section of the Standards, entitled Environment of Care. There, Standard EC.02.05.07 states, “The hospital inspects, tests, and maintains emergency power systems.” Thereafter, a paragraph describing the rationale for this standard is presented, which states that power disruptions could leave a hospital unable to deliver safe care and services and thus should be tested regularly to detect problems and reduce risks. The Standard then describes Elements of Performance that can provide evidence as to whether a criterium is satisfied, such as whether testing has been conducted at the specified frequencies and amounts of load.

Elements of Performance for Genset Testing

The primary Elements of Performance for backup power system testing are found in EC.02.05.07. The relevant provisions are summarized as follows.
Notably, EC 02.05.07 EP 6 specifies that testing is conducted using dynamic load, such as building loads, which could change from moment to moment. If at any time the amount of load drops below the stated minimums during a 30-minute interval, the test is noncompliant. In that event, EC 02.05.07 EP 6 further states the genset(s) must be retested annually using supplemental or dynamic loads equaling 50% of the nameplate rating for 30 minutes plus another 60 minutes at 75% load, for a total of 1½ continuous hours. Here, the supplemental loading requirement can be met using a load bank(s). In some instances, using load banks can provide compliant testing without the potential disruption of transferring building load to backup power. For more information, see the ASCO Power Technologies document entitled Load Banks for Hospitals and Healthcare Facilities.

Within the Hospital Accreditation Standards, each of the above criteria references specific provisions of other standards issued by the National Fire Protection Association, specifically NFPA 99 - Health Care Facilities Code and NFPA 110 - Standard for Emergency and Standby Power Systems. For more information about the NFPA codes and their applicability, review the ASCO Power Technologies document entitled Testing Hospital Backup Power Sources.

Summary

The Elements of Performance in The Joint Commission Hospital Accreditation Standards detail the types of backup power tests that must be evident to obtain or maintain hospital accreditation. The seven elements described herein specify actions that require weekly, monthly, annual, or triennial execution. Each of the requirements refers back to specific provisions of NFPA documents, which can be reviewed for supporting detail. Where supplemental loads are needed to achieve compliance, load banks can be used to achieve minimum loading levels and streamline testing processes. For additional information, contact an ASCO Power Technologies representative.

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