Healthcare Preventive Maintenance: The Key to Safety & Uptime

In the world of healthcare, equipment failure isn’t just a budget line item — it is a clinical crisis. When a ventilator fails or a sterile processing unit goes offline, patient safety is immediately compromised. 

Enter healthcare preventive maintenance, a proactive strategy to service medical and facility assets before they fail. Read our guide on how to use preventive maintenance to stay ahead of issues to ensure 100 percent regulatory compliance and uninterrupted patient care.

Why Healthcare Preventive Maintenance Is a Clinical Necessity

Preventive maintenance (PM) in a hospital setting differs significantly from standard industrial maintenance. While a factory might tolerate a few hours of downtime, a healthcare facility cannot. That’s why implementing a robust PM schedule offers several critical advantages:

• Enhanced patient safety: Regular inspections reduce the risk of mid-procedure equipment malfunctions.
• Strict regulatory compliance: Hospitals must meet rigorous standards set by The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) to maintain funding and accreditation.
• Financial stewardship: Maintaining high-value assets like MRI machines and CT scanners extends their equipment lifespan and prevents costly emergency repairs.
• Increased team efficiency: Clear work orders allow maintenance technicians to move through the facility with purpose rather than “putting out fires.”

The Hierarchy of Healthcare Maintenance Strategies

To stay compliant, healthcare maintenance managers must navigate three distinct types of maintenance protocols:

1. Regulatory-based maintenance: These are non-negotiable tasks required by law or safety codes, such as testing fire dampers, exit signs and backup generators.
2. Manufacturer-recommended maintenance: These tasks follow the “instructions for use” (IFU) provided by the original equipment manufacturer (OEM) to ensure the warranty remains valid and the machine operates within spec.
3. Risk-based maintenance: A risk-based maintenance strategy involves prioritizing assets based on the severity of the impact of their failure. For example, a life-support system receives higher priority than a broken television in a waiting room.

Critical Inventory: Equipment Requiring Constant Oversight

A comprehensive asset inventory management system is the foundation of a successful PM program. In a healthcare environment, your inventory typically falls into these three buckets:

1. Diagnostic Imaging (MRI, CT, X-Ray)

These high-value assets require high-precision maintenance to avoid image artifacts and ensure radiation safety. Example preventive maintenance measures include:

• Daily: Perform calibration checks using a “phantom” to ensure image accuracy and correct radiation dosage. Disinfect patient contact points and controls.
• Weekly: Conduct functional tests for smooth mechanical movement of gantry arms and patient tables.
• Monthly: Inspect high-tension cables and connectors for corrosion or fraying. Clean filters and verify cooling fans are operational to prevent overheating.
• Annual: Schedule a professional deep-service to replace wear items like X-ray tubes, detectors and bulbs.

2. Life Support (Ventilators & Anesthesia Machines)

Because these are “vital” assets, maintenance focuses on the integrity of the gas delivery and battery backup systems. Example preventive maintenance tasks include:

• Per-Use/Daily: Perform a high/low-pressure leak test and calibrate the oxygen monitor. Verify backup manual ventilation equipment (Ambu bags) is present and functional.
• Monthly: Inspect and clean flow sensors and unidirectional valves.
• Quarterly: Test the “Battery Mode” functionality by unplugging the unit to ensure it can sustain power during a failure.
• Annual: Replace internal batteries and sensors regardless of their current state to avoid “metered” failure.

3. Facility Infrastructure (HVAC, Generators, Medical Gas)

This category is the “backbone” of the hospital, directly impacting infection control and operational continuity. Here are a few preventive maintenance examples for these assets:

• HVAC: Change HEPA filters monthly in high-risk areas like ORs or isolation rooms to maintain air quality and pressure. Clean coils and lubricate fan motors quarterly to ensure efficiency.
• Emergency generators: Perform a weekly visual check of fuel and coolant levels. Conduct a monthly “load test” per NFPA 110 standards to ensure the transfer switch functions during a power outage.
• Medical gas: Conduct monthly leak testing on gas manifold systems and verify that alarm panels are operational.

Navigating the Regulatory Landscape

Hospitals face unique pressure from organizations like The Joint Commission and the Centers for Medicare & Medicaid Services (CMS). These bodies require “audit-ready” documentation at all times.

Creating an alternate equipment maintenance (AEM) program is one of the most effective ways to optimize resources, but it is also one of the most heavily scrutinized areas during a CMS audit. Under CMS Regulation 42 CFR 482.41(c), hospitals are generally expected to follow manufacturer recommendations unless they can prove a different approach is safer or more efficient.

The CMS “Golden Rules” for Maintenance Flexibility

According to CMS Memo S&C 14-07-Hospital, you can deviate from OEM suggestions for activities and frequencies, provided you adhere to these strict guardrails:

• Ineligible equipment: You cannot use an AEM for imaging/radiologic equipment, medical lasers or any equipment where federal or state law specifically mandates OEM adherence.
• Maintenance history required: You cannot place “new” equipment on an AEM. You must follow OEM guidelines until you have built a sufficient internal maintenance history to justify a change.
• Qualified decision makers: The decision to move an asset to an AEM must be made by “qualified personnel” — typically a clinical engineer or an experienced maintenance manager with documented expertise.
• The “Safety Shield”: Any AEM strategy must not reduce the safety of the equipment and must be based on accepted standards like ANSI/AAMI EQ103.

Step-by-Step: Creating a Compliant AEM Program

If the OEM suggestions are inefficient — for example, a manufacturer suggests a monthly check on a device that has never failed in five years — you can create an AEM using this framework:

1. Conduct a Formal Risk Assessment

You must document why the asset is a candidate for AEM. CMS surveyors look for “Critical Equipment” (also known as high-risk), which includes any device where failure could cause serious injury or death.

• Evaluate: Severity of harm, likelihood of failure and the clinical setting.
• Document: If a device is used in an ICU, it might be ineligible for AEM, while the same device in a standard clinic might qualify.

2. Define the Alternate Strategy

An AEM isn’t just “doing less.” It can involve:

• Altered frequencies: Moving a quarterly check to semi-annually.
• Altered activities: Focusing on battery health instead of mechanical casing if history shows the battery is the only common failure point.
• Predictive maintenance: Using sensors to monitor equipment health in real-time rather than following a calendar.

3. Maintain “Audit-Ready” Documentation

This is where many facilities fail. Your AEM program must be in writing and include:

• A clear standard operating procedure (SOP) for each AEM task.
• The rationale for the deviation from the OEM.
• A unique ID number, manufacturer, model and serial number for every asset in the program.
• A record of all equipment failures to determine if the AEM strategy was the cause.

If your maintenance planner cannot produce an SOP or a completed preventive maintenance schedule during a surprise inspection, the facility risks heavy fines or loss of accreditation. Using a CMMS ensures that every service entry is timestamped and documented for accountability.

How Coast Streamlines Healthcare Compliance

Managing these moving parts manually is a recipe for disaster. Coast provides a centralized preventive maintenance software solution that turns your maintenance goals into automated workflows. Here are just a few features that help those in the healthcare sector:

• Standardized checklists: Attach specific SOPs to every work order so maintenance technicians know exactly what to inspect.
• Mobile-first access: Technicians can update work order management tasks on their phones while standing next to the equipment, improving data accuracy.
• Real-time communication: If a technician finds a safety hazard, they can use built-in messaging to alert the maintenance manager immediately.
• Automated PM triggers: Never miss a regulatory deadline with notifications that alert your team weeks before a task is due.

In the healthcare sector, the goal of maintenance is simple: zero unplanned downtime. By focusing on equipment maintenance and leveraging preventive maintenance software, your facility can move from a reactive “break-fix” mentality to a world-class reliability program.

Ready to modernize your healthcare maintenance? Sign up for a free account of Coast today to start building your preventive maintenance schedule.