Alternative Equipment Maintenance has been legal since 2014. Standardized guidance did not exist until now.
For a decade, HTM departments built AEM programs from scratch. Some followed AAMI EQ56. Others adapted TJC interpretive guidelines. Many relied on internal risk matrices with no external validation. The result: wide variation in AEM program quality, inconsistent documentation, and uncertain compliance posture during surveys.
ANSI/AAMI EQ103:2024 changes this. Published by AAMI’s Alternate Equipment Management Working Group, the standard establishes minimum requirements for AEM programs in healthcare delivery organizations. It provides the concrete guidance the industry has needed since CMS opened the door to alternative maintenance a decade ago.
Here is what EQ103 covers, what it means for your CMMS, and which platforms are ready for it.
The AEM compliance gap: 2014 to 2024
In 2014, the CMS Survey and Certification Group issued a letter permitting hospitals to develop AEM programs. The premise was sound: not every piece of equipment needs manufacturer-recommended maintenance intervals. Low-risk devices with strong reliability histories should be maintained differently than high-risk life-support equipment.
The problem was interpretation. CMS provided permission without prescription. Different health systems developed divergent approaches. Some built rigorous risk assessment frameworks. Others reduced maintenance intervals without formal documentation. Accrediting bodies had no consensus standard to survey against.
This created a compliance gap. HTM directors who wanted to implement AEM programs faced a choice: build something defensible with no external benchmark, or avoid AEM entirely and absorb higher maintenance costs.
EQ103 closes the gap.
What ANSI/AAMI EQ103:2024 establishes
The standard was built by comparing four existing frameworks: AAMI EQ56 (recommended practices for medical equipment management), AAMI EQ89 (guidance on AEM), CMS Conditions of Participation, and TJC standards. The working group identified where these frameworks overlapped, where they conflicted, and where gaps existed.
EQ103 addresses six core areas:
Documentation, governance, and management structures. AEM programs need formal governance. The standard defines who approves AEM decisions, how decisions are documented, and what oversight structures must exist. Ad hoc AEM decisions made by individual technicians do not meet the standard.
Equipment eligibility criteria. Not every device qualifies for AEM. EQ103 defines the criteria for determining which equipment falls under AEM status, including risk classification, device history, and clinical application. This replaces the informal “we decided this device was low-risk” approach.
Maintenance and inspection requirements. AEM does not mean less maintenance. It means different maintenance. The standard specifies what inspection and maintenance activities are required for AEM equipment, including how adjusted intervals are determined and validated.
Written policies and procedures. EQ103 requires written policies covering selection, storage, maintenance, and redeployment of AEM equipment. Verbal agreements and tribal knowledge do not satisfy the standard.
Training requirements. HTM professionals managing AEM programs must receive specific training. The standard defines what competencies are required and how training is documented.
Audit readiness. Every element of the standard is designed to produce documentation sufficient for accrediting body review. The goal is a program defensible under survey conditions.
What the co-chairs say
Maggie Berkey of Bio-Electronics, a co-chair of the working group, framed the standard’s value in practical terms: “HTM professionals can use the standard to make sure that at a minimum you have every single ‘T’ crossed and ‘I’ dotted when you go and talk to your accrediting body.”
Colleen Haugen-Ortiz of GE HealthCare, the other co-chair, emphasized adoption: EQ103 was written to “facilitate uniformity and easy adoption.” The intent is a standard hospitals deploy, not a standard hospitals shelve.
Both statements point to the same objective. EQ103 is designed to eliminate the guesswork in AEM program design and give HTM directors a defensible framework for surveyor conversations.
What EQ103 means for your CMMS
If your department runs an AEM program, or plans to start one, your CMMS becomes the system of record for compliance. EQ103’s requirements translate directly into CMMS capabilities.
AEM equipment identification and tracking. Your CMMS needs to flag devices approved for AEM status separately from standard PM equipment. This is not a tag or a note field. It requires a distinct classification with its own reporting pathway.
Risk assessment documentation. Each device placed into an AEM program requires a documented risk assessment. Your CMMS must store these assessments, link them to specific devices, and make them retrievable during surveys. Paper files in a binder do not meet the standard’s intent.
Adjusted maintenance schedules. AEM equipment operates on modified maintenance intervals. Your CMMS must manage these schedules independently from manufacturer-recommended intervals, track compliance against the adjusted schedule, and flag overdue work orders.
Rotating pool management. AEM programs often involve equipment pools with rotating deployment. Your CMMS needs to track which devices are in active service, which are in storage, and which are due for maintenance based on their deployment status.
Audit-ready reporting. Surveyors will ask for AEM program documentation. Your CMMS must produce reports showing: which devices are in the AEM program, what risk assessments were performed, what maintenance was completed, and what the compliance rate is. Generating this report should take minutes, not days.
Which CMMS platforms support AEM workflows
Not all platforms handle AEM equally. The market splits into two tiers: purpose-built HTM platforms with native AEM support, and generic maintenance platforms requiring custom configuration.
Purpose-built platforms with AEM support
Phoenix AIMS includes AEM compliance tracking as a built-in feature. The platform was designed around CMS and TJC mandates, and AEM workflows are part of the core compliance module. AEM equipment gets distinct classification, adjusted scheduling, and dedicated compliance reporting. For departments already on Phoenix AIMS, EQ103 compliance is a configuration task, not a development project.
Accruent TMS supports AEM program documentation and management within its healthcare compliance toolset. The platform handles AEM equipment classification, risk documentation, and compliance reporting as part of its broader TJC compliance package. Integration with PartsSource and Fluke OneQA extends into AEM workflows for parts tracking and test documentation.
Nuvolo maps AEM tracking directly to EC.02.04.01 EP 5 and EP 6, the TJC elements most relevant to equipment maintenance programs. The platform includes risk scoring and MTBF (mean time between failures) calculations as native features, supporting the evidence-based maintenance intervals EQ103 requires. For health systems on ServiceNow, Nuvolo’s AEM capabilities integrate with the broader enterprise asset management framework.
Generic platforms: configuration required
MaintainX, Limble, UpKeep, eMaint, Fiix, and similar generic CMMS platforms do not include native AEM tracking. These platforms handle work orders, PM scheduling, and asset management well. AEM-specific workflows require custom fields, custom reports, and manual process enforcement.
This does not mean generic platforms are incompatible with EQ103. It means the compliance burden shifts from the software to your team. You build the AEM classification system. You create the risk assessment forms. You design the reports. You maintain the separation between AEM and standard PM schedules.
For small departments with limited AEM programs (fewer than 100 devices), custom configuration on a generic platform is workable. For large health systems running AEM across thousands of devices, purpose-built support reduces risk and administrative overhead.
What comes next: the forthcoming TIR
AAMI plans to release a Technical Information Report (TIR) on AEM implementation as a companion to EQ103. TIRs provide practical implementation guidance beyond what the standard itself specifies. Expect the TIR to include worked examples, implementation checklists, and common pitfalls.
For departments starting AEM programs now, EQ103 provides the minimum requirements. The TIR will provide the implementation playbook. Build your program to EQ103 specifications and anticipate adjustments when the TIR is published.
The bottom line
EQ103 replaces a decade of improvisation with a defined standard. For HTM directors, this is straightforward: build AEM programs to EQ103 requirements, document everything in your CMMS, and prepare for surveyors who now have a specific benchmark to survey against.
The departments at greatest risk are those with informal AEM programs built on undocumented risk assessments and ad hoc interval adjustments. EQ103 makes the documentation standard explicit. If your program does not meet it, the next survey is the wrong time to find out.
For the full platform comparison, read our Best CMMS Software for Healthcare guide.
Sources
- ANSI/AAMI EQ103:2024. “Alternative Equipment Maintenance (AEM): Minimum Requirements for Healthcare Delivery Organizations.” Association for the Advancement of Medical Instrumentation, 2024.
- CMS Survey and Certification Group Letter 14-07. Guidance permitting hospitals to develop alternative equipment maintenance programs. Centers for Medicare & Medicaid Services, 2014.
- AAMI EQ56:2013. “Recommended Practice for a Medical Equipment Management Program.” Association for the Advancement of Medical Instrumentation.
- AAMI EQ89:2015. “Guidance for Alternative Equipment Maintenance (AEM) and Medical Equipment Management Programs (MEMP).” Association for the Advancement of Medical Instrumentation.
- The Joint Commission EC.02.04.01. Environment of Care standard for medical equipment management. The Joint Commission.
- AAMI News. Reporting on EQ103 development and co-chair statements (Maggie Berkey, Colleen Haugen-Ortiz).
