Compliance Calculation

If I have 100, and take away 95, how many are left? Answer: 0. Here’s a methodology that virtually assures JCAHO compliance.
Copyright, May, 2003.

Do you want to virtually assure a continuous 9x% maintenance compliance rate? Simply implement the following procedure: report compliance as a percent of devices in your maintenance program whose inspections “are completed as scheduled.”

Let’s say it’s April, 2003, and you print out a list of all 100 devices that are due in April, 2003. Like a good manager, you assign these to your technicians, and like good technicians, they perform their work and enter their work orders. Now it’s the end of April and you run your compliance report and find that of the 100 devices handed out, 95 were inspected. You report 95% maintenance compliance for that month, and go on to the next month.

Let’s also say that all of the devices in your program have a one year inspection interval, and a year later, April, 2004, you again ask for everything that is due in that month. This time however, only 95 devices are handed out to the technicians. The five not completed from a year ago (lost, stolen, hidden, or not having sufficient staff to find them) will not come up, this month or in any other month – because you only asked for devices that have due dates for the current month and the CURRENT year.

In other words, each and every month, devices that “are not found” are effectively removed from maintenance tracking, and from compliance calculations. Relying on this method continually adjusts the work you have to do – in accordance with the work you are able to do.

Is this ethical? You decide. Is it legal? Yes, for JCAHO (2003), and presumably everyone else. Is it compelling? Yes it is, because inventories are notoriously inaccurate for reasons, good and bad, making it inordinately difficult to calculate compliance. Is it necessary to rely on this kind of management? It is not.

I’ll bet my collection of bulging filing cabinets that the least favorite issue among the BME administrative class is the calculation of maintenance compliance. And it’s hard to get inside help in managing this conundrum: administrators don’t like maintenance for a number of reasons, and neither does The Joint Commission (JCAHO). Look at the facts.

Departments hear they must be at least x% compliant, yet that number isn’t referenced in any JCAHO specifications manual (2003), nor is the definition for “compliant,” or for that matter “maintenance.” It’s a fog out there, and yet those involved in hospital equipment maintenance are held to the strict standards interpretation of the surveyor at hand.

I should add here that I am not criticizing the survey process (that’s another story), nor am I raising issues concerning personnel, or the lack thereof: It’s the (wishy-washy) denominator (stupid).

9x% is the magic number, but 9x% of what? Of everything in inventory? Of what I select to schedule for a given month? Of what I am able to locate with the resources I have at hand? To make compliance percentage meaningful, we must be able to standardize the methodology, and that means standardizing the one variable that muddies the calculations – devices not located.

Equipment not accounted for may be lost, stolen, returned to a vendor, errors in inventory, or simply the result of not having enough resources to do the job. Some of this is forgivable, some of it is otherwise, but including all of these groups in the denominator when calculating compliance will result in unrealistic tallies, just as excluding them will.

One resolution to this “rock and a hard place” predicament is the effective management of the inventory of devices that can’t be found, and to set standards of compliance for this group of equipment.

That means looking for equipment, reviewing the results of your efforts, and defining the follow-up procedures by BME and others. It also means keeping these devices in active inventory, but at some point removing them from compliance calculations.

Define the period of time a device is past-due for its maintenance inspection, after which it is removed from compliance calculations (I have used 18 months because it is more liberal on long interval devices, yet relatively cautious on short intervals). A summary report would then read something like: Maintenance Compliance, 96% with 4.7% of inventory not located within the defined period of xxx. The use of these standards and reporting would provide a meaningful picture of maintenance and inventory health. [Chart]

Note regarding the 18 month period. Yes, I know it’s somewhat arbitrary, but it’s not the time length that matters so much as the consistant reporting (trending) of data. The visibility of equipment not located is significant for a number of reasons – makes compliance percent number more relevant, shows the quality of inventory numbers, invites questions regarding usage and needs, etc.

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