Risk assessment determines the need for, and type of maintenance a device should receive. Calculating compliance should demonstrate the degree to which you were able to perform the maintenance you have established as necessary. Generally speaking, “percent compliance” is a ratio of the number of devices that are inspected on time, divided by the number of devices in the maintenance program. In practice, the number representing all devices in the program is a thorn sticking in the side of this equation. Embedded in the total is an unknown quantity of devices difficult or impossible to find. At issue is the accuracy of inventory records.

In the real world, inventory data are imperfect due to several difficult-to-manage variables: stolen equipment, rentals and loners removed by a vendor, errors in inventory, equipment hidden by staff, or the result of not having enough resources to locate and inspect everything. In the real world, the inventory requiring periodic maintenance--the denominator in a compliance calculation--is defined by each user, in accordance with their own interpretation of the task. Nothing prevents a department from discounting all devices not located during a single month inspection period, or simply inactivating devices that someone thinks are unimportant or impossible to find.

Percent compliance can be increased without increasing the number of maintenance inspections.

In order to meaningfully track compliance within one institution, and between different institutions, the inventory in the maintenance program must be defined in absolute terms. To help visualize this, draw a line extending from the oldest due date to the most future due date, and designate a period (18 months for example) from which we will remove from calculation (not inventory) devices that have not been located. The time period should be long enough to reasonably allow equipment to be found. Note, the area below the curve, represents the quantity of devices included in the periodic maintenance program.

The critical issues are to define a cut-off point for inclusion in the program, and to report the devices removed from compliance calculation along with compliance to the Environment of Care Committee. The report would look something like: 95% compliant, 4.5% devices not located. An in-house standard can be used for "devices not located compliance," the point is, if the numbers reported are 95% compliant, 35% of inventory not located, a flag should go up, and the missing devices scrutinized.

Not standardizing this procedure skews data and accountability—because there is no effective management for inaccuracies inherent in inventories. Without effectively managing inventory, the department cannot effectively track performance, JCAHO cannot accurately compare one institution to another, and ultimately, patients may be placed at increased risk.