Compliance Standard Proposal

This proposal has mutated – see update.
September, 2005.

The Compliance Standard Proposal is an ongoing project. The purpose is to encourage JCAHO to set a standard for how the required compliance percent is calculated. Currently, JCAHO is opposed to setting a standard for calculation because, in their words, “Since the healthcare organizations we accredit vary widely in size, complexity, operations, and risk, our standards rarely are able to prescribe one particular method of compliance (calculation). In addition, prescribing one method of compliance could limit development of other ideas.”(1)


(1) 1/8/2004, letter from JCAHO, Division of Standards and Survey Methods.

JCAHO sets a no-nonsense maintenance inspection completion requirement of 95% completion, yet does not specify how that number is to be calculated. The effect may be not just to promote forms of creative bookkeeping, but to allow the quality of inventory management to remain unknown. For a somewhat detailed discussion of this issue, read “Look to use, before ornament.” –Aesop.

First update–an AAMI article in March/April BI&T journal (pdf file): “Three Critical Issues I’ve Learned in 23 Years in Clinical Engineering” (By the way, the title I had proposed to AAMI was, “The Three Things I Learned In 23 Years.” They have/had no sense of humor!

Other updates to come are responses from JCAHO to this proposal, and other journal publications and editorials.

I welcome readers’ comments, and would like to hear how different institutions perform this calculation–in confidence.

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