“Look to use, before ornament.” – Aesop

Maintenance Compliance Calculation: The Standard To Adopt.
Copyright, September, 2005

Objective: Create a true JCAHO standard for calculating maintenance compliance for health care organizations in the U.S.. Example: The total number of devices whose periodic inspections are not yet due (due dates in the future), divided by the total number of devices in the maintenance program–as adjusted by removing from calculation those devices not located for 18 months or more, past their due date.

Report percent compliance, and percent devices not located.

Why this is necessary.
Currently, there is no standard specifying what “X% compliant” means – the Joint Commission holds departments to a strict standard for which there is no stated definition. Hospital CEOs can be misled regarding there own compliance methodology, BME department heads are pressured by internal edicts stating they must achieve 95% compliance, surveyors can be manipulated and misled by green stickers, selected histories, and convoluted policies – bottom line, regarding clinical engineering compliance, no one really knows what compliance means, yet everyone treats the survey process with solemn concern.

The main problem in establishing a standard: defining the denominator in the calculation.

One could include all devices in inventory, generating an unrealistically low compliance number, or each month exclude all devices not located, thereby enhancing the level of compliance. Devices not located – stolen, rentals and loners removed by a vendor, errors in inventory, hidden by staff, or simply the result of not having enough resources to do the job – is the variable that must be defined in absolute terms in order to establish an effective standard and obtain a meaningful compliance picture.

Comments are closed.