Joint Commission Statement

Briefings on Accreditation and Quality, July 1, 2017.
George Mills, MBA, FASHE, CEM, CHFM, CHSP, Joint Commission director of engineering at the time this policy was created – quoted here from a webinar, verbatim.

Q: With the changes to the standards, will equipment that’s not found or is in use count in favor of or against completion percentage?
Mills: We’ve always said that if you go to a unit to do the work on equipment for service maintenance and it’s on a patient and in use, we’ve never ever advocated taking it off a patient to see if it’s working OK. But [say] you’re there on time, on the date you’re supposed to be doing the work, when the device is in use. At that point, we’d expect that you have some sort of policy to guide you as far as what the next steps are.

Steve [Grimes] gave some good examples of what those next steps could be as far as letting nursing know that as soon as this patient no longer needs this device, to call somebody at your shop so they can send somebody up to do the work.

But [since] you were there on time, you’re going to get 100% credit for that. So you wouldn’t consider yourself to be late servicing that equipment. In a similar situation (with equipment not found), you’re in the unit the equipment is supposed to be in. You look for it and can’t find it. Again, being driven by a strong policy, you go to nursing and say, “I’m looking for X device.” They say, “Jeez, I haven’t seen this up here in a long time.” At that point, you put out an alert saying that you’re looking for it.

And you have maybe a three step process where your first step was that you were on time, so you’re taking the 100% as far as your recordkeeping goes. Maybe your policy says that within five days you return to the unit and look for it again and post it in the nurses’ communications strategies asking nursing to help you find it. Maybe the third step is that you still can’t find it, so you flag it as “deferred until found” or somehow indicate that it didn’t receive its preventive maintenance (PM) because it couldn’t be found. Ask nursing again to help you find it.

The key is that you are going to be taking 100% on your “on time” because you were on time, and you knew what it was. And the fact that you couldn’t complete it wasn’t your fault or a penalty to your shop. The key then becomes whether your policy is robust enough to still make sure that you capture that equipment when it does show up. If it doesn’t show up after a second cycle, do you then remove it from your inventory as “not being in the building?” Maybe it went out with a patient to a nursing home or something like that; you never know.

The point is that for your 100% compliance calculations, if you were there to do the work on time, take the credit for being there on time. Your policy steps in and gives you the next steps, gives you the evidence of what to do next, because you couldn’t service your equipment.

So a surveyor would be looking at your history and would say, “I see you are at 100%, but I see three things that were deferred because they were in use. What does your policy say?” Then if you can explain your policy back to the surveyor, everything should be fine because everything should be reconciled and driven by a written policy to get to that point.


Below is the last response I received from a recent attempt to address this issue with The Joint Commission.

“Dear Alan- I have spoken with everyone you reached out to and I am responding on behalf of those staff. We want to thank you for your efforts expended in your letter from January 24, 2018.  It appears that you have thoroughly researched the topic of equipment maintenance rates. However, the Center for Medicare and Medicaid Services (CMS) has approved our maintenance rate of 100%. The Health care Organization has the responsibility to prove to the Joint Commission surveyor that they are meeting that 100% requirement. Regards, Dawn Glossa, Director Corporate Communications”

Contact the Joint Commission., 630-792-5630
Gail Weinberger, Director, Accreditation and Certification,, 630-792-5766
Anne Bauer, Field Director, Hospital Accreditation,, 630-792-5863
Sharon Sprenger, Health care Quality Evaluation,, 630-792-5968
Mark R. Chassin, M.D., M.P.P., M.P.H., President,, 630-792-5650