A Proposed Fix

First, show real numbers so everyone can know what the actual rate of inspected equipment is. If the rate is 95%, state that, and state why it is 95% and not higher. Second, show the percent and breakdown of equipment not located (“missing”). If the inspection rate is 95%, explain the 5% so that everyone can assess the quality of inventory (a side benefit), and more clearly track and focus on what is not inspected and why it isn’t.

Periodic compliance reporting should look something like this: using a total inventory quantity of 1,000 with 95% of inventory inspected on time, the remaining 5%, or 50 pieces, are past due. This uninspected or unlocated equipment should be explained – e.g., in shop, on patient, or other – along with numbers of intervals missed. The uninspected or unlocated equipment consists of the following:

And of course, at some point, equipment that is not located for some prescribed period can be removed from inventory – after findings are reported, reviewed and signed off by various personnel.

The cutoff from compliance calculation, as shown here, is 18 months. The greatest area under the curve represents the 95% of inventory in compliance. Between the “date of compliance calculation” and the 18 month cutoff is the 5% of inventory that is out of date. Between the 18 month cutoff and “oldest due date” is removed from calculation, but still reported.

A Standard

What policy can The Joint Commission establish to promote maintenance safety, and be appropriate to all? If The Joint had been collecting real data for a period of time, perhaps a meaningful percent could now be set as a standard, tailored for different institution types and sizes. But as things stand now, meeting a standard must mean you meet or better the institution’s benchmark: e.g. 95% compliant with 5% uninspected or missing, means that the institution must meet or better those numbers in the next survey. Or satisfactorily explain why it can’t.

Real maintenance compliance numbers, trended over time, will place a clearer focus on the efforts made to improve performance. Real numbers measure actual results, and the surveyor always has the prerogative of accepting explanations for numbers that deviate from the norm.

The proposed fix keeps the issue of unlocated inventory front and center where it should be. What incentive is there to improve if – as is the case now – you rely on a system that all but guarantees 100%? When it’s likely you are not.

What you don’t know can hurt.