The Joint Commission and the 100% PM Completion

One of the relatively recent changes to The Joint Commission Accreditation standards that directly impacted the HTM community is the requirement for 100% PM completion.  Although this has been out for a couple of years, there is still some questions and confusion as to what constitutes 100% completion.  I wanted to give a personnel interpretation and a suggestion on how it can be accomplished.

When I first heard of this change, I panicked.  I thought it was absurd since there are almost always items in the hospital environment that are unable to be located.  Once I read several articles, asked questions directly to The Joint Commission, and consulted Mega-Gurus in the HTM field, I felt comfortable that 100% was achievable.  I learned “Completion” doesn’t mean performed.  If that is accepted, then what are acceptable actions that can still be counted as completed?  I came up with a short list:

• If you look for an item repeatedly (and documented well)
• If the item is unavailable to use (again multiples attempts and well documented)
• If it fails the PM
• Sent out to vendor but will be completed past PM due date
• Scheduled with a vendor, but past PM due date
• PM kit on backorder

The above listed is what I can argue as a considerable and valid attempt to perform a PM that can counted toward my completion percentage.  Please be ready to defend your methodology as they could have several questions directed to these elements of performances.  I can almost guarantee that it will not be acceptable if the “unable to locate” is only documented on the last day of the month or if you have a high percentage of PMs items not performed.  Hope this helps!