By Rick Joslin, Senior Advisor, Healthcare Strategy & Senior Solutions Architect, Healthcare
The Joint Commission recently published and clarified PM Compliance standards related to grace periods for non-completion.
As a result, healthcare organizations must know their PMs are 100% compliant, documented, reportable, and retrievable.
Last year, over 720 hospitals were fined for non-compliance. With every year bringing new standards, organizations often feel unsure of what to do with those standards and how to remain compliant. While 100% compliance may seem difficult, it’s possible.
First, there are a few key things to think about when it comes to PM compliance:
- Completion vs. Compliance. There is a difference, and to be compliant you must know the difference. Most organizations manage completion, but the follow-up isn’t typically completed. Regulatory agencies manage compliance and if organizations don’t follow up on what they’ve implemented, they can get fined.
- Compliance has rules. You can’t “push” completion just because; there are specific situations stipulated (in use; unable to locate) as well as policy processes (e.g., when does your organization allow pushing?) that you have to follow.
- Staffing isn’t an excuse. Staff shortages are not (usually) a justifiable reason for non-compliance – so don’t even try it.
- Planning is your new best friend. Planning dramatically increases your ability to achieve compliance and lessens the headaches caused by last-minute scrambling.
How can you ensure compliance?
- Planning. Review your upcoming scheduled requirements. This review includes manpower, skill sets, availability of space, equipment and materials.
- Execution. You need a productive team that does not “sit” on their workload. Use reliable vendors, review progress and expect percentage matches (at the quarter-mark through the month, the team should be 25% complete with scheduled events), know what equipment/events can be pushed and what cannot (risk or AEM programs) and expect your team to complete the job the first time they try.
- Measure. All that work and you’ll want to know how it fares. Measure everything – completion percentages, compliance percentages, AEM & Risk, productivity with staff, turnaround times, workloads, etc. By measuring, you’ll know if your compliance efforts are working.
- Document. After you measure, document everything. How often did you look for that equipment? How many times did you try to get into that space? How many times did you talk with the vendor? When was the event completed?
- Understand. Do your research and try to understand the implemented regulations. What is their intent? How have they been applied elsewhere? What are your inspection results?
How can you handle compliance roadblocks?
As with any new standard and implemented regulation, there can be roadblocks and challenges along the way. What can you do to handle compliance roadblocks?
- Implement Policy. Develop, execute and communicate clearly defined maintenance policies. Once you’ve established those policies, review them regularly with employees. Then, adjust and amend policies as necessary.
- Assess. Assessing your inventory regularly and applying AEM when possible eliminates the guesswork on what needs to be done and to what equipment.
- Use analytics. Nothing forces change like publishing your actual progress for all the organization to see.
- Be accountable. Hold yourself (and your team) accountable.
- Ask. Use the many resources out there to get clarification on regulatory policies. You “just didn’t know” isn’t a good enough excuse for non-compliance.
Still feel lost? Accruent has made compliance easy with pre-built tools that better track and increase PM compliance – all based on best practices gleaned from thousands of healthcare organizations. Our turnkey PM compliance package includes dashboards, reports and snap-ins that ensure documentation and visibility of compliance – not just completion.