Looking beyond the top 10 most-cited standards
Continuing Education Objectives
After reading this article, you will be able to:
- Discuss why the same standards are the most cited every six months
- Identify standards that are trouble spots outside of the top 10
For the last several years, The Joint Commission's semiannual list of the most-cited standards has read like a scene from Groundhog Day. Essentially, the same 10 standards are cited over and over; Environment of Care (EC) and Life Safety (LS) issues routinely top the list, while a couple of other standards rotate in and out.
"The thing to keep in mind is the top 10 is heavily influenced by the fact that engineers were introduced to the environmental assessment," says Kate Fenner, managing director of Compass Clinical Consulting. "EC and LS are covered by one dedicated person whose sole focus is to survey these standards, where physician and nurse surveyors have 1,800+ standards to hit."
Rarely discussed, however, are the troublesome standards that may not receive as much attention because they fall outside the top 10. These include:
- Patient rights
- Infection control
- Behavioral health issues
- Dialysis services
Patient rights and infection control are two areas that surveyors are focusing on and scoring as condition-level deficiencies, says Sena Blickenstaff, principal with Blickenstaff Clinical Consulting.
Issues cited include failure to properly display patient rights signage or ensure that patients have been informed of their rights and that their rights are respected throughout their hospital stay.
Fenner agrees. "When The Joint Commission comes in on a complaint finding, it's not because of the humidity in the OR, but that digitalis wasn't correctly administered or that a patient wasn't informed of what was going to happen to her before she went to surgery."
Infection control is an issue in the operating room, especially with endoscopy procedures?specifically, the proper cleaning and disinfecting of supplies, including endoscopy equipment, says Blickenstaff. Another infection control issue is staff failing to wear the proper personal protective equipment.
Dialysis services is also scored at the conditional level. Surveyors are finding that hospitals aren't managing theses services properly, says Blickenstaff.
Behavioral health issues in both the emergency department (ED) and inpatient settings are a big trouble spot for hospitals, say Blickenstaff and Fenner. A large area of concern involves possible delays in care a behavioral health patient may receive in the ED (e.g., how long the patient admitted on an 11-hour hold remains in the ED).
Standards to keep an eye on
The Joint Commission recently released Sentinel Event Alert (SEA) 54 regarding health information technology (IT). Healthcare organizations may have a little bit of time to show they have the appropriate levels of health IT security. "It won't surprise me if we start seeing some review of this during surveys, but I think it will take The Joint Commission a little while to start looking for it," says Blickenstaff.
Top 10 most-cited Joint Commission standards
- EC.02.06.01 (maintenance of a safe environment), 56%
- EC.02.05.01 (management of utility system risks), 53%
- IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 52%
- LS.02.01.20 (maintenance of egress integrity), 50%
- RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 49%
- EC.02.03.05 (maintenance of fire safety equipment and building features), 48%
- LS.02.01.10 (minimization of fire, smoke, and heat damage via building and fire protection features), 46%
- LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 43%
- LS.02.01.35 (fire extinguishment features provided and maintained), 43%
- EC.02.02.01 (management of hazardous materials and waste risks), 36%