The Joint Commission regularly aggregates standards compliance data to pinpoint areas that present the greatest challenges to accredited organizations and certified programs. These data help The Joint Commission recognize trends and tailor education around challenging standards; National Patient Safety Goals (NPSGs); the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM; and Accreditation or Certification Participation Requirements (APRs or CPRs).
The bar graphs on pages 3 to 8 identify the Joint Commission requirements identified most frequently as “not compliant” during surveys and reviews from January 1, 2014, through December 31, 2014. The data represents citations only from organizations due to be surveyed during this time period—that is, data from for-cause surveys are not included. While the text of the requirements also appears in the bar graphs, the full text of each (including elements of performance and scoring information) is published in the respective accreditation or certification manual.
The graphs display the 10 most frequently cited requirements in decreasing frequency for each program. Percentages (rounded to the nearest whole point) indicate the number of organizations that received Requirements for Improvement (RFIs) for the standards shown. (In the data for Health Care Staffing Services Certification, more than 10 standards are displayed because several were tied in their percentage of RFIs.)
Please note that surveyors review compliance with all standards in manuals. This list is provided only to help organizations recognize potential trouble spots.
If you have questions about these requirements, please review the Standards Frequently Asked Questions at http:// www.jointcommission.org/Standards/ FAQs. Questions not addressed on this site may be directed to the Standards Interpretation Group through its online question form at http://www.jointcom mission.org/Standards/OnlineQuestion Form. P
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Page 1 Joint Commission Perspectives®, April 2015, Volume 35, Issue 4 Copyright 2015 The Joint Commission
Top Standards Compliance Data for 2014 (continued)
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ToP STandardS ComPlianCe iSSueS for 2014
52% HR.02.01.03 The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
41% | IC.02.02.01 | The organization reduces the risk of infections associated with medical equipment, devices, and supplies. |
35% | MM.03.01.01 | The organization safely stores medications. |
30% | MM.01.01.03 | The organization safely manages high-alert and hazardous medications. |
26% | IC.02.04.01 | The organization offers vaccination against influenza to licensed independent practitioners and staff. |
25% | WT.03.01.01 | Staff and licensed independent practitioners performing waived tests are competent. |
22% | IC.01.03.01 | The organization identifies risks for acquiring and transmitting infections. |
22% | EC.02.04.03 | The organization inspects, tests, and maintains medical equipment. |
20% | EC.02.02.01 | The organization manages risks related to hazardous materials and waste. |
20% | MM.01.02.01 | The organization addresses the safe use of look-alike/sound-alike medications. |
Note: The data determined for the ambulatory care program were derived from an average of 591 applicable surveys.
ToP STandardS ComPlianCe iSSueS for 2014
37% CTS.03.01.03 The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.
23% HR.02.01.03 The organization assigns initial, renewed, or revised clinical responsibilities to staff who are permitted by law and the organization to practice independently.
22% NPSG.15.01.01 Identify individuals at risk for suicide.
17% IC.02.04.01 The organization facilitates staff receiving the influenza vaccination.
17% CTS.04.03.33 For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.
16% HR.01.02.05 The organization verifies staff qualifications.
15% HR.01.06.01 Staff are competent to perform their responsibilities.
15% EC.02.06.01 The organization establishes and maintains a safe, functional environment. 13% CTS.02.01.11 The organization screens all individuals served for their nutritional status. 12% RC.01.01.01 The organization maintains complete and accurate clinical/case records.
Note: The data determined for the behavioral health care program were derived from an average of 741 applicable surveys. Please also note that the “Human Resources” chapter was significantly revised as of January 1, 2015, and renamed as the “Human Resources Management” chapter.
Page 3 Joint Commission Perspectives®, April 2015, Volume 35, Issue 4 Copyright 2015 The Joint Commission
ToP STandardS ComPlianCe iSSueS for 2014
60% | EC.02.03.05 | The critical access hospital maintains fire safety equipment and fire safety building features. |
57% | EC.02.05.01 | The critical access hospital manages risks associated with its utility systems. |
52% | EC.02.06.01 | The critical access hospital establishes and maintains a safe, functional environment. |
51% IC.02.02.01 The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
45% LS.02.01.20 The critical access hospital maintains the integrity of the means of egress.
41% LS.02.01.30 The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
37% MM.03.01.01 The critical access hospital safely stores medications.
37% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
33% EC.02.02.01 The critical access hospital manages risks related to hazardous materials and waste.
29% EC.02.05.07 The critical access hospital inspects, tests, and maintains emergency power systems.
Note: The data determined for the critical access hospital program were derived from 126 applicable surveys.
ToP STandardS ComPlianCe iSSueS for 2014
31% DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
14% DSDF.2 The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care.
13% DSCT.5 The program initiates, maintains, and makes accessible a medical record for every patient.
13% DSDF.1 Practitioners are qualified and competent.
10% DSPR.1 The program defines its leadership roles.
10% DSSE.3 The program addresses the patient’s education needs.
9% DSPM.5 The program evaluates patient satisfaction with the quality of care.
8% DSDF.4 The program develops a plan of care that is based on the patient’s assessed needs.
6% DSSE.1 The program involves patients in making decisions about managing their disease or condition.
5% DSPR.5 The program determines the care, treatment, and services it provides.
Note: The data determined for the disease-specific care program were derived from an average of 1,379 applicable surveys (which do not include the 2 applicable surveys for Advanced Certification for Lung Volume Reduction Surgery or the 66 applicable surveys for Advanced Certification for Ventricular Assist Device Destination Therapy).
Page 4 Joint Commission Perspectives®, April 2015, Volume 35, Issue 4 Copyright 2015 The Joint Commission
ToP STandardS ComPlianCe iSSueS for 2014
9% | HSHR.1 | The HCSS firm confirms that a person’s qualifications are consistent with his or her assignment(s). |
7% | HSHR.6 | The HCSS firm evaluates the performance of clinical staff. |
5% | HSLD.9 | The HCSS firm addresses emergency management. |
5% | HSLD.5 | The services contracted for by the HCSS firm are provided to customers. |
4% | CPR 5 | The staffing firm submits performance measurement data to The Joint Commission on a routine basis. |
4% HSHR.2
3% CPR 6
As part of the hiring process, the HCSS firm determines that a person’s qualifications and competencies are consistent with his or her job responsibilities.
The staffing firm notifies the public it serves about how to contact the firm’s management and The Joint Commission to report concerns about the quality and safety of patient care provided by the staffing firm’s employees or independent contractors
3% HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information.
3% HSPM.4 The HCSS firm analyzes its data.
Any staffing firm employee or independent contractor who has concerns about the quality and safety of patient
3% CPR 11
care provided by the staffing firm’s employees or independent contractors can report these concerns to The Joint Commission without retaliatory action from the staffing firm.
3% HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.
3% HSPM.3 The HCSS firm collects data to evaluate processes and outcomes.
Note: The data determined for the health care staffing services program were derived from 197 applicable surveys.
ToP STandardS ComPlianCe iSSueS for 2014
42% PC.02.01.03 The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation.
31% PC.01.03.01 The organization plans the patient’s care.
30% IC.02.04.01 The organization offers vaccination against influenza to licensed independent practitioners and staff.
24% RC.02.01.01 The patient record contains information that reflects the patient’s care, treatment, or services.
24% HR.01.02.05 The organization verifies staff qualifications.
23% IC.02.01.01 The organization implements the infection prevention and control activities it has planned.
23% HR.01.06.01 Staff are competent to perform their responsibilities.
22% NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
19% | EM.03.01.03 | The organization evaluates the effectiveness of its Emergency Operations Plan. |
16% | PI.02.01.01 | The organization compiles and analyzes data. |
Note:The data determined for the home care program were derived from an average of 2,186 applicable surveys.
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ToP STandardS ComPlianCe iSSueS for 2014
56% | EC.02.06.01 | The hospital establishes and maintains a safe, functional environment. |
53% | EC.02.05.01 | The hospital manages risks associated with its utility systems. |
52% | IC.02.02.01 | The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. |
50% | LS.02.01.20 | The hospital maintains the integrity of the means of egress. |
49% | RC.01.01.01 | The hospital maintains complete and accurate medical records for each individual patient. |
48% | EC.02.03.05 | The hospital maintains fire safety equipment and fire safety building features. |
46% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
43% LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
43% LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.
36% EC.02.02.01 The hospital manages risks related to hazardous materials and waste.
Note: The data determined for the hospital program were derived from 1,278 applicable surveys.
ToP STandardS ComPlianCe iSSueS for 2014
72% QSA.01.01.01 The laboratory participates in Centers for Medicare & Medicaid Services (CMS)–approved proficiency testing programs for all regulated analytes.
39% HR.01.06.01 Staff are competent to perform their responsibilities.
39% QSA.02.03.01 The laboratory performs calibration verification.
34% DC.02.03.01 The laboratory report is complete and is in the patient’s clinical record.
29% QSA.02.08.01 The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations.
26% QSA.01.03.01 The laboratory has a process for handling and testing proficiency testing samples.
23% EC.02.04.03 The laboratory inspects, tests, and maintains laboratory equipment.
23% QSA.01.02.01 The laboratory maintains records of its participation in a proficiency testing program.
19% HR.01.02.05 The laboratory verifies staff qualifications.
18% QSA.02.04.01 The laboratory evaluates instrument-based testing with electronic or internal systems prior to using them for routine quality control.
Note: The data determined for the laboratory program were derived from an average of 813 applicable surveys.
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ToP STandardS ComPlianCe iSSueS for 2014
36% HR.02.01.04 The organization permits licensed independent practitioners to provide care, treatment, and services.
21% PC.01.02.03 The organization assesses and reassesses the patient or resident and his or her condition according to defined time frames.
18% | IM.02.02.01 | The organization effectively manages the collection of health information. |
18% | MM.03.01.01 | The organization safely stores medications. |
17% | PC.01.02.07 | The organization assesses and manages the patient’s or resident’s pain. |
16% | PC.01.03.01 | The organization plans the patient’s or resident’s care. |
15% NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
15% HR.01.02.05 The organization verifies staff qualifications.
15% IC.02.04.01 The organization offers vaccination against influenza to licensed independent practitioners and staff.
14% PC.02.03.01 The organization provides patient and resident education and training based on each patient’s or resident’s needs and abilities.
Note: The data determined for the nursing care centers program were derived from 371 applicable surveys.
ToP STandardS ComPlianCe iSSueS for 2014
47% HR.02.01.03 The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
39% | IC.02.02.01 | The practice reduces the risk of infections associated with medical equipment, devices, and supplies. |
30% | MM.03.01.01 | The practice safely stores medications. |
21% | MM.01.01.03 | The practice safely manages high-alert and hazardous medications. |
20% | EC.02.05.07 | The practice inspects, tests, and maintains emergency power systems. |
19% | IC.01.03.01 | The practice identifies risks for acquiring and transmitting infections. |
19% | IC.02.04.01 | The practice offers vaccination against influenza to licensed independent practitioners and staff. |
17% | WT.03.01.01 | Staff and licensed independent practitioners performing waived tests are competent. |
17% IC.01.04.01 Based on the identified risks, the practice sets goals to minimize the possibility of transmitting infections.
16% NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
Note: The data determined for the office-based surgery practices program were derived from an average of 113 applicable surveys.
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ToP STandardS ComPlianCe iSSueS for 2014
40% PCPC.4 The interdisciplinary program team assesses and reassesses the patient’s needs.
32% PCPC.3 The program tailors care, treatment, and services to meet the patient’s lifestyle, needs, and values.
11% PCIM.2 The program maintains complete and accurate medical records.
11% PCPC.5 The program provides care, treatment, and services according to the plan of care.
9% PCPM.7 The program has an interdisciplinary team that includes individuals with expertise in and/or knowledge about the program’s specialized care, treatment, and services.
8% PCPI.2 The program collects data to monitor its performance.
8% PCPM.6 Program leaders are responsible for selecting, orienting, educating, retaining, and providing incentives for staff.
6% PCPI.3 The program analyzes and uses its data.
2% PCPC.2 The program communicates with and involves patients in decision making.
2% PCPC.6 The patient’s care is coordinated.
Note: The data determined for the palliative care program were derived from 53 applicable surveys.
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