The Joint Commission regularly aggregates standards compliance data to pinpoint areas that present the greatest challenges to accredited organizations and certified pro- grams. 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 identi- fied most frequently as “not compliant” during surveys and reviews from January 1, 2015, through June 30, 2015. 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 notes, elements of performance, and scoring information) is pub- lished in the respective accreditation or certification manual (on E-dition® and in print).
The graphs generally display the 10 most frequently cited requirements in decreasing frequency for each program. Percentages indicate the number of orga- nizations that received Requirements for Improvement (RFIs) for the standards shown. More than 10 standards are displayed for critical access hospitals, office- based surgery practices, and health care staffing services because several were tied in their percentage of RFIs; only 8 standards are displayed for palliative care because organizations achieved full compliance with the remaining standards.
Surveyors review compliance with all standards in manuals—these graphs are provided only to help organizations recognize potential trouble spots. As a
reminder, The Joint Commission and the American Society for Healthcare Engineer- ing (ASHE) recently launched the Physical Environment Portal to provide resources for reducing findings of noncompliance in environment of care and life safety areas (see August 2015 Perspectives, pages 1, 3).
Please review frequently asked ques- tions at http://www.jointcommission.org/ Standards/FAQs or send your own ques- tions to http://www .jointcommission.org/ Standards/Online QuestionForm. P
Continued on page 3
Page 1 Joint Commission Perspectives®, September 2015, Volume 35, Issue 9 Copyright 2015 The Joint Commission
Top Standards Compliance Data for First Half of 2015 (continued)
Continued from page 1
ToP STandardS ComPlianCe daTa for firST Half of 2015
46% 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.
46% | IC.02.02.01 | The organization reduces the risk of infections associated with medical equipment, devices, and supplies. |
35% | EC.02.03.05 | The organization maintains fire safety equipment and fire safety building features. |
31% | EC.02.05.01 | The organization manages risks associated with its utility systems. |
30% | MM.03.01.01 | The organization safely stores medications. |
27% | EC.02.02.01 | The organization manages risks related to hazardous materials and waste. |
27% | MM.01.01.03 | The organization safely manages high-alert and hazardous medications. |
26% | EC.02.05.07 | The organization inspects, tests, and maintains emergency power systems. |
24% | IC.01.03.01 | The organization identifies risks for acquiring and transmitting infections. |
23% | EC.02.04.03 | The organization inspects, tests, and maintains medical equipment. |
Note: The data determined for the ambulatory care program were derived from an average of 342 applicable surveys.
ToP STandardS ComPlianCe iSSueS for firST Half of 2015
35% 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.
27% HRM.01.02.01 The organization verifies and evaluates staff qualifications.
25% NPSG.15.01.01 Identify individuals at risk for suicide.
21% IC.02.04.01 The organization facilitates staff receiving the influenza vaccination.
20% HRM.01.06.01 Staff are competent to perform their job duties and responsibilities.
17% EC.02.06.01 The organization establishes and maintains a safe, functional environment.
17% CTS.02.01.11 The organization screens all individuals served for their nutritional status.
17% CTS.02.01.05
tion implements a written process requiring a physical health screening to determine the individual’s need for a medical history and physical examination.
15% EC.02.03.05 The organization maintains fire safety equipment and fire safety building features.
14% CTS.02.01.09 The organization screens all individuals served for physical pain.
Note: The data determined for the behavioral health care program were derived from an average of 412 applicable surveys.
Page 3 Joint Commission Perspectives®, September 2015, Volume 35, Issue 9 Copyright 2015 The Joint Commission
ToP STandardS ComPlianCe daTa for firST Half of 2015
63% EC.02.05.01 The critical access hospital manages risks associated with its utility systems.
60% IC.02.02.01 The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
52% | EC.02.03.05 | The critical access hospital maintains fire safety equipment and fire safety building features. |
44% | EC.02.06.01 | The critical access establishes and maintains a safe, functional environment. |
42% LS.02.01.30 The critical access hospital provides and maintains building features to protect individuals from
the hazards of fire and smoke.
35% EC.02.02.01 The critical access hospital manages risks related to hazardous materials and waste.
33% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire,
smoke, and heat.
33% LS.02.01.20 The critical access hospital maintains the integrity of the means of egress.
27% LS.02.01.35 The critical access hospital provides and maintains systems for extinguishing fires.
25% IC.02.01.01 The critical access hospital implements its infection prevention and control plan.
25% LS.01.01.01 The critical access hospital designs and manages the physical environment to comply with the
Life Safety Code.
25% MM.03.01.01 The critical access hospital safely stores medications.
Note: The data determined for the critical access hospital program were derived from 48 applicable surveys.
ToP STandardS ComPlianCe daTa for firST Half of 2015
31% DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
15% 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.
14% DSCT.5 The program initiates, maintains, and makes accessible a medical record for every patient.
14% DSDF.1 Practitioners are qualified and competent.
12% DSDF.4 The program develops a plan of care that is based on the patient’s assessed needs.
9% DSSE.3 The program addresses the patient’s education needs.
8% DSPR.1 The program defines its leadership roles.
8% DSPM.5 The program evaluates patient satisfaction with the quality of care.
5% DSPR.5 The program determines the care, treatment, and services it provides.
5% DSSE.1 The program involves patients in making decisions about managing their disease or condition.
Note: The data determined for the disease-specific care program were derived from 698 applicable surveys (which do not include the 1 applicable survey for Advanced Certification for Lung Volume Reduction Surgery or the 33 applicable surveys for Advanced Certification for Ventricular Assist Device Destination Therapy).
Page 4 Joint Commission Perspectives®, September 2015, Volume 35, Issue 9 Copyright 2015 The Joint Commission
ToP STandardS ComPlianCe daTa for firST Half of 2015
12% HSHR.1 The HCSS firm confirms that a person’s qualifications are consistent with his or her assignment(s).
9% HSLD.5 The services contracted for by the HCSS firm are provided to customers.
8% HSHR.6 The HCSS firm evaluates the performance of clinical staff.
5% HSPM.4 The HCSS firm analyzes its data.
4% HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.
3% CPR 5 The staffing firm submits performance measurement data to The Joint Commission on a routine basis.
3% HSLD.9 The HCSS firm addresses emergency management.
3% HSHR.2 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.
2% HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information.
1% CPR 6
1% CPR 11
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.
Any staffing firm employee or independent contractor who has concerns about the quality and safety of patient 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.
1% HSLD.1 The health care staffing services (HCSS) firm clearly defines its leadership roles.
Note: The data determined for the health care staffing services program were derived from 93 applicable surveys.
ToP STandardS ComPlianCe daTa for firST Half of 2015
39% 35% | PC.02.01.03 IC.02.04.01 | required by law and regulation. The organization offers vaccination against influenza to licensed independent practitioners and staff. |
32% | PC.01.03.01 | The organization plans the patient’s care. |
26% | RC.02.01.01 | The patient record contains information that reflects the patient’s care, treatment, or services. |
26% | IC.02.01.01 | The organization implements the infection prevention and control activities it has planned. |
25% | HR.01.02.05 | The organization verifies staff qualifications. |
24% | HR.01.06.01 | Staff are competent to perform their responsibilities. |
23% 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. | ||
23% | EM.03.01.03 | The organization evaluates the effectiveness of its Emergency Operations Plan. |
20% | PI.02.01.01 | The organization compiles and analyzes data. |
The organization provides care, treatment, or services in accordance with orders or prescriptions, as
Note: The data determined for the home care program were derived from an average of 1,151 applicable surveys.
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ToP STandardS ComPlianCe daTa for firST Half of 2015
59% | EC.02.06.01 | The hospital establishes and maintains a safe, functional environment. |
54% | IC.02.02.01 | The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. |
53% | EC.02.05.01 | The hospital manages risks associated with its utility systems. |
50% | LS.02.01.20 | The hospital maintains the integrity of the means of egress. |
48% | RC.01.01.01 | The hospital maintains complete and accurate medical records for each individual patient. |
46% LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire
and smoke.
45% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke,
and heat.
43% LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.
39% EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.
38% 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 703 applicable surveys.
ToP STandardS ComPlianCe daTa for firST Half of 2015
79% QSA.01.01.01 The laboratory participates in Centers for Medicare & Medicaid Services (CMS)–approved proficiency
testing programs for all regulated analytes.
42% HR.01.06.01 Staff are competent to perform their responsibilities.
32% DC.02.03.01 The laboratory report is complete and is in the patient’s clinical record.
32% QSA.02.03.01 The laboratory performs calibration verification.
32% QSA.01.03.01 The laboratory has a process for handling and testing proficiency testing samples.
32% 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.
27% | QSA.01.02.01 | The laboratory maintains records of its participation in a proficiency testing program. |
23% | EC.02.04.03 | The laboratory inspects, tests, and maintains laboratory equipment. |
19% QSA.02.11.01 The laboratory conducts surveillance of patient results and related records as part of its quality control program.
17% HR.01.02.05 The laboratory verifies staff qualifications.
Note: The data determined for the laboratory program were derived from an average of 413 applicable surveys.
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ToP STandardS ComPlianCe daTa for firST Half of 2015
39% | HR.02.01.04 | The organization permits licensed independent practitioners to provide care, treatment, and services. |
22% | MM.03.01.01 | The organization safely stores medications. |
18% | PC.01.02.07 | The organization assesses and manages the patient’s or resident’s pain. |
18% | PC.01.03.01 | The organization plans the patient’s or resident’s care. |
16% | HR.01.02.05 | The organization verifies staff qualifications. |
14% PC.01.02.03 The organization assesses and reassesses the patient or resident and his or her condition according
to defined time frames.
12% HR.01.06.01 Staff are competent to perform their responsibilities.
12% 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.
12% IC.01.03.01 The organization offers identifies risks for acquiring and spreading infections.
12% 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 153 applicable surveys.
ToP STandardS ComPlianCe daTa for firST Half of 2015
53% IC.02.02.01 The practice reduces the risk of infections associated with medical equipment, devices, and supplies.
52% 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.
25% MM.03.01.01 The practice safely stores medications.
21% NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field
in perioperative and other procedural settings.
19% IC.01.03.01 The practice identifies risks for acquiring and transmitting infections.
15% IC.02.04.01 The practice offers vaccination against influenza to licensed independent practitioners and staff.
15% MM.01.01.03 The practice safely manages high-alert and hazardous medications.
15% WT.03.01.01 Staff and licensed independent practitioners performing waived tests are competent.
15% WT.04.01.01 The practice performs quality control checks for waived testing on each procedure.
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% MM.01.02.01 The practice addresses the safe use of look-alike/sound-alike medications.
Note: The data determined for the office-based surgery practices program were derived from 85 applicable surveys.
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ToP STandardS ComPlianCe daTa for firST Half of 2015
29% | PCPI.2 | The program collects data to monitor its performance. |
29% | PCPI.3 | The program analyzes and uses its data. |
24% | PCPC.3 | The program tailors care, treatment, and services to meet the patient’s lifestyle, needs, and values. |
24% | PCPC.4 | The interdisciplinary program team assesses and reassesses the patient’s needs. |
14% | PCIM.2 | The program maintains complete and accurate medical records. |
14% 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.
10% PCPM.6 Program leaders are responsible for selecting, orienting, educating, retaining, and providing incentives for staff.
5% PCPC.5 The program provides care, treatment, and services according to the plan of care.
Note: The data determined for the palliative care program were derived from 21 applicable surveys.
Page 8 Joint Commission Perspectives®, September 2015, Volume 35, Issue 9 Copyright 2015 The Joint Commission