Top Standards Compliance Data for 2014

EC and LS trouble spots show up for many settings

The Joint Commission regularly

aggregates standards compliance

data to pinpoint areas that present the greatest challenges to accredited organi- zations. These data help The Joint Commis- sion recognize trends and tailor education around challenging standards. In turn, they can help accredited organizations focus improvements and educate staff.

The table at right identifies the Joint Commission environment of care (EC), life safety (LS), and tightly related infec- tion control (IC) requirements with which organizations were most frequently “not

compliant” during surveys and reviews from January 1, 2014, through December 31, 2014. The data represent citations only from organizations due to be surveyed during this time period; that is, data from for-cause sur- veys are not included. While the text of the requirements appears in the table, the full text of each (including elements of perfor- mance and scoring information) is published in the respective accreditation or certification manual.

Percentages (rounded to the nearest whole point) indicate the number of organizations that received Requirements for Improvement (RFIs) for the standards shown. The most frequently cited requirements are displayed in decreasing frequency for each program.

Please note that surveyors review com- pliance 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.jointcommission.org/Standards/ OnlineQuestionForm. EC

Top EC and LS Standards Compliance Data for 2014*

AHC	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.
	Note: The data determined for the ambulatory care program were derived from an average of 591 applicable surveys.
BHC	15%	EC.02.06.01	The organization establishes and maintains a safe, functional environment.
BHC	Note: The data determined for the behavioral health care program were derived from an average of 741 applicable surveys.
CAH	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.
	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%	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.
HCSS	5%	HSLD.9	The HCSS firm addresses emergency management.
OME	19%	EM.03.01.03	The organization evaluates the effectiveness of its Emergency Operations Plan.
OME	Note: The data determined for the home care program were derived from an average of 2,186 applicable surveys.
HAP	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.
	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.
LAB	23%	EC.02.04.03	The laboratory inspects, tests, and maintains laboratory equipment.
LAB	Note: The data determined for the laboratory program were derived from an average of 813 applicable surveys.
OBS	39%	IC.02.02.01	The practice reduces the risk of infections associated with medical equipment, devices, and supplies.
	20%	EC.02.05.07	The practice inspects, tests, and maintains emergency power systems.
	Note: The data determined for the office-based surgery practices program were derived from an average of 113 applicable surveys.

* No EM standards were identified as top contenders for this time frame.

AHC, Ambulatory Care; BHC, Behavioral Health Care; CAH, Critical Access Hospitals; HCSS, Health Care Staffing Services Certification; OME, Home Care; HAP, Hospitals; LAB, Laboratory and Point-of-Care Testing; OBS, Office-Based Surgery Practices.