A
number of Joint Commission standards require written docu- mentation to maintain com-
pliance. In some instances, a health care organization can be found noncompliant with a standard if documentation is absent, even if the organization correctly performed the activity to be docu- mented. These standards are indicated in
the comprehensive accreditation manuals and E-dition with a D icon.
Environment of Care (EC) profes- sionals and other staff can use the tool below to ensure that they have sufficient documentation to remain in compli- ance with The Joint Commission’s EC standards. The checklist below lists
the standard number, the element of
performance number, the item to be documented, and the accreditation program applicability for the required documentation. In the final column, staff can indicate whether or not the correct documentation is present. A key at the end of this checklist (page 8) explains the abbreviations used. EC
Standard | Element of Performance | Required Documentation | Program Applicability | Documentation Present (Y/N) |
EC.01.01.01 | 3 | Written plan for environmental safety of everyone who enters the organization’s facilities | AHC, BHC, CAH, HAP, LAB, NCC | |
EC.01.01.01 | 4 | Written plan for managing the security of everyone who enters the organization’s facilities | AHC, BHC, CAH, HAP, LAB | |
EC.01.01.01 | 5 | Written plan for managing hazardous materials | AHC, CAH, HAP, LAB | |
EC.01.01.01 | 6 | Written plan for managing fire safety | AHC, BHC, CAH, HAP, LAB, NCC | |
EC.01.01.01 | 7 | Written plan for managing medical equipment | AHC, CAH, HAP, LAB | |
EC.01.01.01 | 8 | Written plan for managing utility systems | AHC, BHC, CAH, HAP, LAB, NCC | |
EC.02.01.01 | 9 | Written procedures to follow in the event of a security incident | CAH, HAP | |
EC.02.01.01 | 15 | Written procedures to following in the event of a patient or resident elopement | NCC | |
EC.02.01.03 | 1 | Written policy prohibiting smoking | BHC, CAH, HAP, NCC | |
EC.02.01.03 | 3 | Written criteria in which some individuals may smoke | BHC, NCC | |
EC.02.01.05 | 1 | Define criteria for assessing safety of foster care family’s physical environment | BHC | |
EC.02.01.05 | 13 | Periodic reassessment of safety of foster care family’s physical environment | BHC | |
EC.02.02.01 | 1 | Inventory of hazardous materials and waste | AHC, CAH, HAP, LAB, OME, NCC | |
EC.02.02.01 | 3 | Written procedures to follow in response to hazardous materials or waste spill or exposures | AHC, CAH, HAP, LAB, NCC, OME | |
EC.02.02.01 | 11 | Permits, licenses, manifests, and safety data sheets as required by law and regulation | AHC, CAH, HAP, NCC, OBS, OME | |
EC.02.02.01 | 14 | Checks of radiology staff for radiation exposure and amounts of exposure | AHC | |
EC.02.03.01 | 9 | Written fire response plan | AHC, BHC, CAH, HAP, LAB, OBS | |
EC.02.03.03 | 5 | Critique of fire drills to evaluate fire safety equipment, building features, and staff response | CAH, HAP, LAB, NCC, OME | |
EC.02.03.05 | 1 | Test dates of supervisory signal devices | AHC, BHC, CAH, HAP, NCC,OBS, OME | |
EC.02.03.05 | 2 | Test dates of valve tamper switches and water-flow devices | AHC, BHC, CAH, HAP NCC, OBS, OME | |
EC.02.03.05 | 3 | Test dates of duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, smoke detectors | AHC, BHC, CAH, HAP, OBS, OME |
Standard | Element of Performance | Required Documentation | Program Applicability | Documentation Present (Y/N) |
EC.02.03.05 | 4 | Test dates of visual and audible fire alarms | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 5 | Test dates of fire alarm equipment for notifying first responders | AHC, BHC, CAH, HAP, NCC, OBS, OME | |
EC.02.03.05 | 6 | Test dates of fire pumps under no-flow conditions | AHC, BHC, CAH, HAP, NCC, OBS, OME | |
EC.02.03.05 | 7 | Test dates of water storage tank high- and low-level alarms for automatic sprinkler systems | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 8 | Test dates of water storage tank temperature alarms for automatic sprinkler systems | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 9 | Test dates of main drains at system low point or all system risers for automatic sprinkler systems | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 10 | Test dates of fire department water supply connections for automatic sprinkler systems | AHC, BHC, CAH, HAP, NCC, OBS, OME | |
EC.02.03.05 | 11 | Test dates of fire pumps under flow for automatic sprinkler systems | AHC, BHC, CAH, HAP, OME | |
EC.02.03.05 | 12 | Test dates for standpipe systems water flow | AHC, BHC, CAH, HAP, OME | |
EC.02.03.05 | 13 | Test dates of automatic fire-extinguishing systems in a kitchen | BHC, CAH, HAP, NCC, OME | |
EC.02.03.05 | 14 | Test dates of carbon dioxide and other gaseous automatic fire- extinguishing systems | AHC, BHC, CAH, HAP, OME | |
EC.02.03.05 | 15 | Inspection dates of portable fire extinguishers | AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME | |
EC.02.03.05 | 16 | Maintenance dates of portable fire extinguishers | AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME | |
EC.02.03.05 | 17 | Test dates of standpipe occupant hoses | AHC, BHC, CAH, HAP, OME | |
EC.02.03.05 | 18 | Test dates of fire and smoke dampers | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 19 | Test dates of automatic smoke-detection shutdown devices for air- handling equipment | AHC, BHC, CAH, HAP, OBS, OME | |
EC.02.03.05 | 20 | Test dates of sliding and rolling fire doors | AHC, BHC. CAH, HAP, OME | |
EC.02.03.05 | 21 | Test dates of fire alarm and fire detection systems | LAB | |
EC.02.03.05 | 22 | Preventative maintenance dates of fire alarm and fire detection system components | LAB | |
EC.02.03.05 | 23 | Test dates of automatic fire extinguishing systems | LAB | |
EC.02.03.05 | 25 | Maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems, including the following:
| CAH, HAP | |
EC.02.03.05 | 26 | Test dates for the following:
| OME | |
EC.02.04.01 | 2 | Inventory of medical equipment | AHC, CAH, HAP, LAB | |
EC.02.04.01 | 3 | [CAH, HAP] Identify high-risk medical equipment on inventory [LAB] Activities and frequencies for inspecting, testing, and maintaining laboratory equipment [NCC] Activities and frequencies for inspecting, testing, and maintaining all medical equipment on the inventory | CAH, HAP, LAB, NCC | |
EC.02.04.01 | 4 | Activities and frequencies for inspecting, testing, and maintaining medical equipment on inventory | CAH, HAP, NCC |
Standard | Element of Performance | Required Documentation | Program Applicability | Documentation Present (Y/N) |
EC.02.04.01 | 5 | Activities and frequencies for inspecting, testing, and maintaining the following items according to manufacturers’ recommendations:
support the use of alternative maintenance strategies | CAH, HAP | |
EC.02.04.01 | 6 | [AHC, NCC] Written procedures to follow when medical equipment fails [HAP, CAH] Written criteria to support the determination whether it is safe to permit medical equipment to be maintained in an alternate manner | AHC, CAH, HAP, NCC | |
EC.02.04.01 | 7 | Identify equipment on inventory that is included in an alternative maintenance program | CAH, HAP | |
EC.02.04.01 | 9 | Written procedures to follow when medical equipment fails | BHC, CAH | |
EC.02.04.03 | 2 | Inspection, tests, and maintenance of all high-risk equipment | AHC, CAH, HAP, NCC, OBS | |
EC.02.04.03 | 3 | [AHC, CAH, HAP] Inspection, tests, and maintenance of all non- high-risk equipment [BHC] inspection, tests, and maintenance of all medical equipment [NCC] Inspection, tests, and maintenance of all non–life-support equipment | AHC, BHC, CAH, HAP, NCC | |
EC.02.04.03 | 4 | Performance testing and maintenance of all sterilizers | AHC, CAH, HAP, LAB, OBS | |
EC.02.04.03 | 5 | Equipment maintenance and chemical and biological testing of water used in hemodialysis | AHC, CAH, HAP, OBS | |
EC.02.04.03 | 6 | Major repairs and parts replacement for each instrument or piece of equipment | LAB | |
EC.02.04.03 | 7 | Preventive maintenance, periodic inspection, and performance testing of each instrument or piece of equipment | LAB | |
EC.02.04.03 | 8 | Evaluation of measuring equipment and instruments for all critical operating characteristics | LAB | |
EC.02.04.03 | 9 | Evaluation of automated volumetric equipment | LAB | |
EC.02.04.03 | 10 | Temperature of temperature-controlled spaces and equipment | LAB | |
EC.02.04.03 | 11 | Retention of daily, weekly, monthly, quarterly, or semiannual performance testing and function checks for at least two years | LAB | |
EC.02.04.03 | 14 | Inspection, testing, and calibration of nuclear medicine equipment | HAP, LAB | |
EC.02.04.03 | 16 | Evaluation of the accuracy of analytical balances using ANSI/ASTM Class standard weights | LAB | |
EC.02.04.03 | 17 | Measurement of radiation dose produced by each diagnostic CT imaging system for the adult brain, adult abdomen, pediatric brain, and pediatric abdomen by a qualified medical physicist And Verification by a qualified medical physicist that the radiation dose produced and measured for each protocol tested is within 20% of the CTCIvol displayed on the CT console. Document the dates, results, and verifications of these measurements. | AHC, CAH, HAP | |
EC.02.04.03 | 19 | Performance evaluation of all CT imaging equipment by a diagnostic medical physicist | AHC, CAH, HAP | |
EC.02.04.03 | 20 | Performance evaluation of all MRI equipment by a diagnostic medical physicist or MRI scientist | AHC, CAH, HAP | |
EC.02.04.03 | 21 | Performance evaluation of all nuclear medicine imaging equipment by a diagnostic medical physicist or nuclear medicine physicist | AHC, CAH, HAP | |
EC.02.04.03 | 22 | Performance evaluation of all positron emission tomography (PET) by a diagnostic medical physicist | AHC, CAH, HAP |
(continued on page 8)
Copyright 2016 The Joint Commission
Standard | Element of Performance | Required Documentation | Program Applicability | Documentation Present (Y/N) |
EC.02.04.05 | 1 | Written procedures for flow cytometry that address instrument performance | LAB | |
EC.02.04.05 | 5 | Records of the flow cytometry instrument performance | LAB | |
EC.02.05.01 | 2 | Written inventory of all operating components of utility systems | CAH, HAP, LAB | |
EC.02.05.01 | 3 | [CAH, HAP] Identify high-risk operating components of utility systems [LAB, NCC, OME] Identify in writing the activities for inspecting, testing, and maintaining all operating components of utility systems on the inventory | CAH, HAP, LAB, OME | |
EC.02.05.01 | 4 | [CAH, HAP] Activities and frequencies for inspecting, testing, and maintaining all operating components of utility systems in the inventory [LAB, OME] Identify intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory [NCC] Identify the frequencies for inspecting, testing, and maintaining all operating components of the utility systems on the inventory | CAH, HAP, LAB, NCC, OME | |
EC.02.05.01 | 5 | Activities and frequencies for inspecting, testing, and maintaining the following items according to manufacturers’ recommendations:
support the use of alternative maintenance strategies | CAH, HAP | |
EC.02.05.01 | 6 | Written criteria to support the determination whether it is safe to permit operating components of utility systems to be maintained in an alternate manner | HAP, CAH | |
EC.02.05.01 | 7 | [AHC, NCC, LAB, OBS] Map the distribution of utility systems [CAH, HAP] Identify operating components of utility systems on inventory that are included in an alternative maintenance program | AHC, CAH, HAP, LAB, NCC, OBS | |
EC.02.05.01 | 9 | Written procedures for responding to utility system disruptions | AHC, BHC, CAH, HAP, LAB, NCC | |
EC.02.05.01 | 16 | Map the distribution of utility systems | CAH, HAP | |
EC.02.05.07 | 1 | Dates of (at least) monthly functional tests of battery-powered lights required for egress for 30 seconds | AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME | |
EC.02.05.07 | 2 | [AHC] Dates of functional tests of battery-powered lights required for egress for 1½ hours every 12 months [BHC, CAH, HAP, LAB, NCC, OBS, OME] Dates of functional tests of battery powered lights required for egress for 1½ hours every 12 months, or date of replacement of batteries every 12 months and, during replacement, a random test of 10% of all batteries for 1½ hours | AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME | |
EC.02.05.07 | 3 | Dates of functional tests of stored emergency power supply systems for 5 minutes or as specified for its class | AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME | |
EC.02.05.07 | 7 | Dates of tests of emergency generators | AHC, CAH, HAP, LAB, NCC, OBS | |
EC.02.05.09 | 1 | [AHC] Tests of all piped medical gas and vacuum systems in ambulatory surgical centers that elect to use The Joint Commission deemed status option [CAH, HAP, NCC] Documentation of inspections, tests, and maintenance of critical components of piped medical gas systems | AHC, CAH, HAP, NCC | |
EC.02.05.09 | 2 | Completion dates of tests of piped medical gas and vacuum systems for purity, correct gas, and proper pressure when these systems are modified, installed, or repaired | CAH, HAP, NCC |
Key: EC = Environment of care; AHC = Ambulatory Health Care; BHC = Behavioral Health Care; CAH = Critical Access Hospital; HAP = Hospital; LAB = Laboratory;
NCC = Nursing Care Center; OBS = Office-Based Surgery; OME = Home Care.
Program applicability in this checklist refers to the documentation requirement, not the element of performance (EP) itself. In some instances, an EP may apply to additional accreditation programs but without a documentation component.
