The Joint Commission has identified the top areas for noncompliance among standards; National Patient Safety Goals; the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery; and Accreditation and Certification Participation Requirements.
The top five Joint Commission requirements identified most frequently as “not compliant” during surveys and reviews from Jan. 1 through June 30 follow.
Ambulatory Care:
- Infection Prevention and Control standard 02.02.01, which says that the accredited facility reduces infection risks that are tied to devices, medical equipment, and supplies; 49% were noncompliant.
- Human Resources standard 02.01.03, which says that the accredited facility grants clinical privileges — initial, renewed, and revised — to individuals who are permitted by the organization and by law to practice independently; 48% were noncompliant.
- Medication Management standard 03.01.01, which says that the accredited facility safely stores its medications; 39% were noncompliant.
- Environment of Care standard 02.04.03, which says that the accredited facility inspects its medical equipment, tests it, and maintains it; 35% were noncompliant.
- Environment of Care standard 02.03.05, which says that the accredited facility maintains fire safety in terms of the equipment and building features; 34% were noncompliant.
Hospitals:
- Environment of Care standard 02.06.01, which says that the accredited hospital establishes and maintains an environment that is safe and functional; 66% were noncompliant.
- Infection Prevention and Control standard 02.02.01, which says that the accredited hospital reduces the risk of infections that are tied to devices, medical equipment, and supplies; 59% were noncompliant.
- Environment of Care standard 02.05.01, which says that the accredited hospital manages risks associated with its utility systems; 56% were noncompliant.
- Life Safety standard 02.01.20, which says that the accredited hospital maintains the integrity of the means of egress; 50% were noncompliant.
- Life Safety standard 02.01.35, which says that the accredited hospital provides and maintains systems for extinguishing fires; 47% were noncompliant.
Office-Based Surgery Practices:
- Human Resources standard 02.01.03, which says that the accredited practice grants clinical privileges — initial, renewed, and revised — to individuals who are permitted by law and permitted by the organization to practice independently; 71% were noncompliant.
- Infection Control and Prevention standard 02.02.01, which says that the accredited practice reduces the risk of infections that are tied to devices, medical equipment, and supplies; 53% were noncompliant.
- Environment of Care standard 02.04.03, which says that the accredited practice inspects medical equipment, tests it, and maintains it; 41% were noncompliant.
- Infection Control and Prevention standard 01.03.01, which says that the accredited practice identifies the risks for acquiring infections and transmitting them; 27% were noncompliant.
- National Patient Safety Goal 07.01.01, which says the accredited practice complies with the hand hygiene guidelines for the CDC or the World Health Organization; 25% were noncompliant.
