2011’s Hit Parade: Examining the Most Frequently Cited TJC Requirements

The Joint Commission (TJC) has once again offered an overview of the most challenging requirements during 2011 surveys. The listing closely matches the experience informally discussed in the field with Record of Care 01.01.01 as the most frequently cited requirement, followed closely by Life Safety 02.01.20, 02.01.10, and 02.01.30, and Environment of Care 02.03.05.

The frequency of these citations is also in line with Compass Clinical Consulting’s experience on survey readiness assessments.

RC.01.01.01 The hospital maintains complete and accurate medical records for each individual patient.

LS.02.01.20 The hospital maintains the integrity of the means of egress.

LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.

This high number of violations of standard RC 01.01.01 reflects the complexity of creating and maintaining a complete and accurate record of care for each patient. New computer systems and the mixture of computerized and paper records, coupled with multiple users—many of whom are not aware of regulatory and hospital policy requirements—make meeting this standard’s requirement a challenge for even the most organized and well-managed hospital.

Assuring compliance requires a multidisciplinary approach to designing documentation systems and developing mechanisms of oversight. Because care is multidisciplinary, no one discipline or function can own this responsibility—all disciplines must be involved.

The prevalence of Life Safety Code and Environment of Care citations may reflect the increased participation of engineering professionals in the survey process. Because of the knowledge base and assessment skills of these professionals, they are particularly adept at ferreting out deviations from standards. Hospitals should place a greater emphasis on these important areas than they have in the past and carefully assess and assure compliance.

Survey compliance is important, and even more so, patients and staff merit no less than a safe environment for care and work.

For more information or to discuss our Clinical Compliance and Accreditation services, please visit our website or contact Kate Fenner, RN, PhD, or Cary Gutbezahl, MD, at (513) 241.0142.