Earlier this year, we shared with you 2011’s most frequently cited Joint Commission (TJC) requirements, as well as a snapshot of TJC survey reports from the first quarter of 2012.
The Executive Briefing from TJC has yielded a new “most popular” list. The most frequently cited deficiencies have been expanded to 20 from the previous 10. The former “top 10” list included multiple citations in Life Safety (LS) and Environment of Care (EC). The new list still is dominated by LS and EC findings with 11 of the 20 total—four in Life Safety and seven in Environment of Care. No other area comes close in terms of frequency.
The predominance of LS and EC citations makes evident that the use of specialized LS/EC surveyors compared to the past practice of using administrative surveyors continues to increase the number of findings. Survey preparation must now adapt to encompass this reality.
But number one on TJC’s new list is RC.01.01.01, once again reminding us that attaining and maintaining a complete and accurate medical record is the largest accreditation standard challenge confronting clinicians. In fact, 61% of hospitals surveyed received this finding, which means that hospitals need to focus on reining in use of date/time stamps and assuring that clinical documentation is thorough.
In addition to assuring thorough documentation, Compass Clinical Consulting suggests that hospital accreditation professionals become well versed in the intricacies of Life Safety and Environment of Care. Moreover, we encourage accreditation professionals to reach out to the managers responsible for these areas (usually safety, building, plant, and physical operations leaders) to make sure they are up to speed with the increasingly rigorous application of these standards. In many hospitals, these areas handle the survey on their own and have little internal scrutiny. But now, with surveyors who have greater expertise in Life Safety, Environment of Care, and survey methods, it is much more difficult to get through survey without deficiencies being identified. Given this new reality, these areas must be better integrated into the continuous readiness program. A proactive effort to better connect lives out the truism, “Trust, but verify.”
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