The Joint Commission (TJC) recently released the top standards compliance data for 2016. TJC aggregates standards compliance data regularly to pinpoint the areas that present the greatest challenges to accredited organizations and certified programs.

The trends identified by these data inform TJC’s education around challenging standards; National Patient Safety Goals (NPSGs); the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery; and Accreditation or Certification Participation Requirements (APRs or CPRs). Additionally, these trends can be helpful for accredited organizations in their compliance efforts and in preparing for survey.

Bar graphs provided in the April 2017 edition of The Joint Commission Perspectives identify TJC standards most frequently scored as “not compliant” during accreditation surveys and certification reviews in a variety of categories from January 1, 2016, through December 31, 2016.

Below are the top five most frequently cited standards for Ambulatory Care, Behavioral Health, Critical Access Hospitals, Home Care, and Hospitals.

Ambulatory Care
  1. IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
  2. HR.02.01.03: The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
  3. EC.02.03.05: The organization maintains fire safety equipment and fire safety building features.
  4. MM.03.01.01: The organization safely stores medications.
  5. EC.02.04.03: The organization inspects, tests, and maintains medical equipment.
Behavioral Health Care
  1. CTS.03.01.03: The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.
  2. HRM.01.02.01: The organization verifies and evaluates staff qualifications.
  3. NPSG.15.01.01: Identify individuals at risk for suicide.
  4. HRM.01.06.01: Staff are competent to perform their job duties and responsibilities.
  5. IC.02.04.01: The organization facilitates staff receiving the influenza vaccination.
Critical Access Hospitals
  1. EC.02.05.01: The critical access hospital manages risks associated with its utility systems.
  2. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  3. EC.02.06.01: The critical access establishes and maintains a safe, functional environment.
  4. EC.02.03.05: The critical access hospital maintains fire safety equipment and fire safety building features.
  5. LS.02.01.30: The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
Home Care
  1. PC.02.01.03: The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation.
  2. PC.01.03.01: The organization plans the patient’s care.
  3. HR.01.06.01: Staff are competent to perform their responsibilities.
  4. IC.02.01.01: The organization implements the infection prevention and control activities it has planned.
  5. RC.02.01.01: The patient record contains information that reflects the patient’s care, treatment, or services.
Hospitals
  1. EC.02.06.01: The hospital establishes and maintains a safe, functional environment.
  2. IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  3. EC.02.05.01: The hospital manages risks associated with its utility systems.
  4. LS.02.01.35: The hospital provides and maintains systems for extinguishing fires.
  5. LS.02.01.30: The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
The full list of 10 top cited standards for each is available in The Joint Commission Perspectives.

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