Survey prep: Identify the most frustrating standards

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After reading this article, you will be able to:

  • Name the most cited Joint Commission standards
  • Discuss the most common problem areas among the National Patient Safety Goals
  • Identify frequently cited areas of the Leadership chapter
  • Describe current challenges in the Record of Care chapter

According to an old Chinese proverb, it is better to sweat more during peace and bleed less during war.

The saying was invoked by Lisa Eddy, RN, CPHQ, CSHA, senior consultant at The Greeley Company, during her presentation at the 3rd Annual Association of Healthcare Accreditation Professionals conference in Las Vegas May 14–15. Her presentation, "Continuous Survey Readiness," ran through the most cited Joint Commission standards and methods for avoiding RFIs in these areas.

In healthcare accreditation, "peace is the time before the surveyors come," said Eddy. And not only during the 18-month survey window. "This is all the time," she said.

To prepare for a survey, it’s best to take a look at the most frequently cited standards, which The Joint Commission considers the biggest challenges.

Approximately 5% of all standards make up 85% of all RFIs for hospitals. The number of elements of performance this year rose to more than 2,000, Eddy noted.

"A lot of these are white noise. There is no way they would be able to look at them all," she said. There are known problem areas on which The Joint Commission focuses, and these become the most frequently cited standards. The Greeley Company refers to these as the Frustrating 5%.

National Patient Safety Goals

The National Patient Safety Goals remain a constant source for RFIs. Most common citations include:

  • Critical test/values
  • Labeling of secondary containers
  • Do-not-use abbreviations
  • Patient education in safety
  • Anticoagulant use
  • Look-alike/soundalike medications
  • Patient identification
  • Universal Protocol

Medication reconciliation has been a most cited standard perennially, but The Joint Commission is revisiting the concept this year.

The Universal Protocol will undergo a similar reexamination this year (see the related story on p. 12).

In addition, the Provision of Care chapter has its share of challenges. Chief among them is communicating standards for history and physical exams due to recent changes. The field continues to struggle with this concept as physicians and other staff members cling to previous rules for history and physicals.

New standards state that a history and physical is good for up to 30 days, but there must be an update to the history and physical within 24 hours after admission or registration (as with day surgery) prior to a procedure.

Other Provision of Care challenges include assessment, pain management, education, plan of care, operative/invasive procedures/sedation, behavioral health, and restraint management.

Restraints will be updated again soon, so "if your restraints policy is working for you now, don’t change anything," said Eddy.

Old challenges and new

The Medication Management chapter continues to challenge hospitals and provide for a significant number of RFIs in areas such as security of medications, complete orders, stability of medications, outdates, emergency medications, and concentrations.

"There’s a saying: ‘There’s medication, and there’s everything else,’ " said Eddy.

Although Medication Management has been a frequently cited chapter for years, there are new contenders on the scene, such as the Leadership chapter.

"We’re seeing a lot come up surrounding the culture of safety survey," said Eddy.

Hot spots include:

  • Patient safety
  • Analyzing and assessing data
  • Contracted services
  • Policies and procedures
  • Patient flow
  • Conflict management

Surveyors are looking at how hospitals collect data regarding how they are working to improve the culture of safety at their facility. "You need a statistically valid tool," said Eddy. "We see a lot of hospitals working culture-of-safety questions into their HCAHPS surveys."


Record of Care remains a challenge. One new requirement, the dating and timing of all entries, is being cited frequently. There are few surprises among the other most-cited standards in this chapter:

  • Immediate postoperative note
  • Documentation of care
  • Authentication of telephone orders
  • Legibility/medical record review
  • Ambulatory list

And no list of top cited standards is complete without an eye toward environment of care (EoC). "These are all easily, easily cited," said Eddy.

The list of most frequently cited EoC standards reads like a who’s who of hospital challenges: emergency management, general safety, Life Safety Code®, interim life safety, and suicide risk assessment.

Another challenge is defibrillator testing, a requirement that can become an easy target for a falsification of records citation. Often, staff members will say the defibrillator has been tested on a floor that doesn?t use the equipment frequently (e.g., behavioral health or the neonatal ICU).

As a test, ask staff members to demonstrate the use of the defibrillator. If they don’t know how to operate it, they just made an unintentional falsification.