Joint Commission releases update to top standards ­compliance issues

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Joint Commission releases update to top standards ­compliance issues

Medical records rises above life safety for most problematic

After reading this article, you will be able to:

  • Describe how top cited standards have changed in the past 12 months
  • Identify which standards appear most frequently on most-cited lists
  • Describe how the Life Safety Code comes into play with the most cited standards
  • Identify which standards in the top-cited list are directly related to patient care


Each year, The Joint Commission unveils which standards were among the most cited by surveyors not just for hospitals, but across all of the agency's accreditation programs. Its most recent list, covering calendar year 2010 surveys, reveals many repeat offenders among the most problematic standards; however, there is also a shift in focus from building issues to more patient care-centric challenges.

For several years, fire safety and Life Safety Code® (LSC)-related standards have topped most-cited or most-problematic lists, so to see these once again among the highest-ranked problematic standards is not surprising. For The Joint Commission's hospital accreditation program, specifically, these problem areas made up four of the top five most challenging.

We got a glimpse of this trend in September 2010, when The Joint Commission released its midyear data on most-challenging standards at its annual Executive Briefings meetings. The single greatest problem area at the time was RC.01.01.01, which requires hospitals to maintain, for each individual patient, complete and accurate medical records. Noncompliance with the standard had spiked from 49% at year-end 2009 to 62% by mid-2010. By the end of 2010, according to these latest statistics, RC.01.01.01 had jumped to 65% noncompliance.

According to a presentation by Pat Adamski, RN, MS, MBA, director of the Standards Interpretation Group and the Office of Quality Monitoring, at the New York Executive Briefings last year, hospitals are running into the most difficulties complying with dating and timing of entries. While The Joint Commission has removed the Measures of Success for the elements of ­performance (EP) related to dating and timing of entries (specifically EPs 11 and 19), hospitals must still maintain compliance.

"For the past three years [2008-2010], the same top standards compliance issues continue to remain in the top 10-20," says ­Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA.

Di Giacomo-Geffers advises benchmarking to research where your organization stands with respect to each of these identified problem areas.

"It would be to each organization's benefit to benchmark their performance with this data," she says. "Drill down to how well your organization is doing in comparison. Showcase your best practices and share with other organizations."

Di Giacomo-Geffers anticipates additional information from The Joint Commission explaining these fixtures in the top challenging standards list.

"Perhaps The Joint Commission will address this in their Booster Paks in 2011," she says. "Many hospitals love the Booster Paks."

Life Safety challenges

The LSC continues to plague hospitals during survey, with three of the top five most-cited standards falling under this category-specifically LS.02.01.20 (second on the list), LS.02.01.10 (number three), and LS.02.01.30 (number five).

LS.02.01.20, which deals with maintaining the integrity of means of egress, climbed four percentage points between 2009 and 2010 and increased to 51% noncompliance by year's end. The main issue under this standard? Hallway clutter. This evergreen issue is one for which hospitals still have not found a solution.

LS.02.01.10, which requires that building and fire protection features are designed and maintained in such a way that the effects of smoke, heat, and fire are ­minimized, actually saw a dip in mid-2010 from 48% to 44% noncompliance, but finished out the year with a higher rate of ­noncompliance than in 2009 (49%).

Finally, LS.02.01.30, which looks at how the hospital provides and maintains building features to protect individuals from fire and smoke hazards, was dinged 40% of the time. This increased from 37% noncompliance in 2009.

While this wrapped up the LSC's presence on the list of most-cited standards, we are not done with facilities issues. Environment of Care (EC) appears on the list at number four, specifically EC.02.03.05. This standard deals with fire safety equipment maintenance, as well as features of the building designed for fire safety, up four percentagepoints from 38% noncompliance to 42%.

Again, the culprit behind noncompliance is a known issue hospitals still struggle to resolve: complete and accurate documentation. Hospitals frequently outsource these inspections, but are they reading the resultant reports and following up on problems identified by these contractors?


Medication Management challenges

Medication management makes two ­appearances on the latest top-cited standards list-first with MM.02.01.01 at number six, and MM.04.01.01 wrapping up the list at number 10.

MM.03.01.01, which involves safe medication ­storage, clocks in with 33% noncompliance. This is yet another standard that saw what appeared to be an improvement in mid-2010 (from 34% to 31% ­noncompliance) only to end the year on the downswing.

This standard covers expired medications, a perennial issue many hospitals are consistently cited on.

The other most problematic Medication Management standard, MM.04.01.01-which requires clear and accurate medication orders-clocks in at 28% noncompliance. This number is down slightly from in 2009 (30%) and can be attributed primarily to not following the organization's own policies and procedures.


Rounding out the list

The remaining standards are a smattering of common challenges. None are surprises, as all three appeared on the midyear report for 2010.

Number seven for the year-end totals is from the ­Record of Care chapter: RC.02.03.07, verbal orders, specifically the receiving and recording of these orders. This ­consistently challenging standard was cited 33% of the time for 2010, and it was one of the few standards that saw a notable downtick in the percentage of citations (down from 37% in 2009).

According to the Executive Briefings report, RC.02.03.07, EP 4-verbal orders must be authenticated within the time frame as indicated by law or regulation-remains the most problematic section.

Provision of Care makes its first appearance on the list at number eight. PC.01.02.03 deals with patient ­assessment-that is, the hospital must both assess and reassess the patient and that patient's condition ­according to defined time frames.

This standard was cited 31% of the time. Of all the standards on this list, PC.01.02.03 saw a substantial jump in citations between 2009 and 2010 (up from 20% the previous year). Again, this appears to fall under the category of documentation issues.

The remaining problematic standard, which was the ninth most cited for calendar year 2010, comes from the Infection Control chapter: IC.02.02.01, which looks at how hospitals work to reduce infection risk ­associated with medical devices, equipment, and supplies. Like PC.01.02.03, IC.02.02.01 also saw a fairly significant jump in noncompliance from 2009, up from 21% to 29% (it hovered at 31% in mid-2010).

This standard was at 1% noncompliance in 2008. The most-cited EPs at last fall's Executive Briefings were those involving mid- to high-level disinfection of medical equipment, as well as storage issues.