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Top challenging standards, 2011-2012

Top challenging standards, 2011-2012

Joint Commission reveals midyear stats

After reading this article, you will be able to:

  • Identify trends in the top problematic standards centered around buildings and facilities
  • Discuss how timing and dating of orders plays into 2012's most problematic standards
  • Describe infection control challenges that caused the most noncompliance in the past year


Identify the standard where leadership will be held ­accountable for noncompliance Every fall, The Joint Commission unveils updated statistics regarding the standards and ­National Patient Safety Goals that have been causing the most ­problems with compliance out in the field. As in years past, the top 20 problematic standards have remained relatively stable, with some slight fluctuation in just how ­problematic-in terms of noncompliance and RFIs-each was demonstrated to be.

Unsurprisingly, facilities issues-Life Safety Code® (LS) and Environment of Care (EC)-thoroughly dominated the top 10 list. Only three standards, RC.01.01.01 from the Record of Care chapter, IC.02.02.01 from Infection Control, and MM.03.01.01 from Medication Management, appeared in the top 10 among non-facilities issues.

Overheard at The Joint Commission's Hospital Executive Briefings in Brooklyn in ­September was one tongue-in-cheek suggestion by a veteran survey coordinator: "The buildings are too old. Sell the buildings!" Sarcasm aside, though, aging facilities do play into this trend, with another four EC standards showing up in the top 20, making 11 of the top 20 building related.

But before we can delve into building-related issues, let's take a look at the 800-pound gorilla on the list: the perennial top-cited standard, RC.01.01.01, the dating and timing of medical records.

According to Pat Adamski, RN, MS, MBA, FACHE, director of The Joint Commission's Standards Interpretation Group, three specific problem EPs stand out: EP 19, which addresses timing, EP 11, which addresses dating, and EP 6, which addresses the information included in the record.

"Dating and timing, particularly timing, continues to be a problem," Adamski told the Brooklyn audience.

And even in cases with successful dating and ­timing, the record must have sufficient information to ­justify the care, treatment, and services provided by the organization.

RC.01.01.01 did see an improvement in the ­percentage of hospitals found noncompliant, however, dropping from 66% at this time last year down to 61%.


Building issues

George Mills, MBA, FASHE, CEM, CHFM, CHSP, director of The Joint Commission's Department of ­Engineering, was on hand to address the many building-related problematic standards, beginning with an old annual favorite: LS.02.10.20, specifically EP 13, targeting corridor clutter. This standard dropped 4% in noncompliance this year down to 51%.

"If it looks like corridor clutter, it probably is," said Mills.

Mills did deliver some good news, however, ­noting that crash carts, isolation carts, and chemo carts are ­allowed in corridors as "in use." He also said that Life Safety surveyors have been ­instructed to be less "gotcha" about carts in hallways.

"If I catch a surveyor with chalk in their pockets" to mark whether a cart has been moved or not, he said, he won't be happy.

More good news: dead-end corridors-those hallways that lead to nowhere, often ending in a window-can be used as storage.

Additionally, this standard also covers suite issues-definitions of suites and what they can be used for. The real issue, Mills noted, is that suites, which can be used for storage, are not identified on the drawings provided to surveyors.

"If it's not on the drawing as a suite, it's an intervening corridor," said Mills. Hospitals should define boundaries, dimensions, and exits for all suites.

The building issues keep coming, with LS.02.01.10 appearing third on the list. Forty-seven percent noncompliance might not sound very good, but, as Mills pointed out, it's a significant (5%) improvement over last year as hospitals work to address barrier penetrations and issues with doors and ducts.

This standard continues to be dinged by The Joint Commission based largely on not following procedure. "If the staff needs a door open, get a work request in! Do it right," said Mills.

Number four on the list this year is, in fact, the No. 1 problematic standard for critical access ­hospitals: maintaining fire safety equipment (EC.02.03.05), ­specifically inspections of safety equipment such as fire extinguishers.

This is another situation where the work is being done, but not being properly documented. "There's a lack of management," said Mills. "The documentation is not available on the day of survey."

The solution is simple, he said: Build accountability into your contracts. At the end of each day, tell your contractor you want a list of deficiencies.

Because of the management component to this ­standard, The Joint Commission will double ding an organization for noncompliance-not just under the EC standard, but also ­under Leadership.

"The hope is that leadership can teach their staff to manage the process," said Mills.


Infection Control and Med Management

Midway through the top 10 we come across the lone ­Infection Control chapter standard to appear in the top 20. IC.02.02.01 targets the reduction of infection risks through medical equipment, devices, and supplies-­the noncompliance rate for this standard is 39%.

This standard, tied to two specific Conditions of Participation, infection control and surgical services, is about "making sure these processes are robust and address the safety of your patients," said Adamski. "We continue to find issues. Staff knowledge is the issue. There is an ­assumption of competency that does not exist."

Next up is the last remaining non-building standard to breach the top 10 list. MM.03.01.01, with 36% non­compliance, addresses safe storage of medication. This standard's challenges are twofold: first, the storage of medications within manufacturer guidelines, and second, the security of medication storage.

"It's the volume of requirements that bubble up under this standard that makes it problematic," said Adamski.

For example, The Joint Commission does not require logs for refrigerators, but it does require monitoring.

"You need pharmacy involved here as well-is a medication that has been stored below the ­recommended temperature still viable?" said Adamski.

Adamski noted that the Centers for Disease Control and Prevention can be consulted for vaccine ­references, and manufacturer guidelines will provide salient ­details, such as whether preservatives are used in a given medication, that can help determine when a medication should be pitched.

Additional areas hospitals should look at under this challenging standard are EP 6, which addresses access to medications by authorized individuals, EP 7, ­addressing medication labeling, and EP 8, addressing expired or otherwise damaged medications. As the old saying goes, if you have one vial of expired medication, your surveyor will find it!


More Life Safety

Life Safety returns to the top 10 at numbers seven (LS.02.01.30) and eight (LS.02.01.35). It's helpful to look at these standards together in terms of noncompliance because both address fire issues and both "go back to management," Mills said.

LS.02.01.30 targets building features to protect against fire and smoke. LS.02.01.35 is more ­prescriptive, ­addressing how much space is maintained below a ­sprinkler deflector over storage.

Mills suggested a visual queue explaining to staff where the height cutoff is in storage areas to prevent noncompliance with the sprinkler requirement.

The top 10 are rounded out by two EC standards, starting with EC.02.06.01, which requires organizations to maintain a safe environment for care.

"If there is a wild card, this is it," said Mills.

A lot of ground is covered under this standard, ­ranging from hazards created by uneven carpets to ­unsecured oxygen cylinders. (Exterior safety falls under a separate standard, EC.02.01.01.) EC.02.06.01 also looks at ventilation and ­humidity, everything ranging from air pressure to hot and cold calls. Proper humidity levels are particularly important for preventing mold growth.

"When we see humidity issues, mold is growing in the walls, etc.," said Mills.

Rounding out the top 10 is EC.02.02.01, which deals with personal protective equipment and hazardous waste handling and exposure.