October 02, 2012 | | Comments 0
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We’re number 2! We’re number 2!

As September draws to a close, it’s time for a recap of the survey year according to the information provided at Joint Commission Executive Briefings, held in locations all across this great nation.

One interesting change is that rather than covering the 10 most frequently cited standards during Joint Commission surveys, the scope has expanded to the 20 most frequently cited standards. And the reason for the expansion, you might well ask? As near as I can tell (or so I’ve been told), it’s because the Life Safety and Environment of Care standards have taken over the top 10 to the extent that the Joint needed to adjust to keep some of the clinical issues on the map.

So, by my calculations, 12 of the 20 most frequently cited standards reside pretty squarely in the management of risk in the physical environment (there’s one that may not seem to “fit”, but trust me on this – it’s definitely something we need to have on the radar. More on that in a moment).

Removing the clinical standards, we come up with a tally of:

#2, with 52% of hospitals having been cited – LS.02.01.20 – Integrity of means of egress

#3, with 47% of hospitals having been cited – LS.02.01.10 – Design and maintenance of building and fire protection features

#4, with 40% of hospitals having been cited – EC.02.03.05 – Maintenance and testing of fire safety equipment and fire safety building features

#5, with 39% of hospitals having been cited – IC.02.02.01 – Managing the risks of infections associated with medical equipment, devices, and supplies (this is the sort of an odd one, but you’ll see it fits – I gar-on-tee that)

#7, with 36% of hospitals having been cited – LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke

#8, with 35% of hospitals having been cited – LS.02.01.35 – Fire extinguishing system requirements

#9, with 32% of hospitals having been cited – EC.02.06.01 – Establishment and maintenance of a safe, functional environment

#10, with 29% of hospitals having been cited – EC.02.02.01 – Management of hazardous materials risks

So, that’s an 80% showing for the EC/LS clan in the top 10. Now, one thing we’re going to have to try and figure out is this:

Are they finding this stuff because they’re looking for it? Or,

Are they looking for this stuff because it’s easy to find?

That’s your discussion point for the week – let’s see what you can come up with and we’ll get to the rest of the Top 20 next week.

Entry Information

Filed Under: Environment of careLife Safety Code


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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