Joint Commission shares 2017 standards compliance data for healthcare facilities

By: March 27th, 2018 Email This Post Print This Post

The Joint Commission (TJC) has released its lists, each based on the type of facility surveyed, of the requirements most frequently scored as “not compliant” during accreditation surveys and certification reviews during the 2017 calendar year.

The list of requirements scored as “not compliant” during 1,443 hospital surveys:

  1. LS.02.01.35: Systems for extinguishing fires are provided and its systems/devices are appropriately installed and maintained. (86%)
  2. EC.02.05.01: Utility systems are well designed, inventoried, monitored, and managed according to written procedures when disruptions in the utility system occur. (73%)
  3. LS.02.01.30: Building features are maintained which prevent the spread and fueling of fire and smoke. (72%)
  4. IC.02.02.01: Infection prevention and control activities are performed relative to the cleaning, storing, and disposing of medical equipment/devices. (72%)
  5. EC.02.06.01: Physical environment (e.g., lighting, temperature, ventilation, equipment, furnishings, space, etc.) is safe and functional. (70%)
  6. LS.02.01.10: Effects of fire, smoke, and heat are mitigated through the design and maintenance of building and fire protection features. (66%)
  7. EC.02.02.01: Risks related to hazardous materials and hazardous waste are managed as described in written policy. (63%)
  8. LS.02.01.20: Means of egress are maintained. (62%)
  9. EC.02.05.05: Testing and regular inspections of utilities are done. (62%)
  10. EC.02.05.09: Medical gas and vacuum systems are labeled, tested, inspected, and maintained. (59%)

The list of requirements scored as “not compliant” during 104 surveys of office-based surgery practices:

  1. IC.02.02.01: Infection prevention and control activities are performed relative to the cleaning, storing, and disposing of medical equipment/devices. (63%)
  2. HR.02.01.03: Individuals permitted by law and the organization to practice independently are granted by the practice initial, renewed, or updated clinical privileges. (61%)
  3. EC.02.04.03: Testing and regular inspections of medical equipment are done. (37%)
  4. MM.03.01.01: The hospital’s medications are stored in a manner which maintains their integrity, minimizes their diversion, reduces dispensing error, and promotes availability while following manufacturer guidelines, laws, and regulations. (34%)
  5. IC.02.01.01: Implementation of the written infection surveillance, prevention, and control plan is implemented by the hospital. (27%)
  6. NPSG.03.04.01: Medications, medication containers, and other solutions removed from their original container and placed into a container, both on and off the sterile field, are labeled as consistent with safe medication practices. (24%)
  7. HR.01.06.01: The organization has a competency assessment process in place. (23%)
  8. EC.02.05.07: Emergency power systems are tested, inspected, and maintained as required by the Life Safety Code®. (22%)
  9. WT.04.01.01: Quality control checks are performed as defined in the quality control plan for waived testing. (20%)
  10. MM.01.01.03: High-alert and hazardous medications defined by the hospital are safely managed. (18%)

Comments

By Allan Brack on March 30th, 2018 at 9:41 am

I lecture at many hospitals on Blood Bourne Pathogen issues relative to scalpel blade removal and needle sticks. It remains a mystery to me, that so few hospitals are aware of the need to use a single handed scales blade removal device for used scalpels. Hands or two handed use of hemostats or needle drivers are common as are post surgical cuts. So called safety scalpels are adding to the injuries through non-closure by the surgeon when passing the scalpel back to the nurse. Will OSHA and or The Joint Commission ever take action or will the 70,000 cuts a year continue?

 

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