Accreditation

Joint Commission’s top-cited standards list gives hospitals plenty to work on

Briefings on Accreditation and Quality, November 1, 2017

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In what is likely a result of a new survey matrix, new or revised Life Safety and Environment of Care requirements, and increased pressure from CMS, hospitals scored much worse across the board on The Joint Commission’s list of most challenging standards for the first half of 2017, compared to the same period last year. The Joint Commission released its list in the September issue of Perspectives.

Nine of the top 10 cited standards were the same as in 2016. However, almost double as many hospitals were scored under the top two most-cited standards in 2017: Life Safety standards LS.02.01.35, requiring hospitals to maintain fire extinguishing systems, and LS.02.01.30, which requires building features to protect against fire and smoke hazards.

While it may seem like you need more resources now to get ready for survey, be-fore going to your leadership to ask for more money or workers, take a good look at your compliance with the top four most challenging standards identified by The Joint Commission and solicit help from clinical staff in spotting NFPA 101 Life Safety Code® (LSC) violations.

“Make sure you are working smart first,” recommends Jennifer Cowel, a former Joint Commission director of service operations and now president of Patton Healthcare Consulting in Naperville, Illi-nois. “Of the many things hospitals focus on, there may be a need to reprioritize the effort it takes to stay compliant with the top 10 scored EC/LS standards.”

Nailing those standards has a lot of value, she says.

“Some may take a better and more active partnership between facilities staff and unit staff. The unit staff may have to extend the ability of facilities to note and report violations so they can be fixed," Cowel says. "Facilities staff cannot be everywhere all the time, but clinical staff are in the best position to be the first to notice incorrect air pressure, incorrect tem-perature, broken ceiling tiles, or missing sprinkler escutcheons.”

Look for these common violations under the most challenging standards seen on survey reports this year, says Cowel. The following percentages reflect the proportion of hospitals The Joint Commission surveyed in the first six months of 2017 who failed that standard.

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