April 20, 2018

The 5 accreditation requirements that most hospitals miss, according to the Joint Commission

Daily Briefing

    The Joint Commission last week published a list of the five requirements hospitals and other health care organizations were most likely to miss in 2017.

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    According to the Joint Commission, the list is based on a review of its hospital accreditation and certification surveys conducted in 2017.

    Top 5 requirements hospitals did not comply with

    The top 5 hospital accreditation requirements most likely to be cited as "not compliant" in 2017 were:

    1. Provides and maintains systems for extinguishing fires, for which 86% of hospitals were not compliant;
    2. Manages risks associated with a hospital's utility systems, for which 73% of hospitals were not compliant;
    3. Provides and maintains building features to protect individuals from the hazards of fire and smoke, for which 72% of hospitals were not compliant;
    4. Reduces the risk of infections associated with medical equipment, devices and supplies, for which 72% of hospitals were not compliant;
    5. Established and maintains a safe, functional environment, for which 70% of hospitals were not compliant.

    For critical access hospitals (CAHs), the top 5 accreditation requirements most likely to be cited as "not compliant" in 2017 were:

    • Manages risks associated with hospital utility systems, for which 85% of CAHs were not compliant;
    • Provides and maintains systems for extinguishing fires, for which 83% of CAHs were not compliant;
    • Reduces the risk of infections associated with medical equipment, for which 72% of CAHs were not compliant;
    • Building and fire protection features are designed and maintained to minimize effects of fire, smoke, and heat, for which 70% of CAHs were not compliant;
    • Inspects, treats and maintains medical gas and vacuum systems, for which 69% of CAHs were not compliant.

    Top 5 accreditation misses for other organizations

    The Joint Commission also published the top 5 accreditation requirements most likely to be cited as "not compliant" in 2017 for ambulatory care and home care providers.

    For ambulatory care providers, the top five were:

    • Reduces the risk of infections associated with medical equipment, devices, and supplies, for which 60% of ambulatory care providers were not compliant;
    • Safely stories medications, for which 49% of ambulatory care providers were not compliant;
    • Grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently, for which 47% of ambulatory care providers were not compliant;
    • Inspects, treats, and maintains medical equipment, for which 38% of ambulatory care providers were not compliant;
    • Manages risks associated with its utility systems, for which 38% of ambulatory care providers were not compliant.

    For home care providers, the top five were:

    • Provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation, for which 42% of home care providers were not compliant;
    • Plans patient care, for which 41% of home care providers were not compliant;
    • Implements planned infection prevention and control activities, for which 34% of home care providers were not compliant;
    • Staff who are competent to perform their responsibilities, for which 32% of home care providers were not compliant;
    • Patient record contains information that reflects the patient's care, treatment, or services, for which 29% of home care providers were not compliant (Vaidya, Becker's Clinical Leadership & Infection Control, 4/17; Joint Commission article, 4/11).

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