8 challenging standard areas for Joint Commission ambulatory accreditation

According to The Joint Commission, the most challenging standards include the environment of care, human resources and infection control areas.

The most challenging standards related to the environment of care include:

1. Security and safety risks are managed:

• Identify risks
• Take action to minimize risk
• Control access to security sensitive areas

2. Manage hazardous materials and waste

• List of hazardous materials/waste
• Hazardous chemicals
• Hazardous energy
• Label hazardous materials/waste

3. Maintain fire safety equipment/building

• Document monthly fire extinguisher checks

4. Medical equipment is maintained, tested and inspected

• Test and maintain all high-risk equipment
• Test and maintain medical equipment on inventory
• Document testing and maintenance of sterilizers

5. Collect information to monitor conditions in the environment

• Evaluate each environment of care plan annually

The human resources challenging standards include:

6. Clinical privileges are granted to licensed independent practitioners

• Primary source verify training
• Review PI activities
• Ensure privileges are site-specific
• Leaders grant privileges

The infection control challenging standards include:

7. Identify risks for acquiring and transmitting infection

• Identify risks based on geographic/pops served
• Prioritize document identified risks

8. Reduce the risk of infections associated with medical equipment devices, supplies

• Cleaning and performing low-level disinfection of medical equipment, device and supplies
• Perform intermediate and high-level disinfection and sterilization
• Storage

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