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Top 10 Compliance Findings Cited in Joint Commission Outpatient Surveys

A fairly small number of standards are often cited in Joint Commission surveys of ambulatory facilities, says Virginia McCollum, RN, associate director of the department of standards interpretation at the accrediting agency. Ms. McCollum reports the following standards were the top 10 "requirements for improvement" from Jan. 2011 to July 2011 at 50 different types of ambulatory facilities, ranging from ambulatory surgery centers to sleep labs and imaging centers. "Since these are the most frequently cited observations, this list is a good starting point on what areas to look at within your own organization," she says.

1. Credentialing and privileges (48 percent of inspected facilities). This standard (HR.02.01.03) involves verifying credentials of licensed independent practitioners, including physicians. "Verifying credentials is a very tedious process," Ms. McCollum says. "It has a lot of pieces." For example, the work involves finding the original source of a credential or privilege and checking with the National Practitioner Data Bank every two years.


2. Safe storage of medications (31 percent). Standard MM.03.01.01 requires the facility to safely store medications. This includes making sure medications are stored in a secure place, according to manufacturers' recommendations, and have not expired.

3. Infection control measures (27 percent). This standard (IC.02.02.01) involves implementing infection prevention and control activities when cleaning and disinfecting medical equipment, devices and supplies. For example, surveyors make sure surfaces have been disinfected properly, intermediate and high-level disinfection has been performed and medical equipment, devices and supplies have been stored or disposed of.

4. Infection control surveys (21 percent). Standard IC.01.03.01 requires the facility to perform a risk-analysis on acquiring and transmitting infections. The analysis is based on the facility's geographic location, community and population served.

5. Hand hygiene (21 percent). Referencing a National Patient Safety Goal (NPSG.07.01.01), this standard involves following CDC or World Health Organization guidelines for handwashing.

6. Lab test records (19 percent). This so-called "waived testing" standard (WT.05.01.01) requires keeping records of certain lab tests performed for the facility. For example, results for internal and external controls must be documented in the patient's clinical record and results must be accompanied by reference intervals.

7. Verifying staff qualifications (17 percent). Human resources standard HR.01.02.05 involves verifying qualifications of staff. For example, licenses have to be verified at the primary source.

8. Lab quality control checks (17 percent). This second waived testing standard on the list (WT.04.01.01) requires performing quality control checks for each waived testing procedure performed at the facility. These can include instrument-based testing, quality control checks performed on each day of patient testing and non-instrument control checks.

9. Environment of care (16 percent). The "environment of care" standard (EC.04.01.01) requires the facility to monitor conditions in the environment, such as conducting a proactive risk analysis and performing continual monitoring, internal reporting and investigations. The category also includes monitoring injuries to patient, occupational illness and staff injuries and property damage.

10. Labeling medications (16 percent). Here surveyors apply another National Patient Safety Goal (NPSG.03.04.01) to make sure that all medications and medication containers are labeled with such information as the preparation date and the date and time of expiration.


Learn more about the Joint Commission.



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