This month’s edition of Perspectives summarizes Joint Commission scoring patterns. It includes the accreditation and certification programs for the full calendar year 2018. And, it contains the “usual suspects” and a few surprises.
Joint Commission Scoring Patterns
Although they have changed position, you’ll find the frequently scored hospital standards familiar.
For example, we noted that IC.02.02.01, fell from number three during the first half of 2018, to number five. This is the standard where issues relative to HLD and sterilization are scored. Non compliant hospitals on this standard dropped from 74% in the first half year to 71% for the full year. This means there was an approximate drop of 6% during the later half year. We assume it ties to the change in focus from clinical practice guideline minutia to MIFU. This change caused some surveyor confusion which affected the scoring.
One standard, IC.02.01.01, dropped out of the top 10. It scored in 61% of hospitals during the first half of the year. IC.02.01.01 is a catch all standard and includes scoring for any kind of potential infection control hazard. The hazards include adhesive residue, cardboard, mixed storage of clean and dirty supplies and more.
But, dropping out of the top ten is not that significant. First, number ten in the new listing is still scored in 62% of hospitals. Second, if IC.02.01.01 remained scored in 61% of hospitals it means, that’s still significant. It may have dropped out but that doesn’t decrease its significance.
The New Number 10
This new number ten is EC.02.05.09, which did not make the previous top ten lists.
In fact, EC.02.05.09 is a complex standard with 14 diverse elements of performance. It includes dealing with medical gases, piped gasses and stored cylinder gases. In our experience, the three most frequently cited issues are:
- EP12 on commingling of full and empty cylinders.
- EP6 describing an excessive number of cylinders stored
- EP11 which includes blocking medical gas shut off valves
In addition, there are newer expectations that some organizations may have missed during the conversion to LSC 2012. This includes EP 1 on categorization of medical gas systems, and EP’s 4 and 5 relative to labeling doors where medical gases are stored.
Self Assessment & Continuous Review
Subject this new arrival to the top ten list and the other usual suspects to a complete self assessment and continuous review including:
- EOC rounds, tracer rounds
- Administrative rounds
- Any other periodic inspection processes
The frequency of scoring these issues is huge. In fact, 88% of hospitals fail on LS.02.01.35. And, nine other common standards fall between 61% to 80% noncompliance rates.
For the most part, this is not because of a lack of action. Hospitals examine these issues and take corrective actions. But, maintaining continuous compliance with these issues is so difficult. The only solution is to:
Over and over again until you stop finding these common flaw issues in your organization.
In this most recent listing TJC, also included a grid displaying the most frequently scored standard by accreditation program in a side-by-side comparison. If you have multiple programs, this is a nice tool to help focus. In fact, you can see the similarities in scoring hospitals and critical access hospitals, and to a lesser extent ambulatory facilities. What was surprising is the infrequent cross over with more commonly paired or tailored programs like hospital plus behavioral health, hospital plus home care, or hospital plus nursing care center.
Whether you need assistance with survey process changes like these or other Joint Commission standards, we can help. Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services including support developing healthcare’s reporting culture.