Focus on Compliance in Health Care

Have you ever wondered what the most frequent citations are during Joint Commission surveys? Speculate no more! The Joint Commission has teamed up with The American Society for Healthcare Engineering (ASHE) to identify the top eight physical environmental standards that are most frequently cited during Joint Commission surveys. Physical Environmental standards include, but are not limited to, fire safety features, egress concerns, and mechanical and electrical system design and operation issues. Citations are made during on-site surveys conducted by The Joint Commission every three years as a part of the process that allows hospitals to maintain their accreditation.

The Joint Commission is one of three Hospital Accrediting Agencies in the United States that The Centers for Medicare and Medicaid Services (CMS) has given authority. It may be the most widely recognized agency since it accredits the majority of hospitals, and has a whopping total of 4,400 hospitals under its belt! The Joint Commission has had deeming authority since 1965 and was established by healthcare professionals to improve patient care delivery. According to the ASHE website, ASHE is the largest association devoted to optimizing the physical environment of health care facilities, and its primary members are facility managers.

The united effort between ASHE and The Joint Commission has been titled “Focus on Compliance”. Technical documents and resources, as well as the list of top citations, will be provided to help hospitals address critical issues. Every two months they will highlight a physical environmental standard.

The first set of topics published in August/September 2015 focuses on utility systems (EC.02.05.01).

The Top 5 Performance Issues:

1. Inappropriate Room Pressurization
2. Failure to label Electric Panels
3. Lack of Emergency Lighting
4. Failure to Label Utilities
5. Inappropriate Electrical Issue

The ASHE Website will provide more information on each topic, including a narrative of terms and concepts, case studies, sample assessment forms, and standard operating procedure documents. The complete topic list from the website includes:

  • October/November 2015: Means of egress (LS.02.01.20)
  • December/January 2016: Built environment (EC.02.06.01)
  • February/March 2016: Fire protection (EC.02.03.05)
  • April/May 2016: Building and fire protection features (LS.02.01.10)
  • June/July 2016: Life safety protection (LS.02.01.30)
  • August/September 2016: Automated suppression systems (LS.02.01.35)
  • October/November 2016: Hazardous materials and waste management (EC.02.02.01)

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