Several Joint Commission standards for hospitals have embarrassingly low compliance rates. Two Joint Commission experts — Jerry Gervais, CHFM, CHSP, an engineer and associate director in the Joint Commission's Standards Interpretation Group and Mary Carol Mooney, RN, MSN, senior associate director of the commission's Standards Interpretation Group — discuss how hospitals fall short and what they need to do to comply.
Note: The problem standards are ranked in order of noncompliance in 2008.
1. Meeting the code for fires and other "life safety" issues. In 2008, 45 percent of surveyed hospitals failed to fully comply with this Environment of Care standard, which involves making sure the hospital is prepared for fires and similar events. In fact, Mr. Gervais says this standard has had the highest rate of non-compliance for the past seven years. The code, then known as EC.5.20, has been changed to Life Safety standard LS.01.01.01.
Mr. Gervais says the Life Safety Code has to be strict because hospital patients, unlike occupants of most buildings, are not capable of self-preservation in a fire. This standard involves a very complex set of requirements, covering everything from a broken door closer to a firewall that has been penetrated.
It can be very difficult for hospital staff to stay on top of deficiencies, he says. For example, a laundry chute door that functioned properly in the day shift may suddenly break down at midnight without anyone fixing it. When a hospital hires contractors who do not know about healthcare requirements and unwittingly penetrate required firewalls, it simply compounds its compliance problems.
To ensure compliance, Mr. Gervais recommends making sure the staff is educated. "You shouldn't just tell them, 'Don't do this,'" he says. "You need to explain why. They need to understand the intent." He also recommends hiring contractors who have experience working in a healthcare facility.
2. Accepting and transcribing verbal or telephone orders. Forty-three percent of hospitals surveyed in 2008 fell short of this information management standard, IM.6.50. A common problem that hospitals have with compliance is making sure when a telephone order is received that it is signed off by the physician within 48 hours, Ms. Mooney says.
One reason for this requirement, she says, is to make sure the doctor's verbal order has been interpreted correctly. "This is a patient safety issue," she says. "If there has been a mistake, then it can be caught fairly early."
Ms. Mooney concedes that keeping up on the authentication or sign-off of verbal orders is challenging, particularly in an ICU, where, for example nurses, may be frequently calling the doctor and get 5-10 orders every few days.
To make sure the doctor signs the verbal order, one tip is to put a flag in the chart, but the doctor still may not sign-off within the time limit. "The healthcare worker today is very busy, which presents a challenge for organizations," Ms. Mooney says. She says nurses can take an active role by stopping doctors and asking them to sign orders whenever they come on the floor. She adds that doctors need to be educated on the importance of this requirement.
3. Properly storing medications. Thirty-seven percent of hospitals surveyed in 2008 missed fully complying with this medication management standard, MM.2.20, which has to do with properly and safely storing medications.
"Medications may be left sitting out on a counter, when they are supposed to be locked away or refrigerated," Ms. Mooney says. All medications have to be kept under lock and key, and narcotics often have to be double-locked. Regular checks by staff is way to make sure this happens.
4. Dealing with critical hospital tests. Thirty-seven percent of hospitals surveyed in 2008 didn't fully comply with this National Patient Safety Goal, NPSG Requirement 2C. Hospitals are required to "measure, assess, and take appropriate action to improve the timeliness of reporting and receipt of critical tests and critical results and values." Tests include imaging studies, laboratory tests and electrocardiograms. Critical tests, such as stat exams, always require rapid communication of results, but even normal tests that fall well outside of normal ranges require rapid communication. Hospitals should be collecting data on how these tests are handled in order to improve timeliness.
Ms. Mooney says this goal can be met by developing a flowchart for reporting critical tests, establishing required timeframes for reporting and reporting the results of all critical tests to the appropriate licensed caregiver.
5. Keeping a complete and accurate medical record. Thirty-one percent of hospitals surveyed in 2008 failed to meet the full intent of this information management standard, IM.6.10, which requires hospitals to "keep a complete and accurate medical record for patients assessed, cared for, treated or served."
The standard required 18 elements of performance in 2008. In 2009 it was split between five standards in the hospital manual chapter Record of Care, Treatment and Services, which are RC.01.01.01, RC.01.02.01, RC.01.03.01, RC.01.04.01 and RC.02.01.01.
The medical record must contain enough information to identify the patient, support the diagnosis and condition and justify the care, treatment and service, Ms. Mooney says. It must also document the course and results of care, treatment and service, and promote continuity of care among providers. Every entry in the medical record needs to be dated, with the author identified and, when necessary, authenticated.
6. Maintaining equipment and building features for fire safety. Twenty-six percent of hospitals surveyed in 2008 were not fully compliant with this environment of care standard, EC.5.40, now split into three standards: EC.02.03.05, LS.03.01.34 and LS.03.01.35. Moreover, Mr. Gervais says non-compliance has been increasing.
The standard covers two areas: fire detection, such as maintaining smoke detectors, and fire suppression, such as use of sprinklers. Hospitals that were built before 1991 are not required to install sprinklers unless they are remodeling.
Compliance requires complex testing on a weekly, quarterly and annual basis. If one test is left out, surveyors will note that.
7. Labeling medications. Twenty-five percent of hospitals surveyed in 2008 failed to fully meet this National Patient Safety Goal, NPSG Requirement 3D. This requirement reads: "Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field."
Ms. Mooney says this goal requires labeling each medication immediately after it is filed. Medications should not be filled in batches and then labeled.
8. Verifying qualifications of staff. Twenty-two percent of hospitals surveyed in 2008 didn't fully comply with this human resources requirement, HR.1.20, which reads: "Ensure staff qualifications are consistent with individual job responsibilities."
Ms. Mooney says this standard involves verifying the licenses of nurses or therapists with state regulators when they arrive and leave the organization. It can be done through the state's Web site by downloading the information, printing it and putting it in the employee’s file. She says hospitals usually do not have a problem carrying this out when employees are hired but may skip this when they leave.
9. Conducting a 'time out' just before surgery. Twenty-one percent of hospitals surveyed in 2008 did not fully comply with the Universal Protocol, UP Requirement 1C. In the "time out," the full surgery staff checks all important aspects of the surgery. Ms. Mooney says this means that everybody in the OR stops and performs one last check.
10. Comparing a patient's medications. Nineteen percent of hospitals surveyed in 2008 were not fully compliant with this National Patient Safety Goal, NPSG Requirement 8A. The goal is to "compare the patient's current medications with those ordered for the patient while under the care of the organization." Ms. Mooney says this involves reconciling new medications with those the patient is already taking. However, the Joint Commission has declared a moratorium on scoring this requirement as it develops new language, which is expected to go into effect in 2011.
Additional advice
Ms. Mooney says some good advice in complying with any of the requirements is to make sure that staff is appropriately oriented and receives ongoing education regarding organization policies and compliance with the standards. "Outreach and training makes the hospital more effective," she advises.
Mr. Gervais is concerned that the recession will make it more difficult for hospitals to comply. "In hard economic times hospitals are pressured to do so many things," he says. For instance, "there are staffing issues."
But both of them point out there are ways to improve compliance without spending a lot of money. For example, many of the standards require hospitals to create and complete forms used to report data. They advise that forms should be as simple as possible to ensure that they will be filled out correctly and still meet the intent of the standard.
If you have a question about complying with Joint Commission standards, please click www.jointcommission.org/Standards/OnlineQuestionForm/ or call (630) 792-5900.
Note: The problem standards are ranked in order of noncompliance in 2008.
1. Meeting the code for fires and other "life safety" issues. In 2008, 45 percent of surveyed hospitals failed to fully comply with this Environment of Care standard, which involves making sure the hospital is prepared for fires and similar events. In fact, Mr. Gervais says this standard has had the highest rate of non-compliance for the past seven years. The code, then known as EC.5.20, has been changed to Life Safety standard LS.01.01.01.
Mr. Gervais says the Life Safety Code has to be strict because hospital patients, unlike occupants of most buildings, are not capable of self-preservation in a fire. This standard involves a very complex set of requirements, covering everything from a broken door closer to a firewall that has been penetrated.
It can be very difficult for hospital staff to stay on top of deficiencies, he says. For example, a laundry chute door that functioned properly in the day shift may suddenly break down at midnight without anyone fixing it. When a hospital hires contractors who do not know about healthcare requirements and unwittingly penetrate required firewalls, it simply compounds its compliance problems.
To ensure compliance, Mr. Gervais recommends making sure the staff is educated. "You shouldn't just tell them, 'Don't do this,'" he says. "You need to explain why. They need to understand the intent." He also recommends hiring contractors who have experience working in a healthcare facility.
2. Accepting and transcribing verbal or telephone orders. Forty-three percent of hospitals surveyed in 2008 fell short of this information management standard, IM.6.50. A common problem that hospitals have with compliance is making sure when a telephone order is received that it is signed off by the physician within 48 hours, Ms. Mooney says.
One reason for this requirement, she says, is to make sure the doctor's verbal order has been interpreted correctly. "This is a patient safety issue," she says. "If there has been a mistake, then it can be caught fairly early."
Ms. Mooney concedes that keeping up on the authentication or sign-off of verbal orders is challenging, particularly in an ICU, where, for example nurses, may be frequently calling the doctor and get 5-10 orders every few days.
To make sure the doctor signs the verbal order, one tip is to put a flag in the chart, but the doctor still may not sign-off within the time limit. "The healthcare worker today is very busy, which presents a challenge for organizations," Ms. Mooney says. She says nurses can take an active role by stopping doctors and asking them to sign orders whenever they come on the floor. She adds that doctors need to be educated on the importance of this requirement.
3. Properly storing medications. Thirty-seven percent of hospitals surveyed in 2008 missed fully complying with this medication management standard, MM.2.20, which has to do with properly and safely storing medications.
"Medications may be left sitting out on a counter, when they are supposed to be locked away or refrigerated," Ms. Mooney says. All medications have to be kept under lock and key, and narcotics often have to be double-locked. Regular checks by staff is way to make sure this happens.
4. Dealing with critical hospital tests. Thirty-seven percent of hospitals surveyed in 2008 didn't fully comply with this National Patient Safety Goal, NPSG Requirement 2C. Hospitals are required to "measure, assess, and take appropriate action to improve the timeliness of reporting and receipt of critical tests and critical results and values." Tests include imaging studies, laboratory tests and electrocardiograms. Critical tests, such as stat exams, always require rapid communication of results, but even normal tests that fall well outside of normal ranges require rapid communication. Hospitals should be collecting data on how these tests are handled in order to improve timeliness.
Ms. Mooney says this goal can be met by developing a flowchart for reporting critical tests, establishing required timeframes for reporting and reporting the results of all critical tests to the appropriate licensed caregiver.
5. Keeping a complete and accurate medical record. Thirty-one percent of hospitals surveyed in 2008 failed to meet the full intent of this information management standard, IM.6.10, which requires hospitals to "keep a complete and accurate medical record for patients assessed, cared for, treated or served."
The standard required 18 elements of performance in 2008. In 2009 it was split between five standards in the hospital manual chapter Record of Care, Treatment and Services, which are RC.01.01.01, RC.01.02.01, RC.01.03.01, RC.01.04.01 and RC.02.01.01.
The medical record must contain enough information to identify the patient, support the diagnosis and condition and justify the care, treatment and service, Ms. Mooney says. It must also document the course and results of care, treatment and service, and promote continuity of care among providers. Every entry in the medical record needs to be dated, with the author identified and, when necessary, authenticated.
6. Maintaining equipment and building features for fire safety. Twenty-six percent of hospitals surveyed in 2008 were not fully compliant with this environment of care standard, EC.5.40, now split into three standards: EC.02.03.05, LS.03.01.34 and LS.03.01.35. Moreover, Mr. Gervais says non-compliance has been increasing.
The standard covers two areas: fire detection, such as maintaining smoke detectors, and fire suppression, such as use of sprinklers. Hospitals that were built before 1991 are not required to install sprinklers unless they are remodeling.
Compliance requires complex testing on a weekly, quarterly and annual basis. If one test is left out, surveyors will note that.
7. Labeling medications. Twenty-five percent of hospitals surveyed in 2008 failed to fully meet this National Patient Safety Goal, NPSG Requirement 3D. This requirement reads: "Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field."
Ms. Mooney says this goal requires labeling each medication immediately after it is filed. Medications should not be filled in batches and then labeled.
8. Verifying qualifications of staff. Twenty-two percent of hospitals surveyed in 2008 didn't fully comply with this human resources requirement, HR.1.20, which reads: "Ensure staff qualifications are consistent with individual job responsibilities."
Ms. Mooney says this standard involves verifying the licenses of nurses or therapists with state regulators when they arrive and leave the organization. It can be done through the state's Web site by downloading the information, printing it and putting it in the employee’s file. She says hospitals usually do not have a problem carrying this out when employees are hired but may skip this when they leave.
9. Conducting a 'time out' just before surgery. Twenty-one percent of hospitals surveyed in 2008 did not fully comply with the Universal Protocol, UP Requirement 1C. In the "time out," the full surgery staff checks all important aspects of the surgery. Ms. Mooney says this means that everybody in the OR stops and performs one last check.
10. Comparing a patient's medications. Nineteen percent of hospitals surveyed in 2008 were not fully compliant with this National Patient Safety Goal, NPSG Requirement 8A. The goal is to "compare the patient's current medications with those ordered for the patient while under the care of the organization." Ms. Mooney says this involves reconciling new medications with those the patient is already taking. However, the Joint Commission has declared a moratorium on scoring this requirement as it develops new language, which is expected to go into effect in 2011.
Additional advice
Ms. Mooney says some good advice in complying with any of the requirements is to make sure that staff is appropriately oriented and receives ongoing education regarding organization policies and compliance with the standards. "Outreach and training makes the hospital more effective," she advises.
Mr. Gervais is concerned that the recession will make it more difficult for hospitals to comply. "In hard economic times hospitals are pressured to do so many things," he says. For instance, "there are staffing issues."
But both of them point out there are ways to improve compliance without spending a lot of money. For example, many of the standards require hospitals to create and complete forms used to report data. They advise that forms should be as simple as possible to ensure that they will be filled out correctly and still meet the intent of the standard.
If you have a question about complying with Joint Commission standards, please click www.jointcommission.org/Standards/OnlineQuestionForm/ or call (630) 792-5900.