TJC List of the Top 10 Compliance Issues Cited During Surveys

Biannually,The Joint Commission (TJC), an accreditation and certification non-profit, publishes a list of the top 10 compliance issues cited during surveys.  Below is the most recent list of compliance issues for hospitals, ambulatory care, critical care hospitals, and office based surgery accreditation programs. 

I. Top Standards Compliance Issues for 2012 - Hospitals
60% RC.01.01.01 - The hospital maintains complete and accurate medical records for each individual patient.
51% LS.02.01.20 - The hospital maintains the integrity of the means of egress.
46% LS.02.01.10 - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
42% IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
40% EC.02.03.05 - The hospital maintains fire safety equipment and fire safety building features.
39% LS.02.01.30 - The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
35% EC.02.06.01 - The hospital establishes and maintains a safe, functional environment.
35% MM.03.01.01 - The hospital safely stores medications.
34% LS.02.01.35 - The hospital provides and maintains systems for extinguishing fires.
34% EC.02.05.01 - The hospital manages risks associated with its utility systems.
 
II. Top Standards Compliance Issues for 2012 - Ambulatory Care
52% HR.02.01.03 - The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
34% MM.03.01.01 - The organization safely stores medications.
31% IC.02.02.01 - The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
24% IC.01.03.01 - The organization identifies risks for acquiring and transmitting infections.
18% EC.02.02.01 - The organization manages risks related to hazardous materials and waste.
16% NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
16% WT.03.01.01 - Staff and licensed independent practitioners performing waived tests are competent.
15% EC.02.04.03 - The organization inspects, tests, and maintains medical equipment.
15% HR.01.02.05 - The organization verifies staff qualifications.
15% MM.01.02.01 - The organization addresses the safe use of look-alike/sound-alike medications.
 
III. Top Standards Compliance Issues for 2012 - Critical Access Hospitals
55% EC.02.03.05 - The critical access hospital maintains fire safety equipment and fire safety building features.
48% LS.02.01.10 - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
44% EC.02.05.01 - The critical access hospital manages risks associated with its utility systems.
42% LS.02.01.20 - The critical access hospital maintains the integrity of the means of egress.
38% EC.02.05.07 - The critical access hospital inspects, tests, and maintains emergency power systems.
36% IC.02.02.01 - The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
34% EC.02.02.01 - The critical access hospital manages risks related to hazardous materials and waste.
32% LS.02.01.30 - The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
32% MM.03.01.01 - The critical access hospital safely stores medications.
29% EC.02.06.01 - The critical access hospital establishes and maintains a safe, functional environment.
29% LS.02.01.35 - The critical access hospital provides and maintains systems for extinguishing fires.
 
IV. Top Standards Compliance Issues for 2012 - Office-Based Surgery Practices
49% HR.02.01.03 - The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
29% IC.02.02.01 - The practice reduces the risk of infections associated with medical equipment, devices, and supplies.
26% MM.03.01.01 - The practice safely stores medications.
15% NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
13% IC.01.03.01 - The practice identifies risks for acquiring and transmitting infections.
13% NPSG.03.04.01 - Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
11% PI.02.01.01 - The practice compiles and analyzes data.
11% WT.05.01.01 - The practice maintains records for waived testing.
10% IC.02.04.01 - The practice offers vaccination against influenza to licensed independent practitioners and staff.
10% EC.02.05.07 - The practice inspects, tests, and maintains emergency power systems.
10% HR.01.06.01 - Staff are competent to perform their responsibilities.