The Joint Commission collects data on organizations’ compliance with standards, National Patient Safety Goals (NPSGs), the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements.
The Top 5 Joint Commission requirements identified most frequently as “not compliant” during surveys and reviews from Jan. 1 through June 30, 2019.
Top five most challenging requirements for hospitals, based on noncompliance rates are:
1. The hospital provides and maintains systems for extinguishing fires (91 percent).
2. The hospital manages risks associated with its utility systems (80 percent).
3. The hospital establishes and maintains a safe, functional environment (78 percent).
4. Ensure that building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. (73 percent).
5. Inspect, test, and maintain utility systems. (71 percent).
Top five most challenging requirements for ambulatory care, based on noncompliance rates are:
1. The organization reduces the risk of infections associated with medical equipment, devices, and supplies (60 percent).
2. The organization provides and maintains equipment for extinguishing fires (56 percent).
3. The organization implements infection prevention and control activities (52 percent).
4. Maintain fire safety equipment and fire safety building features (46 percent).
5. Manage risks related to hazardous materials and waste (45 percent).
