ED Accreditation Update

Hospitals struggle to comply with Joint Commission standards regarding corridor cluttering and medical record keeping

ED managers can take corrective steps in their departments

Emergency department managers should take note of a couple of standards that had very high non-compliance rates for the first six months of 2011, according to data released by the Oakbrook Terrace, Il-based Joint Commission. One of these standards involves the requirement that a hospital "maintains the integrity of the means of egress." It is one of the foundational elements of the accrediting agency's "life safety" code, according to Michael Chisholm, CPE, CHFM, an associate director of the standards information group for engineering at the Joint Commission (JC). However, he emphasizes that despite high awareness of the issue, hospitals routinely struggle to comply, which explains the 57% percent noncompliance rate reported by the JC.

"If you look at fire history, regardless of whether it is in hospitals or not, one of the leading causes of death is obstructed or inadequacy of egress," says Chisholm. Yet hospital surveyors encounter these obstructions in hospital corridors all the time. "They'll see computers on wheels, linen carts, linen hampers, all types of machines, and a sundry of operational things," he says.

The problem, says Chisholm, is that hospital administrators often overlook the complexity of the issue. "Clinicians, by manner of delivering care, want to have everything readily available," he says. But this tends to create a cluttering problem because many hospitals lack adequate storage space for the computers-on-wheels and other technical devices that have proliferated in health care. As a result, these items end up in hospital corridors, says Chisholm.

To appropriately tackle the issue, Chisholm says that hospital leaders need to look at it from a materials management standpoint. This means running an inventory of everything, assessing what items staff really need to do their jobs, and then getting rid of all items that they don't need or that are redundant. "In my experience, there are always things hospitals can get rid off," says Chisholm. "You don't need 20 computers-on-wheels on a typical nursing floor that has 24 patients."

Once administrators have cleared away all the items that personnel don't need, then it's time to investigate whether they can reduce the size of needed equipment or perhaps find equipment than can perform two or three different functions, explains Chisholm, adding that alternative storage solutions need to be investigated as well. "You don't want to fill an unused room with a bunch of stuff, but if it is just used for equipment, we can accept that," he says. "Put a closer on the door of the room so that it closes automatically."

End patient boarding

Another standard that the JC reported as one of the most frequent areas of noncompliance has to do with maintaining "complete and accurate medical records for each individual patient." On this issue, the JC said there was a 69% noncompliance rate among its accredited hospitals.

The matter should be of particular concern to EDs that make a habit of boarding patients, according to James Augustine, MD, the director of clinical operations at EMP Management in Canton, OH. "Emergency department documentation of emergency care is typically inadequate to record the necessary elements of inpatient care, and does not incorporate the required medication reconciliation, nutritional status, and health care legal issues," he says. "In many cases, a 'tracer' review of the patient documentation for a patient boarded in the ED will not satisfy the needs of a Joint Commission review."

The best way to stay in compliance on this issue is to end the practice of boarding patients, says Augustine. "Admitted patients do not belong in the ED, with a few rare exceptions," he says.


  • James Augustine, MD, Director of Clinical Operations, EMP Management, Canton, OH. E-mail: jaugustine@emp.com.
  • Michael Chisholm, CPE, CHFM, Associate Director, Standards Information Group, Engineering, the Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5900.