SDS Accreditation Update

The top troublesome standards in surveys by The Joint Commission

When examining compliance issues before your survey by The Joint Commission, consider the quote from former president Ronald Reagan: "Trust, but verify."

"In your [facility], when we start going through some of the top scored standards are things that your staff are saying, 'Oh we've got this covered, we're doing this in the new electronic medical record,'" says Jennifer Cowel, RN, MHSA, vice president and principal at Patton Healthcare Consulting in Glendale, AZ. "That's wonderful, but at some point you're going to have to stop and ask, 'Let me see our compliance with … let's see the data on …' because sometimes the data does not speak as highly as staff's perception of compliance."

Cowel recently spoke on The Joint Commission's "Top Scored Standards and Other Troublesome Requirements" at a webinar sponsored by AHC Media, publisher of Same-Day Surgery. (For ordering information, see Resource at end of the article.) She held leadership and management roles for more than 17 years with The Joint Commission.

On Day 1 of the survey, expect the surveyors to visit your OR, visit your ICU (if you are a hospital), then come together at lunch and start sharing notes, she says. "They start forming conclusions pretty early in the survey process about how your survey is going to go," Cowel says.

Focus your time and money on the issues scored high in noncompliance, she says. "So when that survey team comes back after that first couple of tracers in the morning on day one, they're going to be talking, 'Hey, this is an organization that's on top of it. They've heard us, they're listening, and they're really focusing on some of these very challenging issues.'"

New problem areas: Environment of care

For those facilities that haven't been surveyed in a couple of years, one key difference is that most of the top problematic standards are not in the provision of care areas or traditional care areas. Instead, they're in the life safety or environment of care, Cowel says.

"These are the things that had traditionally been scored by the life safety code surveyor, which are now also being scored, during your onsite survey, by the clinical surveyors, by the doctor, the nurse, the administrator," she says.

In 2011, 40% of hospitals surveyed were out of compliance with EC.02.03.05. The hospital maintains fire safety equipment and fire safety building features. The figures for ambulatory and office-based organizations were not released.

Clinicians should be learning more about these standards, learning to identify gaps in these standards, and communicating those gaps to leaders, she says.

On the list for years: Medication storage

Safe medication storage (MM.03.01.01) is another problematic standard, Cowel says.

In 2011, 32% of ambulatory organizations were out of compliance, and 27% of office-based surgery facilities were not in compliance. The hospital non-compliance rate was not released by The Joint Commission.

"This particular standard has been on the list for years, and I would imagine it will be on the list for years," she says.

The Joint Commission has a booster pack available to all accredited organizations free of charge on the extranet that covers challenges and the recommendations for compliance with this standard, Cowel says. "But the largest problem that has been scored in this area has been medication temperatures, and The Joint Commission surveyors are coming around saying, 'Let me see the last month of refrigerator temperatures…' to see gaps in compliance with your own record or your own policy on this area," she says.

When you educate your staff, only keep out one month of a log if you're still using paper, Cowel says. "It is so tempting and so easy if the surveyor is given the last 12 months of logs to sit there and thumb through it while a conversation is going on, and if you show me 12 months of refrigerator logs, there's a guarantee that I'm going to find two dates in the last 12 months that you forgot to record it," she says.

Another problem area is that if the medication refrigerator is out of the proper temperature range, you have to document what you did about it, and the staff members need to able to verbalize what was done. They might say, "Well we turned it down. We checked it again." These steps must be documented on the logs, Cowel emphasizes.

For ambulatory surgery, the question comes up: How do you monitor temperatures on the weekends in areas that are only open Monday through Friday? If the ambulatory area is part of an inpatient facility that says temperatures are checked every day, surveyors will go to your ambulatory areas and ask to see the logs for Saturday and Sunday. Your policy should match your actions, Cowel says.

"In your five-day settings, it is perfectly acceptable to say, 'We capture temperature on days of operation, and we have high-low thermometers that we check back over the weekend to ensure that ours did not go wildly out of range over the weekend. And we have a policy in place on what we're going to do if our temperatures went out of range,'" Cowel says. "For both policy and review, don't forget those areas." (For information on another problem standard, having a complete medical record, see story, right.)


The webinar "Focus on 2012 – TJC top scored standards & other troublesome requirements" includes two tracer tools. One is a department walk-through checklist, and one is an environment of care document review. The price for the webinar and the tools is $350. To order, go to

A big problem area: Complete medical record

One of the most problematic standards for organizations accredited by The Joint Commission is the requirement for a complete medical record (Record of Care.01.01.01). In 2011, 66% of hospitals were non-compliant with that standard. The non-compliance rates for ambulatory and office-based organizations were not released.

"The biggest issue is timing of entries into the medical record: EP 19," says Jennifer Cowel, RN, MHSA, vice president and principal at Patton Healthcare Consulting in Glendale, AZ. "And when you've got still a blended record or a paper copy record, you've got to get all practitioners — doctors, nurses, and anyone else who is entering into the medical record — to time those entries."

Legibility also is scored, she says. "If you can't read it, the surveyor can't read it, and a couple people around you can't read it, they will score it out here," Cowel says.

If you are still using a paper record system, and if you are having significant challenges trying to get your practitioners to sign, date, and time all their entries, "consider using that data as part of the ongoing professional practice evaluation of your physician and licensed independent practitioners," she advises. "If you measure it, monitor it, and present it up through the department, that [process], in other organizations, has had a greater degree of success in getting behavior to change."

The Centers for Medicare and Medicaid Services (CMS) allows stamps, but "if you're using stamps in your organization, you can't have them prefilled in with the date or a time stamp even," Cowel says. "You can only do a 'fill-in-the-blank' signature where it's clear that the physicians themselves have signed, dated, and timed each entry in the medical record."