What should you worry about getting right for survey?
10 standards missed by more than a third of hospitals
Even the best hospitals are likely to get something wrong during a survey, and Paul Ziaya, MD, a surveyor in his tenth year with The Joint Commission, has an encyclopedic knowledge of the ones that are most likely to be a problem. When The Joint Commission released its top 10 list of problems cited during surveys, Ziaya rattled off the numbers related to the standards and the most common problems associated with them from memory with ease.
About half of all hospitals get dinged on the first seven on the list, and the last three are problems for between 35 and 40% of facilities, so they aren’t insignificant issues. And the things that the hospitals get wrong that fall under each standard seem to be the same, too, Ziaya notes.
Critical access hospitals (CAH) have a slightly different list, but they share seven of the same elements. (See page 75 for critical access hospital top 10 list.)
For non-CAH facilities, Ziaya outlined each of the top 10 problem standards and the common issues related to them that he finds during surveys.
1. 52% of hospitals have issues with LS.02.01.20: "The hospital maintains the integrity of the means of egress." This is usually related to hospitals having clutter impeding patients’ ability to exit their rooms and the building, mostly because there is equipment in the halls that isn’t something that is used every 30 minutes. Computer work stations that are left to charge, trash cans — they can be left for hours, Ziaya says. Crash carts or chemo carts can be left, but the other stuff? It has to be stored away.
2. 52% of hospitals have problems with RC.01.01.01: "The hospital maintains complete and accurate medical records for each individual patient." Ziaya says the main issue here is timing — whether an order was acted on in a timely manner. Sometimes, it was, but if it wasn’t logged, it is unknown. And if it wasn’t written down, it might as well not have happened.
3. 48% have problems with LS.02.01.10: "Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat." The most common finding under that standard is holes found in the ceiling and firewalls that were drilled in order for cords to pass through, and then inadequately sealed up, he says. "Each of those penetrations has to be sealed with fire-rated material." If it isn’t verified that the holes are filled with the right material — either by pictures or having a checklist filled out by having a walk through with the appropriate official, then you could be one of the hospitals that makes up the 48%, Ziaya says.
4. 47% of hospitals have issues with standard EC.02.05.01: "The hospital manages risks associated with its utility systems." This is mostly related to ventilation systems, Ziaya says, especially where the environment has to go from cleanest to less clean — like from the operating theater out, or from sterile processing out. "Make sure you have proper air flow and monitoring. Surveyors will do a simple tissue test. They will take a tissue and where the door meets the floor, make sure a tissue floats in the proper direction. If it doesn’t, we evaluate further. I teach this as a cheap technique to do on a recurring basis. Belts can break. Don’t assume it’s all running fine," he says.
5. 46% have problems with IC.02.02.01: "The hospital reduces the risk of infections associated with medical equipment, devices, and supplies." This can be something critical related to cleaning and packaging, as well as issues like ensuring the proper cleaning agent is used. Storing of equipment is also an issue, he says, such as whether endoscopes and laryngoscope blades are stored so that you know they have not been contaminated post-sterilization. "You have to be sure they remain sterile once they are. This is one of those things that is potentially an immediate threat to patients," Ziaya says.
6. 45% of hospitals have problems with LS.02.01.30: "The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke." This relates to the third standard cited above, he says. "Hazardous areas are constructed to protect other areas. Flammable storage areas are designed for that purpose, so use them for flammable stuff, not general storage. Don’t use other rooms for flammable materials." Make sure that the doors close properly and that the gaps between and under doors meet requirements for the room. "If you have removed an automatic closure or a sweep from under a door, then you cause a breakdown in that fire prevention. The other thing that’s important is that facility folks should have a program in place to regularly check these things. A door that closed right yesterday may not today. If you can educate the staff on units to be mindful of these things, it serves a couple of functions: It helps them to understand how important these items can be, so they don’t remove the sweep or are more careful. And it can also magnify the number of eyes you have to see if a door is not closing properly. Then they can call facilities staff to repair it quickly and you aren’t stuck doing a frenzied sweep and repair right before survey," he says.
7. 45% of hospitals have problems with EC.02.03.05: "The hospital maintains fire safety equipment and fire safety building features." Another fire-related standard, this relates to testing fire suppression and alarm systems, smoke detectors, and appropriate flow devices to make sure that the sprinklers will work. "A lot of this is about documentation," he says, again noting that if it wasn’t documented, it didn’t happen. "And you can’t just say you checked the sprinklers or the smoke detectors. You have to document that you checked each and every device."
8. 39% fail to comply with EC.02.06.01: "The hospital establishes and maintains a safe, functional environment." This general standard is about issues such as whether interior spaces meet the needs of the patient population and issues of ventilation, temperature, and humidity. "It’s very broad, and encompasses things that don’t fit into other areas," he says. Think of issues that affect storage rooms, rather than ORs. You want to maintain appropriate temperature and humidity for what you store in them, which might differ from other areas of the hospital, he says.
9. 36% of hospitals are dinged on LS.02.01.35: "The hospital provides and maintains systems for extinguishing fires." The last of the fire-related standards on the list, this relates to fire suppression such as sprinklers, and also extinguishers in kitchen areas. It also includes an issue many hospitals fail to comply with: how far from the ceiling you can store things and how close to sprinkler heads you can store things. Store something too close to one and you impact the path of the spray, making it potentially useless in the event of a fire. There must be 18 inches between a sprinkler head and storage. You also can’t have anything resting on the pipes that feed the sprinkler systems — not anything, he says. It can cause the pipes to kink and impede water flow.
10. 35% of hospitals have issues with MM.03.01.01. "The hospital safely stores medications." The biggest issue here is medication security and diversion prevention. The second most commonly scored item, he says, is properly labeling medication for expiration. "When multi-dose vials are opened and put in use, the original expiration is not valid," he says. "Then it’s 28 days from when you opened it. There are some exceptions, but still, it has to be redated. Once you open it, the clock ticks."
Why so much emphasis on fires? Ziaya is convinced you don’t hear a lot about fires in hospitals because of the diligence related to the topic. "The focus on these aspects has been maintained," he says.
As for the overall list, Ziaya doesn’t think it has changed a lot over time. "Life safety and environment issues are always prominent and require diligent documentation," he says. Infection control is also an issue, and he notes that RC 01.01.01 has been at the top of the list for several years.
"Often, the issues hospitals face relate to documentation," he concludes. "Organizations have to demonstrate that the right tests were done, or record the results of those tests. These things matter, particularly when taken together."
For more information on this topic, contact Paul Ziaya, MD, surveyor, Joint Commission, Oakbrook Terrace, IL. Email: [email protected].
Top 10 Standards Issues for Critical Access Hospitals
Percent Standard Standard
with problems Number Explanation
60% EC.02.03.05 The critical access hospital maintains fire safety equipment and fire safety building features.
54% EC.02.05.01 The critical access hospital manages risks associated with its utility systems.
49% LS.02.01.20 The critical access hospital maintains the integrity of the means of egress.
47% IC.02.02.01 The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
44% LS.02.01.30 The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
42% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
38% EC.02.02.01 The critical access hospital manages risks related to hazardous materials and waste.
35% LS.02.01.35 The critical access hospital provides and maintains systems for extinguishing fires.
31% EC.02.05.09 The critical access hospital inspects, tests, and maintains medical gas and vacuum systems.
30% EC.02.05.07 The critical access hospital inspects, tests, and maintains emergency power systems.
30% EC.02.06.01 The critical access establishes and maintains a safe, functional environment.
