Almost two-thirds of hospitals are not compliant with Joint Commission’s top LS, EC standards

The Joint Commission (TJC) twice a year publishes in its Perspectives newsletter a series of top 10 lists, filtered by type of healthcare facility, of the standards most often cited by its surveyors.

After reading the most recent compliance information published in the April issue, Steve MacArthur, a senior consultant with The Greeley Company in Danvers, Massachusetts, concluded on his HCPro blog, Mac’s Safety Space, “to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots” of the list for hospitals.

Chances are that if your facility was scrutinized in one of the 1,443 surveys TJC conducted at hospitals across the nation last year or in one of the 130 surveys at critical access hospitals (CAH), you are very familiar with the latest lists of TJC’s most commonly cited standards.

Almost two-thirds of the hospitals surveyed in 2017 were found noncompliant in at least one—and possibly many more—of the top 10 most challenging standards for hospitals.

And, as MacArthur notes, all of the top 10 for 2017 were in or linked to the Environment of Care (EC) and Life Safety (LS) chapters. Those requirements have gone through major revisions in the wake of the adoption of the 2012 NFPA codes, and CMS has voiced strong concerns that accrediting organizations are not being tough enough when surveying the physical environment.

Still, it may come as a surprise to see just how often hospitals failed some of those standards.
In 2016, EC.02.06.01, requiring a safe environment, was the most challenging standard, with 68% of hospitals noncompliant. In 2017, a whopping 86% of hospitals were cited under LS.02.01.35 for problems maintaining fire extinguishing systems, putting it atop the list.

For CAHs, the top most cited standard in 2016 at 67% of hospitals was EC.02.05.01, which requires hospitals to manage utility risks. That shot up to 85% of CAHs surveyed in 2017.

The only standard on the list not in the LS or EC chapters is Infection Control (IC) standard IC.02.02.01, which has an EC-related component because it requires hospitals to cut down on infections connected to medical equipment, devices, and supplies.

“It’s the intersection of IC and the environment and always will be,” MacArthur wrote.

This standard is often cited because of failures in the cleaning and reprocessing of endoscopes; it’s also the standard most often cited on a condition level, leading to a ruling that the hospital is an immediate threat to life and safety (ITL). That automatically suspends a hospital’s accreditation until the problem is resolved, according to TJC officials.

IC.02.02.01 is fourth on the list, while EC.02.06.01 and EC.02.05.01 are also in the top five and among the standards most likely to be associated with a high likelihood of harm, which can lead to an ITL, according to information TJC officials released during last fall’s Executive Briefing.

“[The latest citation data] clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until … it starts to decline in ‘fruit-bearing,’” wrote MacArthur, who suspects “a lot of the safe, functional environment findings are coming from tracers.”

MacArthur added: “I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment. If so, congratulations! And, perhaps most importantly, what’s your secret?”

The following are the 10 most challenging standards for hospitals and CAHs surveyed in all of 2017. The percentages reflect how many hospitals were cited under that standard, regardless of severity of the violation. Percentages in parentheses are for 2016.

Most-cited standards, hospitals

1. LS.02.01.35—Fire extinguishing systems, 86% (51% in 2016)
2. EC.02.05.01—Utility system risks, 73% (57%)
3. LS.02.01.30—Building features protect against fire, smoke, 72% (50%)
4. IC.02.02.01—Infection control of equipment, devices, supplies, 72% (60%)
5. EC.02.06.01—Safe environment, often a catch-all standard, 70% (68%)
6. LS.02.01.10—Features designed to minimize fire, heat, smoke, 66% (48%)
7. EC.02.02.01—Management of hazardous materials, 63% (47%)
8. LS.02.01.20—Means of egress, 62% (49%)
9. EC.02.05.05—Maintenance of utility systems, 62% (not on 2016 list)
10. EC.02.05.09—Maintenance of medical gas systems, 59% (n/a)

Most-cited standards, CAHs

1. EC.02.05.01—Utility system risks, 85% (67% in 2016)
2. LS.02.01.35—Fire extinguishing systems, 83% (50%)
3. IC.02.02.01—Infection control of equipment, devices, supplies, 72% (64%)
4. LS.02.01.10—Features designed to minimize fire, heat, smoke, 70% (46%)
5. EC.02.05.09—Maintenance of medical gas systems, 68% (not on 2016 list)
6. LS.02.01.30—Building features protect against fire, smoke, 65% (50%)
7. EC.02.03.03—Fire drills, 61% (32%)
8. EC.02.05.05—Maintenance of utility systems, 58% (n/a)
9. LS.02.01.20—Means of egress, 58% (44%)
10. EC.02.03.05—Maintains fire safety equipment and features, 56% (54%)

To find the most cited standards for home healthcare, nursing care centers, and other organizations and programs accredited by TJC, go to the April 2018 issue of “Perspectives.”

Editor’s note: A version of this article first appeared in Inside the Joint Commission, a DecisionHealth newsletter.