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Get it Right the First Time: Forgo Joint Commission Drama

The Joint Commission can be a dreaded, looming entity for healthcare facilities. Don’t fret! We’ve laid out the five most common deficiencies, and how you can avoid them.

Keep an Eye Out for These Common Problems
The five most frequently found hospital deficiencies in the first half of 2013 according to the Joint Commission are:

1. The hospital fails to maintain complete and accurate medical records for each individual patient.

2. The hospital fails to maintain the integrity of the means of egress.

3. The hospital fails to reduce the risk of infections associated with medical equipment, devices and supplies.

4. The hospital fails to manage risks associated with its utility systems.

5. Building and fire protection features are not designed and maintained to minimize the effects of fire, smoke and heat.

How to Avoid Making These Mistakes
With all the things to worry about in your facility, the five mistakes are easy to make. Prevention is better than correction. Here’s how to prevent these deficiencies in the future:

1. Promote a Culture of Safety in Your Facility. Safety culture forms the foundation of all activities within a hospital including those examined by surveyors. Without the proper leadership and staff engagement in safety, hospitals are more likely to be deficient in key safety requirements.

2. Be Prepared. Being prepared and organized for your survey is crucial. Mock surveys are an effective way to identify potential deficiencies before the Joint Commission gets there. Approaching preparedness as a way to improve the hospital or organization will help the hospital provide the safest, most quality care possible.

3. Have and Environment of Care and Life Safety Standards. Having a sanitary and safe environment at all times will prevent infection, cross-contamination, or life-safety deficiencies. Having regular inspections will help identify any safety deficiencies.

4. Maintain Your Records. Hospitals must maintain records for care, treatment, and services for each individual patient. Just as important are the inspection reports for a hospital. They not only tell your surveyor that you are on your game, but also help you identify and resolve any safety issues. As hospitals move toward to electronic records, the Joint Commission expects record deficiencies to occur much less frequently. Building inspections have moved to online platforms that organize and collect your records according to Joint Commission standards.

5. Have a Sufficient Performance Improvement Plan. Improvement plans are a way for hospitals to identify and correct deficiencies. The Joint Commission monitors hospitals’ progress and will offer suggestion on points of improvement. A complete plan with specific goals and strategies will not only appease the accreditation organization, but also help the hospital improve as an institution overall.

Joint Commission surveys can be worrisome for healthcare facilities, but staying actively involved in health and safety practices will drastically reduce the chances for deficiencies. The key is to catch an issue before the Joint Commission does, and to keep working to reach 100%. In the end, everyone from will be happy, healthy, and safe!

If you need an inspection completed before you next Joint Commission survey, or you’d like to ask questions about your specific case, you can click here to contact an expert, or call 1-800-859-6198.


Joseph Reynolds

Joseph Reynolds