Accreditation Resource: The Most Challenging Hospital Standards in 2009

 

From January through December 2009, the following hospital chapters and standards were most challenging to organizations undergoing JCI on-site surveys, grouped by the standards chapter; the ranking of chapters by number of noncompliant standards found; the most frequently noncompliant standards in that chapter; and the issue covered in the named noncompliant standard.

Standards Chapter

Ranking by Most Noncompliant  Standards Found

Most Frequently Noncompliant Standard in Chapter

Subject Matter of Most Frequently Noncompliant Standard

Facility Management and Safety (FMS)

1

FMS.7.1

Fire safety—safe exit from the facility

Medication Management and Use (MMU)

2

MMU.3

Labeling medications

Assessment of Patients (AOP)

3

AOP.1.2

Medical assessment contains health history and physical exam

Staff Qualifications and Education (SQE)

4

SQE.11

Ongoing professional practice evaluation

Prevention and Control of Infections (PCI)

5

PCI.7.1

Equipment cleaning, disinfection, and sterilization

Management of Communication and Information (MCI)

6

MCI.19.3

Clinical record entries identify the author, when entered, and, if required, time of entry

International Patient Safety Goal (IPSG)

7

IPSG.4

Correct-patient, correct-procedure, and correct-site surgery—use of a checklist and time out

Care of Patients (COP)

8

COP.2.1

Care plan

Patient and Family Rights (PFR)

9

PFR.6.4

Informed consent

Anesthesia and Surgical Care (ASC)

10

ASC.3

Pre-sedation assessment

Access to Care and Continuity of Care (ACC)

11

ACC.3.2

Discharge summary

Quality Improvement and Patient Safety (QPS)

12

QPS.6

Data analyzed when undesirable trends or patterns are found

Governance, Leadership, and Direction (GLD)

13

GLD.1

Governance performance evaluation

Patient and Family Education (PFE)

14

PFE.2

Educational needs assessment and documentation of education


Source: Joint Commission International Accreditation