The Joint Commission has officially announced the most-cited standards for the first half of 2009 and Life Safety standards top the list.
Back in 2007, Life Safety Code consisted of only a single standard (EC.5.20), but was subsequently split into seven standards, leading citations for this area to jump from 29% to 45% in 2008. Three of the top 10 most-cited standards (and the two most-cited) fell under the Life Safety chapter.
Those standards are:
- LS.02.01.20 (45%)—maintaining means of egress. This standard was the most cited in the first half of 2009.
- LS.02.01.10 (43%)—building and fire protection features minimize the effects of fire, smoke, and heat. This was the second-most cited standard.
- LS.02.01.30 (36%)—provision and maintenance of building features to protect individuals from the hazards of fire and smoke. This was sixth among the top 10 standards.
Record of Care standards were found twice in the top 10 most-cited. Verbal orders (RC.02.03.7) were cited 40% of the time, the third-most cited standard, and requirements to maintain complete and accurate medical records (RC.01.01.01), always a trouble area for hospitals, was cited 33% of the time, making it the eighth most-cited standard.
Maintenance of fire safety equipment and fire safety building features (EC.02.03.07) retained a top spot among cited standards at 38%.
The National Patient Safety Goals (NPSG) were cut down significantly for 2010. Requirements for commonly cited NPSGs for critical tests and critical values have been loosened and will not likely appear on future lists of top-cited standards, at least for the time being. In the first half of 2009, however, critical tests/critical values (NPSG 02.03.10) were cited 38% of the time. Another top-cited NPSG in years past, do not use entries, has been moved to the standards and out of the goals.
Universal Protocol is another evolving requirement within the NPSGs and has received extensive review by The Joint Commission in 2009. It is the most cited sentinel event in The Joint Commission’s database, the accrediting body said at Executive Briefings in September. UP.01.03.01, requiring a time out performed immediately prior to starting procedures, was the seventh most-cited standard in the first half of 2009, cited 34% of the time.
Last, two Medication Management standards rounded out the top ten—MM.03.01.01 (33%), medication storage; and MM.04.01.01 (32%), clear and accurate medication orders.
For further analysis of these standards, watch for the upcoming issue of Briefings on The Joint Commission.