Focusing on the Most Cited Standards

Matt Phillion, for HealthLeaders Media , June 8, 2009

It is better to sweat more during peace and bleed less during war, according to an old Chinese proverb. The saying was invoked recently by Lisa Eddy, RN, CPHQ, CSHA, senior consultant for The Greeley Company, during her presentation at the 2009 Association of Healthcare Accreditation Professionals (AHAP) conference in Las Vegas.

Her presentation, "Continuous Survey Readiness," ran through the most-cited Joint Commission standards and methods for avoiding Requirements for Improvement (RFI) in these areas.

In healthcare accreditation, "peace is the time before the surveyors come," says Eddy. And not just the 18 month survey window. "This is all the time," she says. To prepare for that, it’s best to take a look at what The Joint Commission itself has considered the biggest challenges—by looking at the most frequently cited standards.

Approximately 5% of all standards make up 85% of all RFIs for hospitals. The number of Elements of Performance in 2009 rose to more than 2,000, Eddy noted.

"A lot of these are white noise. There is no way they would be able to look at them all," says Eddy. There are known problem areas on which The Joint Commission focuses, and these become the most frequently cited standards, which The Greeley Company calls the Frustrating 5%.

Medication reconciliation has been perennially a most-cited standard, but The Joint Commission is revisiting the concept this year.

In addition, the Provision of Care chapter has its share of challenges. Chief among them is communicating standards for history and physical exams due to recent changes. The field continues to struggle with this concept as physicians and other staff cling to previous rules for history and physicals. New standards state that a history and physical is good for up to 30 days, but there must be an update to the history and physical within 24 hours after admission or registration (as with day surgery) prior to a procedure.

This update "has to happen," said Eddy.

There are also new contenders on the scene—the Leadership chapter in particular.

"We’re seeing a lot come up surrounding the culture of safety survey," said Eddy.

Hot spots include:

  • Patient safety
  • Analyzing and assessing data
  • Contracted services
  • Policies and procedures
  • Patient flow
  • Conflict management

Surveyors are looking at how hospitals collect data about how they are working to improve the culture of safety at their facility.

"You need a statistically valid tool," said Eddy. "We see a lot of hospitals working culture of safety questions into their HCAHPS surveys."

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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