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  On Demand  CE  The Joint Commission Hot Problematic Standards for Hospitals
One of the best ways to be prepared for your unannounced Joint Commission survey is to understand all aspects of the top problematic standards along with information on hot topics related to hospital surveys. Hot topics include standing orders, protocols, clinical alarms, and unlicensed personnel as scribes.

The Joint Commission collects data on the most challenging requirements. The data includes compliance with Joint Commission standards, National Patient Safety Goals, Universal Protocol for preventing wrong site surgery and Accreditation or Certification Participation Requirements (APR and CPR). This program outlines in detail the most problematic standards for hospitals that resulted in Requirement for Improvement (RFIs). Strategies to be compliant will also be discussed.

Trends on the top hot buttons will be identified that assist in effectively focusing on staff education. It will also provide a listing of problematic standards in behavioral health, critical access hospitals, and home care. Hospitals should use this data to proactively investigate their performance to determine compliance! This program will also discuss top problematic standards with the CMS conditions of participation and will provide a crosswalk to the CMS CoPs involving the top problematic standards.

The top problematic standards for hospitals include:
  • RC.01.01.01 (69% in 2011, 65% 2010) The hospital maintains complete and accurate medical records.
  • LS.02.01.20 (57% in 2011, 51% 2010) The hospital maintains the integrity of the means of egress.
  • LS.02.01.10 (57% in 2011, 49% 2010) Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • LS.02.01.30 (47% in 2011, 40% 2010) The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • EC.02.03.05 (42% in 2011, 42% 2010) The hospital maintains fire safety equipment and fire safety building features.
  • IC.02.02.01 (36% in 2011, 29% in 2010) The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • RC.02.03.07 (36% in 2011, 33% 2010) Qualified staff receive and record verbal orders.
  • MM.03.01.01 (34% in 2011, 33% 2010) The hospital safely stores medications.
  • LS.02.01.35 (33% in 2011, 24% in 2010) The hospital provides and maintains systems for extinguishing fires.
  • PC.01.02.03 (33% in 2011, 31% in 2010) The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • MM.04.01.01 (25% in 2011 and 28%% in 2010) Medication orders are clear and accurate.

Program Objectives:
  • Outline the top problematic standards for hospitals by The Joint Commission.
  • Explain the CMS CoP requirements.
  • Identify ways to be compliant with The Joint Commission top problematic standards and the CMS CoP requirements.
Sue Dill Calloway, RN, MSN, JD
  Sue Calloway has been a nurse attorney and medical-legal consultant for more than thirty years. She has presented numerous educational programs for nurses, physicians, and other healthcare professionals on topics such as patient safety, Joint Commission, CMS, and HIPAA issues. She is on the board for the Emergency Medicine Patient Safety Foundation.

Sue has authored over 100 books and thousands of articles. Previously she has been a nursing professor, medical malpractice defense attorney, and director of health policy and risk management for eight years for the Ohio Hospital Association. Sue is also past VP of legal services, compliance officer and privacy officer for a community hospital. She is the author of the book on the 2009 Joint Commission Leadership Standards by HCPro.

Sue Dill Calloway has disclosed no relevant, real or apparent personal or professional financial relationships.
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