Most Challenging Joint Commission Requirements
The Joint Commission has identified the standards/elements of performance that were most frequently cited as “not compliant” during Joint Commission surveys in 2020. Listed below are those most frequently identified for each program:
Ambulatory Health Care
- IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies. EP 2
- IC.02.01.01: The organization implements infection prevention and control activities. EP 2
- MM.01.01.03: The organization safely manages high-alert and hazardous medications. EP 2
- EC.02.05.01: The organization manages risks associated with its utility systems. EP 7
- MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. EP2
Critical Access Hospitals
- IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. EP 2
- EC.02.05.01: The critical access hospital manages risks associated with its utility systems. EP 15
- IC.02.01.01: The critical access hospital implements its infection prevention and control plan. EP 1
- PC.02.01.11: Resuscitation services are available throughout the critical access hospital. EP 2
- EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste. EP 5
Hospitals
- NPSG.15.01.01: Reduce the risk for suicide. EP 1
- IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. EP 2
- IC.02.01.01: The hospital implements its infection prevention and control plan. EP 1
- MM.06.01.01: The hospital safely administers medications. EP 3
- EC.02.05.01: The hospital manages risks associated with its utility systems. EP 15
Office-Based Surgery
- IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. EP 2
- IC.02.01.01: The practice implements infection prevention and control plan. EP 2
- HR.02.01.03: The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. EP 1
- MM.01.01.03: The practice safely manages high-alert and hazardous medications. EP 1
- MM.01.01.03: The practice safely manages high-alert and hazardous medications. EP 2
- MM.01.02.01: The practice addresses the safe use of look-alike/sound-alike medications. EP 1
- MM.03.01.01: The practice safely stores medications. EP 2
For more information, see the Joint Commission Standards Frequently Asked Questions, contact the Joint Commission Standards Interpretation Group at 630-792-5900, or use the Joint Commission online question form.
The first four programs listed below correspond with The Joint Commission’s program categories. The Sterile Processing section has been added for your convenience.
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