Temuan Terbanyak JCI

The Numbers
97 full (initial/triennial) Hospital accreditation

surveys have been conducted using the 3rd
Edition manual.
No measureable element was scored more

than 8 times
times.
Top 20 Not Met standards/MEs:
Cited in at least 4 to 8 surveys each
Client name/ Presentation Name/ 12pt - 3
Copyright, Joint Commission Interna

ational
A total of 334 measurable elements scored

Not Met by at least one organization.
The Top 20
AOP.1.2
AOP 1 2
AOP.1.6 (ME 1)
AOP.1.6 (ME 4)
AOP.6.4
COP.3.8
ASC.3
ASC.4
MMU.1
GLD.1
FMS.7.1
SQE.10
SQE 10 (ME 3)
SQE.10 (ME 4)
SQE.11 (ME 1)
SQE.11 (ME 2)
SQE.11 (ME 3)
MMU.5.1
MMU.6.1
QPS.2.1
IPSG 3
IPSG 4
Copyright, Joint Commission International, 2011. May not be used without permission.

ational
Not Met findings come from

9 chapters:
113
The most Frequently Cited

Standard

ational
The most frequently cited standard was

cited
it d 8 times.
ti
AOP.1.6 Patients are screened for

nutritional
t iti
l status
t t and
d functional
f
ti
l needs
d
and are referred for further assessment
and treatment when necessary.
ME#4 Qualified individuals develop
criteria to identify patients who require
further functional assessment.

ational
AOP.1.6
114
No functional screening criteria

developed
No functional screening policy
developed
If the hospital does not have physical
therapy department and related
professionals,
f
i
l th
the screening
i criteria
it i are
developed by those without the
appropriate credentials

ational
Primary Issues Cited
All of the standards are important

We will discuss the following four
standards to give you a better sense of
why organizations miss critical
standards.
In the appendix of this presentation,
presentation we
list all of our top 20, and their primary
problems.

ational
Additional Standards to Discuss
115
ASC.3
ME#3 There is a pre-sedation

assessment, according to organization
policy,
li
to
t evaluate
l t risk
i k and
d
appropriateness of the sedation for the
patient.

ational
ASC.3 Policies and procedures guide the

care of patients undergoing moderate
and deep sedation.
No pre-sedation policy is developed

Pre-sedation
P
d ti policy
li iis nott in
i liline with
ith th
the
policy for pre-anesthesia assessment
Documented assessment does not
meet policy requirements
Assessment does not really evaluate
the risk of sedation
Pre-sedation assessment is not
documented

ational
116
FMS.7.1 The plan includes prevention,

early
l d
detection,
t ti
suppression,
i
abatement, and safe exit from the
facility in response to fires and non-fire
emergencies.
ME#5 The program includes the safe exit
from the facility when fire and non-fire
emergencies occur.

ational
FMS.7.1
Fire doors are locked or blocked

Emergency exits are not marked or lighted
properly
Hall in patient units are clogged with
equipment and supplies
Structural barriers of the building hamper exit
Inpatient
I
ti t corridor
id doors
d
have
h
key
k locks
l k that
th t
could prevent occupant from exiting the room
Penetrations in smoke compartments

ational
117
International Patient Safety Goals
ME #2 Concentrated Electrolytes are not

present in patient care units unless
clinically necessary and actions are
t k to
taken
t preventt inadvertent
i d t t
administration in those areas where
permitted by policy.

ational
IPSG #3 Improve the Safety of High-Alert

Medications
No policy is written
Concentrated solutions not secure when
present and appropriately labeled
Unaware Magnesium Sulfate 50% is
considered a concentrated electrolyte
Many areas are identified as
necessary

ational
118
International Patient Safety Goals
ME #4 The organization uses a check

list and time-out procedure just before
starting a surgical procedure
procedure.

ational
IPSG #4 Ensure Correct-Site, CorrectP

Procedure,
d
Correct-Patient
C
t P ti t S
Surgery
No documented evidence of using a

checklist
Time-out is not documented
Confusions about the difference
between the time-out and checklist
Not used for all surgical procedures,
e.g. dental & Cesarean section
Resistance to using the protocol at all

ational
119

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The Numbers

97 full (initial/triennial) Hospital accreditation

No measureable element was scored more

Copyright, Joint Commission Interna

A total of 334 measurable elements scored

Client name/ Presentation Name/ 12pt - 4

Copyright, Joint Commission Interna

Not Met findings come from

The most Frequently Cited

Client name/ Presentation Name/ 12pt - 5

Copyright, Joint Commission Interna

The most frequently cited standard was

AOP.1.6 Patients are screened for

Client name/ Presentation Name/ 12pt - 6

Copyright, Joint Commission Interna

No functional screening criteria

Copyright, Joint Commission Interna

Primary Issues Cited

All of the standards are important

Copyright, Joint Commission Interna

Additional Standards to Discuss

ME#3 There is a pre-sedation

Copyright, Joint Commission Interna

ASC.3 Policies and procedures guide the

No pre-sedation policy is developed

Copyright, Joint Commission Interna

Primary Issues Cited

FMS.7.1 The plan includes prevention,

Copyright, Joint Commission Interna

Fire doors are locked or blocked

Copyright, Joint Commission Interna

Primary Issues Cited

International Patient Safety Goals

ME #2 Concentrated Electrolytes are not

Copyright, Joint Commission Interna

IPSG #3 Improve the Safety of High-Alert

Client name/ Presentation Name/ 12pt - 14

Copyright, Joint Commission Interna

Primary Issues Cited

International Patient Safety Goals

ME #4 The organization uses a check

Client name/ Presentation Name/ 12pt - 15

Copyright, Joint Commission Interna

IPSG #4 Ensure Correct-Site, CorrectP

No documented evidence of using a

Copyright, Joint Commission Interna

Primary Issues Cited

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