Top Ten Challenging Ambulatory Care Standards for 2017 | Joint Commission
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Top Ten Challenging Ambulatory Care Standards for 2017

Apr 04, 2018 | 2807 Views

Joyce_WebbBy Joyce Webb, RN, BSN, MBA
Project Director, Division of Standards and Survey Methods
The Joint Commission

AmBuzz readers know spring has sprung when The Joint Commission unveils its annual list of the Top Ten Challenging Standards for accredited Ambulatory Health Care (AHC) organizations and Office-Based Surgery (OBS) practices throughout 2017.

The Joint Commission regularly analyzes standards compliance data to help identify the most common challenges impacting our AHC and OBS customers. Our aim is to recognize compliance trends and help accredited – or those seeking to enter accreditation -- organizations better understand and respond to these ongoing standards compliance challenges. Many of you will recognize these challenging standards – especially the top three – as they have often occupied spots on the ‘Top Ten’ list over the years. 

Below – in addition to tables describing both AHC & OBS standards compliance challenges – are tips and insights that should prove helpful if your organization needs to address the top three topics during your accreditation survey in 2018. Take a look:

1. IC.02.02.01 – The organization reduces the risk of infections associated with medical equipment, devices, and supplies.

Compliance tips: 

  • Make sure staff are familiar with manufacturer’s guidelines for cleaning and disinfection of equipment. This includes contact times for the brands of surface wipes in use, as the contact times often vary. 

  • When sterilizing instruments, implement spot checks to verify adherence to your selected infection control guidelines for pre-cleaning, quality control activities, sterilizer operation, and wrapping and storing sterilized instruments. 

2. MM.03.01.01 – The organization safely stores medications.

Compliance tips: 

  • Assign specific staff to routinely check all stored medications for expiration dates and don’t forget to check procedure trays that contain medications. Make sure staff are aware of manufacturer’s guidelines for medication storage. 

  • Perform periodic spot checks to verify that refrigerated meds have been maintained according to manufacturer’s guidelines. Are medication refrigerator logs complete? Is there documentation of the follow-up steps that were taken if it was found to be out of range?

  • If medications are stored under lock and key, check to see if the key to the medication storage area is also kept secure. 

  • Identify high-alert medications and implement the use of use of special labels or stickers to alert staff. Perform spots checks to monitor for consistent implementation of safety steps.

3. HR.02.01.03 – The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.

Compliance tips: 

  • Designate a detailed-oriented staff member to perform queries and track when verifications are due and follow-up is needed. 

  • Closely review the list of privileges requested/ previously granted to make sure that they are limited to the procedures they will be performing in your organization.


Joyce Webb is a registered nurse with more than 20 years of experience in management and ambulatory health care. Joyce is lead for the development of ambulatory care accreditation standards, survey methods, and surveyor education, and is project lead for the Joint Commission’s Primary Care Medical Home initiative.

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