Ambulatory Buzz

Information on all things ambulatory from The Joint Commission

Top 10 Most Challenging Ambulatory Care Standards in 2019


By Joyce Webb, RN, project director, Division of Healthcare Quality Evaluation  
It’s that time of year again! Time to review the top 10 challenging standards for accredited ambulatory health care (AHC) organizations in 2019.

As you are likely aware, The Joint Commission regularly analyzes standards compliance data to identify the most common challenges impacting our accredited AHC organizations. The intent of this analysis is to recognize compliance patterns and trends to support our accredited organizations – as well as those seeking accreditation – in their efforts to better understand and respond to important standards compliance challenges. 
This blog post lists all the top 10 most non-compliant AHC standards for 2019. Detailed below, are some compliance tips and strategies that should prove especially helpful to your organization when preparing for your next accreditation survey:

1. Reduce the risk of infections associated with medical equipment, devices and supplies.
Compliance Tips:

  •  Review the manufacturers’ guidelines for disinfectant/cleaning products, and operation of equipment such as the ultrasonic cleaner and sterilizer. Ensure all staff receive education and ongoing competency assessment in cleaning, disinfection and sterilization processes, and required quality control activities. Periodically review related quality control logs to monitor compliance.  
  • Evaluate your clean/dirty workflow and processes for storage of “clean” vs “dirty” items. Review your sterilization processes – are biological indicators utilized properly? Are all required metrics (i.e. sterilizer cycle time, temperature and pressure) captured and documented?Conduct spot checks of stored sterilized instruments  – check hinged instruments, storage, peel pack prep and integrity. Observe transport of dirty instruments – are they kept moist to decrease adherence of bioburden? Assess your processes for adherence to manufacturer’s instructions for use, evidence-based guidelines and organizational policy. 

Organizations should review the device (e.g., instrument, handpiece, etc.) manufacturer’s sterilization parameters for each item being reprocessed at their organization and compare it to the sterilizer cycle parameters they are using to reprocess the device. If cycle parameters do not match, the organization may try the following options:

  • Contact the device manufacturer to confirm that the sterilizer cycle parameters being used are acceptable.
  • Reprogram the sterilizer with the assistance of the sterilizer representative to match the device sterilization parameters. 
  • If it is not possible to reprogram an existing sterilizer to match the required device parameters, organizations may need to either replace the device to one with sterilizer compatible parameters or replace the sterilizer with one that can achieve the required device parameters.

2.  Implement your organization’s infection prevention and control activities. 
Compliance tips:

  • Assess staff use of personal protective equipment (PPE), such as gloves, gowns and face shields. Conduct spot checks to monitor compliance and appropriate use of PPE. Determine which evidence-based infection control guidelines are to be followed, ensure staff are educated on them, and that they are available to staff. Verify staff knowledge of and compliance with evidence-based guidelines.
  • Review your infection control-related policies and conduct infection control rounds to monitor compliance.

3. Provide and maintains equipment for extinguishing fires. 
Compliance tips:

  • Check to ensure that sprinkler heads are not damaged and are free from obstruction.Keep in mind that there needs to be at least 18 inches of open space below sprinkler deflectors and the top of storage. This applies to shelving and storage that is located directly below a sprinkler head.   Imagine there is a horizontal plane at the height of the sprinkler deflector and keep all storage (except at the perimeter of the room) below that plane. Ensure that sprinkler piping is not being used to support other items like data cabling, ductwork, etc. Check distances to the nearest portable fire extinguisher - should be 75 feet or less.
  • Ensure that portable fire extinguishers have the appropriate signage and are stored securely, either in a cabinet or on a hanger made for fire extinguishers and hung at least 4 inches off the floor.

Joyce Webb, RN, has 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.