Top 5 most frequently scored requirements for 2023 for select certification programs
The Joint Commission regularly analyzes standards compliance data to identify areas that result in the highest number of Requirements for Improvement (RFIs) in its certified programs. These data help The Joint Commission identify trends and tailor education related to challenging standards.
Below are the Top 5 most frequently cited elements of performance (EPs) from Jan. 1-Dec. 31, 2023, for four categories of certification programs across two certification manuals – the Comprehensive Disease-Specific Care Certification Manual (DSC) and Health Care Staffing Services Certification Manual (HCSS). For more information, including bar charts depicting where findings were placed on the Survey Analysis For Evaluating Risk® (SAFER®) Matrix, see the May issue of Perspectives.
Note: The standards/EPs do not include standards notes, footnotes, references, or rationales. For a comprehensive look at each standard, refer to E-dition®. Also, for advanced disease-specific care programs, the addenda content is not included. For the complete addenda content, refer to E-dition.
Cardiac-specific programs (DSC)
– 174 surveys conducted in 2023
- Acute Myocardial Infarction
- Acute Heart Attack Ready (AHAR) Advanced Certification in Heart Failure (HF) Chest Pain
- Comprehensive Heart Attack Center (CHAC) Heart Failure
- Primary Heart Attack Center (PHAC) Ventricular Assist Device (VAD)
DSDF.03: The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
- EP 2: The assessment(s) and reassessment(s) are completed according to the patient’s needs and clinical practice guidelines.
DSDF.02: The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care.
- EP 5: The program demonstrates evidence that it is following the clinical practice guidelines when providing care, treatment, and services.
DSSE.03: The program addresses the patient’s education needs.
- EP 5: The program addresses the education needs of the patient regarding their disease or condition and care, treatment, and services.
DSDF.03: The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
- EP 3: The program implements care, treatment, and services based on the patient’s assessed needs.
DSCT.05: The program initiates, maintains, and makes accessible a medical record for every patient.
- EP 5: The medical record contains sufficient information to document the course and results of care, treatment, and services.
Health Care Staffing Services (HCSS)
– 43 surveys conducted in 2023
HSLD.09: The HCSS firm addresses emergency management.
- EP 5: The firm tests the emergency management plan at least annually documenting the test date and any opportunities to improve the plan.
HSLD.05: The HCSS firm provides services to customers according to a written agreement.
- EP 4: At a minimum, as part of or in addition to the agreement, the firm provides the customer with a written description of the following: The reassignment of staff only to areas of practice within their clinical competence.
HSHR.02: As part of the hiring process, the HCSS firm determines that a person’s qualifications and competencies are consistent with their job responsibilities.
- EP 1: The firm defines and documents the minimum clinical competence and qualifications consistent with staff job responsibilities.
HSLD.05: The HCSS firm provides services to customers according to a written agreement.
- EP 6: At a minimum, as part of or in addition to the agreement, the firm provides the customer with a written description of the following: How unexpected incidents, errors, and sentinel events that involve HCSS staff are communicated to the firm.
HSLD.05: The HCSS firm provides services to customers according to a written agreement.
- EP 7: At a minimum, as part of or in addition to the agreement, the firm provides the customer with a written description of the following: How occupational safety hazards or events that involve HCSS staff are communicated to the firm.
Orthopedic-specific programs (DSC)
– 487 surveys conducted in 2023
- Advanced Certification in Spine Surgery (ACSS) Advanced Total Hip and Total Knee Replacement (THKR) Joint Replacement – Hip
- Joint Replacement – Knee
- Joint Replacement – Shoulder
- Spinal Fusion
- Spinal Surgery
DSDF.03: The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
- EP 2: The assessment(s) and reassessment(s) are completed according to the patient’s needs and clinical practice guidelines.
DSCT.05: The program initiates, maintains, and makes accessible a medical record for every patient.
- EP 7: The program reviews its medical records for completeness and accuracy.
DSDF.02: The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care.
- EP 5: The program demonstrates evidence that it is following the clinical practice guidelines when providing care, treatment, and services.
DSCT.05: The program initiates, maintains, and makes accessible a medical record for every patient.
- EP 6: The medical record contains sufficient information to facilitate continuity of care.
DSSE.01: The program involves patients in making decisions about managing their disease or condition.
- EP 1: The program involves patients in decisions about their care, treatment, and services.
Stroke-specific programs (DSC)
– 687 surveys conducted in 2023
- Acute Stroke Ready Hospital (ASRH)
- Comprehensive Stroke Center (CSC)
- Primary Stroke Center (PSC)
- Thrombectomy-Capable Stroke Center (TSC)
DSDF.03: The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
- EP 2: The assessment(s) and reassessment(s) are completed according to the patient’s needs and clinical practice guidelines.
DSDF.02: The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care.
- EP 5: The program demonstrates evidence that it is following the clinical practice guidelines when providing care, treatment, and services.
DSSE.03: The program addresses the patient’s education needs.
- EP 5: The program addresses the education needs of the patient regarding their disease or condition and care, treatment, and services.
DSDF.03: The program is implemented through the use of clinical practice guidelines selected to meet the patient’s needs.
- EP 3: The program implements care, treatment, and services based on the patient’s assessed needs.
DSCT.05: The program initiates, maintains, and makes accessible a medical record for every patient.
- EP 5: The medical record contains sufficient information to document the course and results of care, treatment, and services.