Keeping Up With Clinical Risk Management:
2020’s Most Challenging Joint Commission Standard

A Quarterly Publication by Danielle Donovan
Winter 2021

Each year, The Joint Commission (TJC) releases their findings on the requirements most frequently identified as “not compliant” during surveys of various accreditation programs. Although fewer surveys were conducted over 2020 due to COVID-19, TJC was able to identify key requirements where healthcare organizations failed to comply with National Patient Safety Goals (NPSGs) and accreditation standards.

In 2020, the most frequently cited and challenging standard across hospitals, critical access hospitals, and ambulatory care was the Environment of Care standard – (EC) 02.05.01. This standard requires organizations to manage the risks associated with their utility systems, which are physical building systems that support the environment of care, including:

• Electrical distribution and emergency power.
• Vertical and horizontal transport.
• Heating, ventilating, and air conditioning (HVAC).
• Plumbing, boiler, and steam; refrigeration.
• Piped gases.
• Vacuum systems.
• Fire alarm and suppression systems.
• Communication systems, including data exchange systems.

The following are the most notable Elements of Performance (EP) findings that hospitals, critical access hospitals, and ambulatory healthcare facilities were cited for under EC 02.05.01:

EP 1 & 15- Protect Patients from Airborne Contaminants

In areas designed to control airborne contaminants, such as biological agents, gases, fumes, and dust, the ventilation system should provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies that reduce the likelihood of hospital-associated infections (HAI). TJC defines ventilation as moving air from one location to another, including bringing in air from the outside and removing air from the inside. This EP focuses specifically on areas of concern for ventilation, such as critical care areas, operating rooms, special procedure rooms, isolation rooms, laboratories, pharmacies, and sterile supply rooms.

Facilities can protect patients by properly designing and installing ventilation systems that reduce the concentration of airborne contaminants through dilution, filtration, and pressurization.

Ep 9 – Accurate Utility System Control Labeling Provides for Safe Emergency Shutdowns

Facilities must clearly label electrical panels and utility system controls for partial or complete emergency shutdowns. When a utility system failure occurs, the organization has to be prepared to safely shut down or isolate the system, make repairs or replace components, and mitigate any adverse events. This EP requires organizations to maintain a written inventory of all operating components of utility systems, identifying those high-risk components for which there could be a serious risk of harm or death to patients and staff if they were to fail.

Catastrophic events can be mitigated by providing timely communication to users and the clinical team on the status of the affected system at the beginning, during, and at the end of the event. This should be outlined in a utility capacity and usage plan that identifies system vulnerabilities that must be quickly restored during an emergency. This plan should be tested routinely as part of a scheduled emergency management exercise. In addition, organizations must ensure appropriate labeling per the National Fire Protection (NFPA) standards 70 and 70e. Clearly labeled shutdown controls of utility systems remove the risk of adverse events and establish safe conditions to correct the failed system.

There are a number of great resources out there for those responsible for environment of care, such as the TJC website and the American Society for Healthcare Engineers (ASHE). The ASHE Focus website contains helpful videos, case studies, and best practices to ensure that your organization’s environmental controls comply, work properly, and meet high reliability standards.

For more information on environment of care standards, please reach out to the Parker, Smith & Feek Risk Control Team.

Resources and References

1. “The Most Challenging Joint Commission Hospital Requirements 2020.” MCN Healthcare StayAlert!, MCN Healthcare , 9 Aug. 2021, https://stayalert.mcnhealthcare.com/stayalert/alerts/d709245a-f939-11eb-845c-06a64a38c309/view?name=Most-Challenging-Joint-Commission-Hospital-Requirement-2020
2. “Top 5 Most Challenging Requirements for 2020.” The Joint Commission Online , The Joint Commission , 12 May 2021, https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/may-12-2021/top-5-most-challenging-requirements-for-2020/
3. Physical Environment Portal: Module 1, EC.02.05.01 Leadership, The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/physical-enviroment/ec_02_05_01module.pdf
4. Focus on Compliance EC.02.05.01, ASHE. https://www.ashe.org/compliance/ec_02_05_01
5. New 2021 NFPA 70E Fact Sheet Highlights Key Elements of this Important Electrical Safety Standard, National Fire Protection Association. https://www.nfpa.org/news-and-research/publications-and-media/blogs-landing-page/nfpa-today/blog-posts/2020/10/01/new-2021-nfpa-70e-fact-sheet-highlights-key-facts-about-this-important-electrical-safety-standard

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