A list of Ambulatory Care’s most challenging findings for 2021 was recently published by The Joint Commission (TJC). Not surprisingly they fell into three TJC Chapters - Environment of Care, Infection Control, and Human Resources. Below are the top standards that every organization needs to make sure they comply with to avoid a citation.

Environment of Care Chapter

• EC 02.03.05 - focuses on systems and equipment that provide detection, notification, and extinguishment of fire conditions as well as the devices that signal the fire alarm system to activate and notify first responders of a fire emergency.
• EC 02.05.07 – focuses on inspection, testing, and maintenance activities related to electrical infrastructure support systems, for example, emergency lights, generators, and supplemental electrical power systems.

Infection Control Chapter

• IC.02.01.01 - Organizations are required to implement IC activities. This standard is cited if organizations fail to follow state or federal regulations, manufacturer’s instructions for use (MIFU) and/or processes, and organizational policies or procedures.
• IC 02.02.01 – This standard speaks to reducing the risk of infections associated with medical equipment, devices, and supplies. This is where failure to follow the manufacturer’s instructions for use is most frequently cited.

Human Resources Chapter

• HR.02.01.03 – This standard is back on the list again. It requires organizations to grant initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Determining who is permitted by law to practice independently is determined by each individual state.

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