Joint Commission releases data on challenging requirements for OBS practices

If your office-based surgery (OBS) practice is having trouble complying with standards related to clinical privileges and infection control, you’re not alone. The Joint Commission regularly collects data on compliance with standards and other requirements among its accredited health care institutions and has found that these challenges are quite common.

Earlier this year, The Joint Commission released a list of the top five areas of noncompliance for institutions that were scheduled to be surveyed and reviewed during calendar year 2016.1 The data represent citations only from organizations due to be surveyed during this time period.

Five most challenging standards for OBS practices

Data specific to OBS practices were included on the comprehensive list. According to the study results, the top five requirements that were most challenging for OBS practices in 2016 were as follows:

  • Human resources (HR.02.01.03): The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently—with a 60 percent noncompliance rate (which indicates the number of organizations that received requirements for improvement [also known as RFIs] for this standard)
  • Infection control (IC.02.02.01): The practice reduces the risk of infections associated with medical equipment, devices, and supplies—57 percent noncompliance
  • Environment of care (EC.02.04.03): The practice inspects, tests, and maintains medical equipment—41 percent noncompliance
  • IC.01.03.01: The practice identifies risks for acquiring and transmitting infections—24 percent noncompliance
  • National Patient Safety Goals (NPSG.07.01.01): Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines—24 percent noncompliance

Suggested solutions

In a recent post to the Ambulatory Buzz blog, Joint Commission staff offered solutions for complying with some of the standards.2 Joyce Webb, a project manager in The Joint Commission’s department of standards and survey methods, provided guidance for HR.02.01.03—A standard dedicated to verifying that licensed independent practitioners are capable of providing quality, safe patient care. Ms. Webb wrote that compliance with this requirement is one of the most important responsibilities of a health care facility. To become compliant with the requirement, Ms. Webb recommended that OBS practices take the following steps:

  • Designate a detail-oriented point person to handle credentialing and privileging tasks
  • Establish a routine and standardized process for primary source verification and granting of privileges
  • Use a standardized personnel and credentialing file format
  • Monitor time frames for review and renewal of privileges using a calendar or computerized prompts/reminders
  • Obtain a written health attestation from all providers going through the credentialing and privileging processes

Regarding IC.02.02.01, The Joint Commission infection prevention specialist Lisa Waldowski asserts that the standard directly affects patient care. She offered several ideas to help OBS practices comply with the requirement, including the following:

  • Train staff who perform high-level disinfection and sterilization to the appropriate competency
  • Assess competence of those with supervisory oversight to sign off and monitor staff conducting high-level disinfection/sterilization
  • Confirm the location of documented competencies
  • Ensure staff has access to the manufacturer instructions for use of instruments, equipment, and supplies used for high-level disinfection/sterilization
  • Review evidence-based guidelines specific to high-level disinfection/sterilization with frontline staff and ensure future access to updated guidelines
  • Perform staff teach-backs of evidence-based guidelines for high-level disinfection and/or sterilization

In May, The Joint Commission released a new resource on this topic published in Quick Safety, Issue 33, “Improperly sterilized or HLD [High-Level-Disinfectant] equipment—a growing problem.”3

With regard to EC.02.04.03—The practice inspects, tests, and maintains medical equipment—Ms. Waldowski recommends that OBS practices adhere to the manufacturer’s instructions for use. This may include working with facilities/engineering/plant operations and/or contracted staff to ensure compliance.

For IC.01.03.01—The practice identifies risks for acquiring and transmitting infections, according to Ms. Waldowski, the organization’s risk assessment should serve as the basis for developing written goals and measurable outcomes for infection control activities. Other recommendations were that the assessment meets the following criteria:

  • Represents the entire organization
  • Documents prioritized risks
  • Includes input from multiple disciplines, as appropriate
  • Has a continuous process for planning and maintaining infection prevention and control activities

In reference to NPSG.07.01.01 —Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines—the Joint Commission Center for Transforming Healthcare developed a Hand Hygiene Targeted Solutions Tool (TST)® that can help health care institutions become compliant with that requirement. Organizations that have used the TST have increased their overall hand hygiene compliance and decreased their health care-associated infections. For more information on the TST, visit the Joint Commission Center for Transforming Healthcare website.

For the full list of top five challenging requirements for all programs, review the March 29 issue of Joint Commission Online or the April issue of Perspectives.1,4 For more guidance with standards compliance, see The Joint Commission’s Standards Frequently Asked Questions or online question form.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. The Joint Commission. Top standards compliance data announced for 2016. Perspectives. April 2017. Available at: Accessed June 1, 2017.
  2. Kulczycki M. The Joint Commission. Top 10 challenging standards for 2016. Ambulatory Buzz. April 2017. Available at: Accessed June 1, 2017.
  3. The Joint Commission. Improperly sterilized or HLD equipment—A growing problem. Quick Safety, Issue 33. May 2017. Available at: Accessed June 1, 2017.
  4. The Joint Commission. Top five most challenging requirements for 2016. Accreditation and Certification. March 2017. Available at: Accessed June 1, 2017.

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