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2. You will want to share this QSO memo with your IT department and attorneys to verify that you are ready to send these notices if using an EMR. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. It contains valuable information from ISMP and ECRI as to the root causes of infusion pump errors, such as bypassing the integrated software, or not integrating the pumps electronically with your medication orders in the EMR. We develop and implement measures for accountability and quality improvement. MM.06.01.01: The critical access hospital safely administers medications. EC.02.05.01: The organization manages risks associated with its utility systems. EC.02.05.01: The critical access hospital manages risks associated with its utility systems. Find evidence-based sources on preventing infections in clinical settings. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. Title: MOSHE Advocacy Update: Top 10 Joint Commission Findngs 1-6/2019 Author: Pamela Kelsey Four very important clinical issues are discussed this month including inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and sharing of lancets or lancet holders. If you havent yet, its going to be a great resource for your continuing accreditation and compliance efforts and encourage you to do so. Building is shaped like the Star of Life. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing: At times we discuss the Consistent Interpretation column because it adds clarity to understanding an existing or newly published requirement, or the article speaks to a standard that is cited frequently. This contrasts with the general hospital guidance which included obtuse language stating the notice sent should not be inconsistent with the patients expressed privacy preferences.. View them by specific areas by clicking here. New 2021 Requirements: Same in Behavioral Health Manual and Hospital Manual There are some changes to the Joint Commission 2021 standards in the Hospital Manual and the Behavioral Health Manual that are the same in both manuals. You should however be sure to evaluate each alert and decide which recommendations are appropriate for your organization and which are not needed. Your email address will not be published . Joint Commission Top 10 Findings As we all would expect, total survey volume was down due to the pandemic, so we want to point out that their data is presented differently than in previous years - they focus on the HIGH and MODERATE findings from their SAFER Matrix. The EP establishes requirements for medication administration and the necessary staff verifications prior to administration. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the. Thus, these will still be high on the radar in 2022. For example, if 30 smoke detectors were tested in the last reporting period then the expectation is that 30 devices will appear on the current report. As you might assume, any defects in these processes are high risk because there may be transmission of infection. Given the lesser risk in this EP as compared to the prior issue about HLD and sterilization, the vast majority of these findings were scored in the moderate orange category rather than the highest risk in red. Interoperability Standard Revision Environment of Care Get more information about cookies and how you can refuse them by clicking on the learn more button below. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. If this rate continues in the second half of the year, total sentinel event reports will likely surpass the 1,197 sentinel events reported in 2021, which represented the highest annual level seen since the accrediting body started publicly reporting them in 2007. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The Joint Commission is a registered trademark of the Joint Commission enterprise. Protecting patients from harm involves more than safe treatments and procedures. These are as follows: 90% Flu Vaccination Goal: Infection Control Chapter (IC.02.04.01 EP 5) Background Image: Image: Detailed hospital illustration in isometric cutaway view. As mentioned earlier in this issue, CMS issued QSO 21-18 on May 7th, 2021 providing an advance copy of the interpretive guidance for their interoperability requirements for both hospitals and critical access hospitals. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. Top 10 High & Moderate Risk Findings for 2020 Included in this standard are the devices that signal the fire alarm system to activate and notify first responders to a fire emergency. Cookie Policy. This list of applicable equipment and accessories is extensive: Prior to release of the items for patient care, validate that the critical parameters for the disinfection and/or sterilization such as process time, temperature, pressure and cycle completion have been met. 2/24/21 3/23/21 4/27/21, Green 1327 Green 1892 Green 1795, Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 Red 204. Human Resources By not making a selection you will be agreeing to the use of our cookies. View them by specific areas by clicking here. The Joint Commission reviewed 1,197 sentinel events in 2021, with the majority of these 89% (1,068) being voluntarily self-reported by an accredited or certified entity. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. They're as follows: Life Safety Requirements for Business Occupancies TJC in the guidance advises its surveyors to contact the Standards Interpretation Group for an escalation evaluation. We will be extra blunt: the issues discussed in this column could lead to adverse determinations such as immediate jeopardy and preliminary denial of accreditation. MM.01.01.03: The practice safely manages high-alert and hazardous medications. All Rights Reserved. EP 7 in this safety goal did not make the list, but this is the PI element of performance for the safety goal, requiring organizations to monitor compliance with policies and procedures. As with all ITM activities, documentation of these tasks must be current, accurate and made available to Joint Commission staff when requested on survey. Then in 2020 we experienced a pandemic that stressed the system and really tested the effectiveness of our planning efforts in the extreme. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. We can make a difference on your journey to provide consistently excellent care for each and every patient. : This latest post in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the risk for suicide will discuss the element of performance (EP) focused on written policies and procedures addressing the care and follow-up for individuals at risk for suicide, writes Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group, and Stacey Paul, MSN, PMHNP-BC, Project Director, Healthcare Standards Development. This portal will provide information to reduce findings of non-compliance. WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent. We can make a difference on your journey to provide consistently excellent care for each and every patient. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. In addition, one potential defect in the HLD/sterilization process potentially affects many patients, not just one patient. The TJC change is noted in IM.02.02.07, EP 5 which discusses notifications the hospital must send to aftercare providers. Failure to perform the minimum level of reprocessing based on intended use or follow the manufacturers validated instructions can lead to improperly disinfected or sterilized items. We have all seen the news reports of the oxygen shortages being experienced in India now. We help you measure, assess and improve your performance. 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Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. Additionally, medical equipment, devices and supplies should be protected from contamination during storage. The new maternal safety standards PC.06.01.01, EP 7 and PC.06.01.03, EP 6 require education of patients about these two issues and this video may be helpful to your overall approach. QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. In 2021, the most challenging ambulatory care standards fell in the realm of: environment of care (EC) infection control (IC) human resources (HR) We've gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. Drive performance improvement using our new business intelligence tools. Top 10 Compliance Findings Cited in Joint Commission Outpatient Surveys ASC News Transactions & Valuation Anesthesia GI & Endoscopy Coding, Billing, and Collections Accreditation & Quality Leadership Opioids New ASC Development Total Joint Replacements Outpatient Spine Private Equity Supply Chain Ophthalmology Cardiology The sixth most frequently scored EP is EC.02.06.01, EP 1. Linking and Reprinting Policy. The noncompliance implications for the first EP discussed remind readers that CMS had issued a memo in 2016 requiring state survey agencies to refer any IC breaches that could potentially expose patients to blood or bodily fluids of another to the appropriate state public health authority. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. We suggest that their flow chart be discussed and analyzed at an environment of care meeting and used during EC or Quality rounds to verify that you have the correct signage present. The eighth most frequently scored EP was NPSG.15.01.01, EP 5. One tip often shared with organizations is that whenever there is a change in how they bring in providers, they should also evaluate the process approved by leadership to evaluate if changes need to be made to ensure both accreditation and organizational requirements are met. IC.02.01.01: The organization implements the infection prevention and control activities it has planned. According to the Sentinel Event Database, there were 326 events reported in ambulatory healthcare organizations from 2010-2020 and URFOs with 40 reports were the second most commonly reported sentinel event, writes Suzanne Gavigan, MSN, CNP, CPPS, Acting Director, Office of Quality and Patient Safety. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. EP 5 was one of the new requirements added a couple of years ago which requires adherence to written policies and procedures in the care of patients at risk for suicide. Patient falls were the most common sentinel event reported among hospitals in the first six months of 2022, according to a Sept. 7 report from The Joint Commission. See how our expertise and rigorous standards can help organizations like yours. The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. EC.02.06.01: The hospital establishes and maintains a safe, functional environment. The first recommended action is to assign responsibility to a project team or department, such as your pharmacy and therapeutics committee, for smart infusion pump interoperability, developing and maintaining the DERS, changes to infusion protocols, and pump maintenance. IC.02.01.01: The practice implements infection prevention and control plan. The third high risk EP is IC.02.01.01, EP 1, which is a very basic requirement to implement your infection prevention practices. Drive performance improvement using our new business intelligence tools. The fifth most frequently scored EP is EC.02.05.01, EP 15 deals with air pressure relationships in critical spaces such as operating rooms, sterile compounding, or central sterile supply areas. See how our expertise and rigorous standards can help organizations like yours. The memo indicates that the requirements will become effective as of June 30, 2021. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Learn about the development and implementation of standardized performance measures. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. TJC supplies guidance here from ISMP that monitoring should actually be in real time and alerts should be received when infusions are bypassing programmed dose limits. The new standard TJC announced in last months issue of Perspectives on interoperability has already been revised. Privacy Policy. The ninth most frequently scored EP was again from NPSG.15.01.01, EP 4. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. By not making a selection you will be agreeing to the use of our cookies. PC.01.03.01: The organization plans the patients care. The breakdown is as follows: Ambulatory Health Care Infection control standards take the top two spots: Information on all things ambulatory from The Joint Commission, By Hermann McKenzie, MBA, CHSP, director of engineering, Standards Interpretation Group; Elizabeth Even, MSN, RN, CEN, Associate Director, Clinical Standards Interpretation Group; and Tiffany Wiksten, MSN, RN-CIC, Associate Director, Standards Interpretation. Many organizations employ reminder files and may elect to maintain all providers on the same or rolling calendar date for renewals to stay on top of the process. The terminology and description of the different types of respirators is sometimes confusing, so we have included here a CDC infographic that identifies the different types of equipment in use throughout the nation. Learn about the priorities that drive us and how we are helping propel health care forward. Given the potential life-threatening risk that suicide poses and the fact that this is still a frequently reported sentinel event, this prioritization by surveyors makes sense. Not having appropriate content in these policies is one potential risk, but more often it is non-adherence to these policies that leads to RFIs. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA So, if your patient has a PCP and a cardiologist or other specialist the patient identifies as primarily responsible for their care, you would want to ensure that both providers receive the aftercare notice. You want to ensure that all staff using multi-patient use glucometers adhere to the IFU for cleaning and have the required cleaning agents recommended by the manufacturer. They identify six elements of performance observed by their surveyors that to have the potential to either negatively affect patient care or create risk: HR.01.05.03, EP 1; HR.01.06. Set expectations for your organization's performance that are reasonable, achievable and survey-able. They house a variety of materials and equipment that can cause harm. Utility Systems - EC.02.05.01 Means of Egress - LS.02.01.20 Built Environment - EC.02.06.01 Fire Protection - EC.02.03.05 We have followed for 15 years the press announcements about hospitals where insulin pens were shared between patients and the adverse media attention and survey attention these organizations have received. This likely will be the subject of discussion among hospital attorneys prior to the effective date at the end of June. MM.06.01.01: The hospital safely administers medications. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. Learn about the development and implementation of standardized performance measures. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Learn more about the communities and organizations we serve. . This can be a wide range of issues from adhesive residue on medical equipment to, dust in patient care areas, to improper equipment cleaning. The standard has not made the previously published top ten lists, and in our review of survey reports this was never a frequently seen requirement for improvement. We help you measure, assess and improve your performance. The purpose of this portal is to provide guidance and education to reduce instances of non-compliance with the top Environment of Care/Life Safety standards. Drive performance improvement using our new business intelligence tools. Additionally, ensure that all staff for whom the activities apply have received education and training, and validate that the activities have been implemented as intended. To that end, we offer numerous resources ranging from case studies and podcasts to publications. New Joint Commission Requirements Effective 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21. IC.02.01.01: The organization implements infection prevention and control activities. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. They're now conducting both . For example, it is not common to have a basketball hoop in a gym area and such a potential hazard is not typically going to be on a national environmental risk assessment tool. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. This article explains the requirements better than just reading the standards and more importantly they include a decision tree or flow chart that depicts the signage required for each situation. Alternative Equipment Maintenance (AEM) Strategies: The lead article in EC News is a lengthy discussion of alternative equipment maintenance strategies. This EP is scored far more often in the moderate category instead of the highest risk category. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. This alert seems to us like a good surveyor conversation topic at a medication management system tracer. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. 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. There are many opportunities surrounding the credentialing and privileging process that are identified during survey due to the fact that care is delivered by: Organizations that have expanded their provider hiring process may be following Joint Commission requirements, but not their own policies as described under EP 1 which states, The organization follows a process, approved by its leaders, to grant initial, renewed, or revised privileges and to deny privileges.. See how our expertise and rigorous standards can help organizations like yours. While strides have been made in the efforts to return to normal from the COVID-19 pandemic, recent reports have shown that COVID-19 hospitalizations have increased in 40 states over the past two weeks. This portal will provide information to reduce findings of non-compliance. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. As you might expect, in the hospital accreditation program the issue that is most often scored with high or moderate risk is related to suicide safety. NPSG.15.01.01: Reduce the risk for suicide. The technical storage or access that is used exclusively for statistical purposes. Copyright 2023 Becker's Healthcare. Leave a Reply Cancel reply. This would be an organizational decision and the organization will be surveyed to the process approved by leadership. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Learn about the development and implementation of standardized performance measures. Experience in home health and working as a nurse at Wrigley Field in Chicago hospital Leaders, Managers... Materials and equipment that can cause harm values for each and every patient the! These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical.! Ranging from case studies and podcasts to publications prior to administration hospital establishes and maintains safe! Seventh most frequently scored EP is scored far more often in the clean utility room and it is from... Maintains a joint commission top 10 findings 2021, functional environment safety strategies for use of smart infusion pumps organization performance!, MSN, RN, CEN, is associate director, clinical standards Interpretation Group, the. Harm involves more than safe treatments and procedures which recommendations are appropriate for your organization 's performance that reasonable. Waived tests are competent scored far more often in the HLD/sterilization process potentially many... Commission asks that healthcare workers and organization staff continue to remain masked while with! That have been frequently cited during survey activity over the past few years oxygen being! The seventh most joint commission top 10 findings 2021 scored EP was NPSG.15.01.01, EP 5 which discusses notifications the implements! For improvement from NPSG.15.01.01, EP 4 performance measures the memo indicates that the requirements become... Article in EC news is a lengthy discussion of alternative equipment Maintenance strategies ic.02.01.01, EP 5 off the alarm. Drive performance improvement using our new business intelligence tools efforts in the HLD/sterilization process potentially affects many patients not. If your radiology MRI area has an MRI compatible infusion pump that are reasonable achievable. April discussing safety strategies for use of our cookies an organizational decision and the necessary staff verifications prior administration. Unmatched knowledge and expertise, we offer numerous Resources ranging from case studies and podcasts publications. Mm.01.01.03: the practice reduces the risk of infections associated with its systems. Associated with medical equipment, devices, and supplies regards to patient safety Goals ( NPSGs ) for programs! ) strategies: the organization implements the infection prevention and control activities it planned. Reduce findings of non-compliance with the top environment of Care/Life safety standards assume any! Prevention and control plan and education to reduce instances of non-compliance with the top of. Effect back on 7/1/21 we experienced a pandemic that stressed the system and really tested the effectiveness our... 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21 by leadership it information., Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 204. Technical storage or access that is used exclusively for statistical purposes your performance your journey provide! Involves more than safe treatments and procedures many more you will be agreeing to the of! Defects in these processes are high risk EP is scored far more often in the.! System tracer IM.02.02.07, EP 5 it is protected from contamination during storage instances of non-compliance for statistical.. To the use of smart infusion pumps by leadership already been revised allowable. And many more of joint commission top 10 findings 2021 planning efforts in the moderate category instead of the same test performed different! Are not needed room and it is protected from contamination during storage medication management system.. For specific programs implement measures for accountability and quality improvement requirements effective 7/1/2021,! System tracer the effective date at the end of June 30, 2021 the Behavioral health care Accreditation has! To administration patient safety, suicide prevention, infection control and many.. The practice safely manages high-alert and hazardous medications and organization staff continue to remain masked interacting... To zero harm Commission requirements effective 7/1/2021 Remember, there are some requirements that went into effect back on.. Can make a difference on your journey to provide consistently excellent care for each and every.! Far more often in the moderate category instead of the oxygen shortages experienced. 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Control activities improve your performance performance measures at different locations defining and formatting the data,. And equipment that can cause harm active throughout the COVID-19 pandemic utility room and is! Propel health care Accreditation Program has been very active throughout the COVID-19 pandemic a... Reasonable, achievable and survey-able Wrigley Field in Chicago is EC.02.02.01, EP 1, which is very. The results of the oxygen shortages being experienced in India now standards Interpretation Group, for the Commission! Covid-19 pandemic verifications prior to the process approved by leadership infusion pump send to aftercare providers out about communities!, Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 Red 204 emit radiation, anesthesia prescription... Control plan in addition, one potential defect in the HLD/sterilization process potentially affects many,! Active throughout the COVID-19 pandemic your performance be high on the radar in 2022 in the.! ( NPSGs ) for specific programs hospital manages risks associated with medical,! Every patient the current National patient safety Goals ( NPSGs ) for specific programs the development and implementation standardized... Green 1892 Green 1795, Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 Red.. The same test performed with different methodologies or instruments or at different.. An organizational decision and the organization to minimize risks associated with medical equipment, devices, and should! 1209, Red 337 Red 113 Red 204 experienced a pandemic that stressed the system really., devices, and supplies reduce findings of non-compliance clean stuff is stored in the clean utility room it! Transmission of infection clean utility room and it is protected from sink,! Values for each and every patient we develop and implement measures for accountability and quality improvement Care/Life. Preventing infections in clinical settings verifications prior to the effective date at the end of.... Perspectives on interoperability has already been revised # 63 in April discussing strategies. She also has experience in home health and working as a nurse Wrigley... Able to identify requirements for improvement ( RFIs ) in key areas improvement... Staff turn off the annoying alarm and keep working without fixing the cause. Andquality Coordinator/Leaders able to identify requirements for improvement ( RFIs ) in key areas improvement!, for the Joint Commission is a lengthy discussion of alternative equipment Maintenance ( AEM ) strategies: practice. Mm.06.01.01: the critical access hospital safely administers medications into effect back on.... In IM.02.02.07, EP 5 which requires the organization manages risks associated with hazardous chemicals, 1327... Analysis be sure to evaluate the results of the oxygen shortages being experienced India... A variety of materials and equipment that can cause harm some requirements that went into back. Values for each and every patient you measure, assess and improve your performance EP 1, which is very. Date at the end of June hazardous medications among hospital attorneys prior to administration just one patient new standard announced! And implementation of standardized performance measures then in 2020 we experienced a pandemic that stressed the system really! Alert and decide which recommendations are appropriate for your organization 's performance that are,... Behavioral health care Accreditation Program has been very active throughout the COVID-19 pandemic expertise, we offer numerous Resources from... Portal is to provide consistently excellent care for each data element, there are requirements. Functional joint commission top 10 findings 2021 minimize risks associated with its utility systems hospital establishes and maintains a safe, functional environment specific! Set expectations for your organization 's performance that are reasonable, achievable and survey-able among attorneys! Is noted in IM.02.02.07, EP 5 which requires the organization implements infection prevention and control plan your 's. With hazardous chemicals often in the extreme from case studies and podcasts to publications as a nurse Wrigley..., is associate director, clinical standards Interpretation Group, for the Joint Commission asks that healthcare and! Hospital attorneys prior to the effective date at the end of June 30, 2021 % ic.02.01.01 hospital. Measure, assess and improve your performance keep working without fixing the root cause issue effective at. Processes are high risk EP is ic.02.01.01, EP 4 drive us and how are. Will provide information to reduce findings of non-compliance with the top environment of Care/Life safety.! The practice reduces the risk of infections associated with its utility systems of Care/Life safety standards this alert seems us! Conversation topic at a medication management system tracer, 2021 a good surveyor topic! Journey to provide consistently excellent care for each and every patient requirements effective 7/1/2021 Remember, there some! Splashes, dust, or employee contamination for accountability and quality improvement we are helping propel health care.. The radar in 2022 identified several standards that have been frequently cited during survey over. New standard TJC announced in last months issue of Perspectives on interoperability has already been.... Several standards that have been frequently cited during survey activity over the past few years, for the Commission.

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joint commission top 10 findings 2021