Top Compliance Challenges for Ambulatory Care Organizations

The Joint Commission offers an end-of-year analysis by the ambulatory care team to highlight the most frequently cited standards. According to the report, in 2021 the most challenging ambulatory care standards fell into these three categories: environment of care (EC); infection control (IC); and human resources (HR). Each area was presented to subject matter experts and reviewed to share some insights into how to avoid these common challenges across ASCs. 

Presented in a blog on December 20, 2021, the findings to aid ambulatory facilities in meeting these workplace challenges were posted by authors 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 Group.

The Environment of Care is centered around a building’s systems and equipment that provide detection, notification and extinguishment of fire conditions. Included in this standard are the devices that signal the fire alarm system to activate and notify first responders to a fire emergency. According to the authors, “Most of these devices (e.g., pull stations, fire and smoke detectors) are typically not maintained by in-house staff. Consequently, the inspection, testing and maintenance (ITM) tasks are contracted. When this is the case, organizations must ensure they set up maintenance intervals that align with National Fire Protection Association (NFPA) code requirements, be it quarterly, semi-annually or annually.” 

Importantly, one test usually handled by staff is the monthly inspection of fire extinguishers. Additionally, activities related to electrical infrastructure support systems, specifically emergency lights, generators and supplemental electrical power systems, are directly tied to the delivery of patient care. 

The Infection Control standard requiring organizations to implement IC activities is commonly cited for failure to implement IC activities or required evidence-based guidance such as Standard Precautions. This standard may also be cited if organizations fail to follow state or federal regulations, manufacturer’s instructions for use (MIFU) and/or processes organizational policies or procedures. 
The authors’ suggestion is to follow the Infection Prevention & Control Hierarchy to help ensure that the activities the organization implements are compliant with regulations, Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfCs) where applicable, and MIFU. Additionally, leaders need to ensure that all staff for whom the activities apply have received education and training and validate that the activities have been implemented as intended. 

Leaders need to ensure that all staff have received education and training…

The standard meant to help organizations reduce the risk of infections associated with medical equipment, devices and supplies was most commonly cited for failure to ensure that reusable medical devices are reprocessed as per intended use and MIFU, and for failure to store medical equipment, devices and supplies in a manner to protect them from contamination. 

The authors noted, “Today, many organizations are faced with reprocessing complex instruments and devices. It is important to ensure that only manufacturer approved products are used and that all steps of the MIFU are followed for all items undergoing reprocessing, including equipment and accessories.”

Under the Human Resources standards, this area has returned as a top cited compliance issue after a hiatus over the last few years. A challenge for many accredited organizations, the authors state, “It requires organizations to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. The decision on who an organization brings in to care for its patients is arguably the most important decision an organization makes.” 

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. “Many organizations are under the false impression that because the providers they hire are employed elsewhere they do not have to credential.” OSM