Top 2022 TJC Deficiencies and Potential Solutions in the Hospital Environment

Last month, The Joint Commission published the Top TJC Deficiencies for 2022. You probably looked at the list and thought, like I, “No surprises, same performance issues as years past.”  But then my performance improvement training kicked in and challenged me to give this more thought.

Why are we unable to eliminate these findings? What are some strategies for finally conquering these issues and are we willing to invest in the hard work to overcome them?

What are the Top TJC Deficiencies and how can we overcome them?

From an Environment of Care- Life Safety Perspective: The top deficiencies still center around:

  1. The obligation to provide a safe and functional environment (EC 02.06.01) based upon the patient population being served. Often, this standard is referred to as the Environmental “Catch-All” standard, in some way insinuating that these are more nuisance types of findings. It is here we see poorly maintained environments, specifically torn, damaged upholstery, damaged cabinetry and countertops cited.
  2. Utility System controls are labeled to facilitate partial or full shutdowns (EC 02.05.01) portrays similar behavioral gaps associated with labeling of electrical breaker boxes, and kitchen appliance gas supply lines.
  3. Another top scoring area is non-high risk utility systems not being inspected, maintained or tested. It is here where open electrical junction boxes and clutter blocking access to electrical panels is most often cited.

Organizations that appear to have navigated away from these findings have built in accountability expectations with or without accountability consequences. An example of building accountability expectations into the work product is the incorporation of performance expectations into the contract for work inclusive of monetary penalties and/or work inspection prior to release of payment requirements. Contracted employees are often employed for more extensive above ceiling work and having expectations set within the contract gives the organization more ability to hold those workers and companies accountable for adhering to Life Safety and Building Code requirements.

Hardwiring accountability into the staff performance assessment process is also an opportunity that some organizations are utilizing. For instance, can an organization optimize the use of its work order system to also trigger a post-work inspection process to ensure the work was performed as expected? Could this eliminate the presence of open electrical junction boxes?

National Patient Safety Goal 15:

The expectations of the suicide risk identification and mitigation safety goal, involve both clinical interventions and environmental interventions and appeared on the Top Deficiencies list for Hospitals, Behavioral Health, and Critical Access Hospital programs. Of primary concern in these programs was the completion and management of the Environmental Ligature Risk Assessment, a fundamental element substantiating an organization’s ability to recognize a ligature risk and mitigate the risk.

The care environment is not a static environment as it is affected by many external factors. Many organizations have embedded the review and updating of the risk assessment into weekly/monthly activities or have identified key criteria which would trigger a need to review/revise the risk assessment document. For instance, when Plant Operations plan to conduct any type of construction or maintenance to the unit, the risk assessment should be considered. Any risk created by the current environment should be noted in the risk assessment and an intervening mitigation action implemented. Scheduling periodic reviews of the risk assessment during environmental rounds is a great way to engage many sets of eyes into this activity and can serve as a learning opportunity for team members. Hardwiring this into the reporting schedule/calendar for your Environmental Safety Committee could help to ensure the document is kept up to date.

From a clinical care perspective, documentation of the patient’s overall suicide risk and the mitigation plan is another frequently cited area. Overall suicide risk is determined based upon the comprehensive assessment of suicidality which is triggered by the suicide screening and is completed by the licensed care provider. Organizations are often cited for delays in completion of the comprehensive assessment and for not immediately implementing a mitigation strategy (e.g.,1:1 monitoring) once the patient screens at risk.

Organizations should collaborate with their organized medical staff and consider development of a STAT Consult process for the completion of the comprehensive assessment and potential development of an OPPE indicator for those practitioners who are assigned to perform the assessment. Additionally, consideration should be given to establishing an alert system, similar to alert systems in place for Fall Risk and Seizure Risk Alerts which automatically trigger key interventions and communications through the electronic medical record process.

Medication Management and Titratable Medications:

Another area where many organizations are cited is related to Medication Management and specifically management of titratable medications. Historically this was often cited as a scope of practice issue but has migrated to findings at MM 06.01.01.  The element of performance most commonly cited is #3 and the aspect of the element noted as problematic is the requirements that the individual administering the medication verifies that the medication is being administered at the proper time, in the prescribed dose and by the correct route. In the absence of the below list of components needed for a titratable medication order, the verification process cannot be completed.

Required elements of a Titratable Medication Order

  • Medication name, route and concentration
  • Initial or starting rate of infusion (dose/min)
  • Incremental units the rate can be increased or decreased by
  • Frequency for incremental dose adjustments
  • Parameters by which the dose should be adjusted
  • Maximum rate (dose) of infusion

Many organizations have made great advances in eliminating potential medication errors and the potential for patient harm by establishing standardized concentrations and infusion order sets for use within the organization. Standardization in both the concentration and the approach to titration reduces the risk of confusion, establishes a more reliable system for care providers assigned to administer these medications and enhances patient safety.

Organizations that have embraced the concept and principles of High Reliability will recognize the initial investment in time to hardwire the accountability aspects of the mitigation strategies will help to lead the organization to a more reliable, safer organization.

To learn more about Top TJC Deficiencies potential solutions in the hospital environment contact the C&A team at 704-573-4535 or email us at

Leave a Comment

Your email address will not be published. Required fields are marked *

Shopping Cart