JCAHO Top Compliance Issues for 2006

The Joint Commission just released top compliance issues for last year...how do you stack up?

• 58% of hospitals did not improve the effectiveness of communication among caregivers, having problems with verifying verbal orders, using prohibited abbreviations, communicating critical test results, and standardizing hand-off communications

• 46% of hospitals did not accurately and completely reconcile medications across the continuum of care

• 44% of hospitals did not properly and safely store medications

• 30% of hospitals are not properly following the Universal Protocol to prevent wrong-site, wrong-procedure, wrong-person surgery


Issue 1: Communication.

Issue 2: Medication reconciliation.

Issue 3: Medication storage.

Issue 4: Surgical Errors.


Take another look at the first issue...it impacts each of the following three, particularly surgical errors.

What communication development programs do you have in place?

If the answer is "zero," convene a communication improvement committee this afternoon - there's no better time to start the process of clarification.

JCAHO has made their expectations for improvement clear - have you communicated the urgency of these efforts to your team? Do you regularly monitor (using quantitative AND qualitative methodologies) improvements and internal benchmarks?

And for the purposes of self-awareness, take 15 minutes and use the free Alpha Assessment to clarify your leadership and communication strengths (and weaknesses).