The Six Least Compliant Joint Commission Standards

Facilities play a crucial role in the lives of hospital staff and patients. In life or death situations, a hospital’s environment is essential to staff and patient wellbeing. After all, patients spend time in hospitals to pursue healing and the facility plays a massive role. Hospitals are for-profit organizations with tight budgets and a never-ending list of necessary facility upgrades. Challenges lie in the prioritization of these projects, between patient wellbeing and building wellbeing.

Patient and facility wellbeing should not be considered separately. Environment connects patient and facility. By investing and making infrastructure improvements, you are also investing in the overall wellbeing of your patients and staff in the long-term.

Of the 2016 Joint Commission surveyed standards, the following are identified as the six least compliant standards for hospital facilities in the physical hospital environment such as appropriate temperature, ventilation issues and general safety hazards:

    1. Standard EC.02.06.01, 66% non-compliant: Maintain a safe, functional environment and maintain ventilation, temperature and humidity

    1. Standard IC.02.02.01, 59% non- compliant: Reduces risk of infection associated with equipment, devices and supplies

    1. Standard IC.02.05.01, 56% non-compliant: Manage risk associate with utility systems including supply, exhaust, filtration and air exchanges

    1. Standard EC.02.01.20, 50% non-compliant: Manage the Means of Egress, including door locking features & corridor clutter

    1. Standard LS.02.01.35, 47% non-compliant: Manage systems for extinguishing fires including the integrity and other issues including ceiling tiles misplaced, extinguisher signage and blocked access to fire extinguishers

    1. Standard LS.02.01.10, 46% non-compliant: Building and fire protection general requirements: fire-rated door and barrier penetrations

    1. Standard LS.02.01.30, 46% non-compliant: Building and fire protection features: Hazardous area doors and corridor doors such as doors to Suites


The goal of implementing these standards is to create a physical environment that supports clinical function, allowing for the care, treatment and services provided.

Compliance is difficult. In many cases, surveyors can site any unsafe condition in the patient care environment. You and your facility team must anticipate risks to patient safety while mitigating those risks without a specific checklist of unsafe conditions.

That’s where we come in. At BCS, we understand hospital facility equipment and maintenance. It’s our life’s work to nurture the relationship between patients, staff and environment. We can be your partner in solving compliance issues. By providing the highest quality HVAC, building automation and fire and security equipment, we give you control over the environment and peace of mind for quality application.

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