Compliance with a joint commission standard is determined first by scoring the elements of performance (EP). The EPs are the requirements that make up a Joint Commission standard. EPs are scored using the following scale: (0) insufficient compliance, (1) partial compliance, (2) satisfactory compliance, and (NA) not applicable. Scoring of each EP consists of two components: compliance with the requirements and compliance with the track record.

EP Scoring Categories

Each EP has a scoring category of A, B, or C listed in the margin. The category A EPs indicate the presence or absence of requirements, and are scored either (2) or (0). A score of (1) for partial compliance may be given based on track record.

Category B EPs also indicate the presence or absence of the requirements. They can be scored (2) if all the requirements and principles of good process design are considered; scored as (1) if the requirements are met but some principles of good process design are considered; and scored as (0) if it does not meet the requirements. The characteristics of good process design should be consistent with the hospital's mission, values, and goals; meet the needs of the patients; follow currently accepted practices; and incorporate current safety information and relevant performance improvement goals.

Figure 1: If three EPs are scored (1), the standard EC.6.10 becomes not compliant. Click on image to view larger size.

Examples of applying principles of good process design for selecting and acquiring medical equipment (see EC.6.10, EP2) include needs assessment, appropriate selection criteria, comparative clinical and technical evaluations, life cycle cost analysis, clinical effectiveness, patient safety, and human factors.

Category C scores EPs based on the number of times the hospital does not meet the EP. They are based on frequency and require totaling the number of occurrences (the results of performance or nonperformance). They can be scored (2) if there are one or fewer occurrences of noncompliance; (1) if there are two occurrences of noncompliance; and (0) if there are three or more occurrences of noncompliance.

Simply stated, a category A EP is scored more stringently than a category C EP.

The EPs 1 through 7 in EC.6.10 are assigned a category B scoring. The EP 8, which pertains to emergency procedures, is assigned a category A scoring. The EPs 1, 4, 5, and 6 in EC.6.20 are assigned a category C scoring. The EP 2, which pertains to performance and safety testing, and EP 3, which pertains to maintenance of life support equipment, are assigned a category A scoring.

Track Record

The track record is the time an organization has to comply with a standard, an EP, or a requirement. The track record must be met in addition to the requirements of each EP. For a full survey, to get a score of (2), the EP requirements should be met for a period of 12 months or more. If the EP requirements are met for a period of 6 to 11 months, the organization receives a score of (1), and if the EP requirements are met for a period of less than 6 months, it is scored (0).

Compliance with Standards

A Joint Commission standard is scored as compliant or not compliant. After each EP associated with a standard is assessed and scored, the following two rules are used to determine compliance with the standard:

• The standard is scored as not compliant if any EP is scored (0);
• The standard is scored not compliant if 35% or more of its EPs are scored (1).

The standard EC.6.10 has 8 EPs. If one EP is scored (0), or three EPs (see Figure 1) are scored (1), then the standard EC.6.10 would be scored as not compliant.

Arif Subhan, MS, CCE, is senior clinical engineer, Masterplan, Chatsworth, Calif, and chair, education committee, ACCE. For more information, contact