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3 Ways COVID-19 Can Affect Your Joint Commission Inspections

By Cindy Juhas | August 27, 2021

The Joint Commission (TJC) is the nation's oldest and largest standards-setting and accrediting body in healthcare. Most hospitals, Ambulatory Surgery Centers (ASC), and other healthcare facilities are accredited through TJC. Once accredited, healthcare facilities are inspected at least once every three years.

The Joint Commission’s mandate is to increase the quality of patient care by elevating standards and delivery systems in healthcare facilities nationwide. TJC has always been laser-focused on infection prevention, environment of care, and emergency management. As we continue to live through the Covid-19 pandemic, inspections will be even more focused on these important elements.

Equipment Upgrades, Replacements, and Additions

There is a fairly, standard list of equipment upgrades and replacements that healthcare facilities need to complete to pass their inspections.

They include:

  • Storage Solutions
    • Additional storage units, replacing ones that are rusted
    • New cart covers to replace damaged ones
  • Scope Storage Cabinets
    • New scope cabinets that have HEPA air filtration systems

  • Chrome Shelving
    • Replace damaged items, add shelf inlays, make sure nothing is stored on the ground

  • Stainless Steel Equipment
    • Replace any equipment showing rust or pitting

  • Refrigerators/freezers
    • Need to have monitoring systems to insure consistent temperatures

  • Carts
    • Biohazard wheels for OR case carts, replacement wheels for any carts, new cart covers

  • IV Poles
    • Replace broken or rusty equipment, replace wheels

  • Wall-Mounted Items
    • AED cabinets in hallways, PPE dispensers and computer mounts less than 4” Deep in hallways

  • Replacement of Furniture
    • Anything that has torn upholstery like exam tables, recliners, phlebotomy chairs and stretcher pads

  • ADA Compliant Equipment

  • Cubicle Curtains

Recently in a mock TJC inspection in Florida, an inspector recommended splash guards and dividers to aid in infection prevention. Supplies, medication, and equipment cannot be stored on a counter within 36” of a sink. These splash guards can help with this rule if you cannot move these supplies somewhere else. One can expect that more of these types of infection protection items will be needed in the future.

Extended Lead Times

Healthcare facilities get very little notice, if any, prior to a Joint Commission inspection. In the past, replacement equipment has been ordered on an expedited basis, meaning that all items are needed ASAP! As we have all experienced, Covid-19 has caused extended lead times on many raw materials including aluminum, chrome, steel, electronic equipment, plastic, and foam.

Most of the equipment previously cited are manufactured with one or more of these scarce raw materials. Besides raw material shortages, there are significant delays in global and domestic logistics. There is a shipping container shortage, back-up in strategic harbors, and a North American shortage of truck drivers. These issues make for extended lead times for most medical equipment. Many times, manufacturers are not giving ship dates because they just don’t know the answer.

100% Preventive Maintenance Completion Rate

TJC requires 100% of all medical equipment within a facility to be maintained annually. Otherwise, an Alternative Equipment Maintenance (AEM) plan, one that provides historical data as to why the equipment is not getting annual Preventive Maintenance (PM), must be generated. Prior to Covid-19, there was a shortage of biomedical technicians across the country.

Due to lay-offs, illness or retirements, this situation has worsened. Over the past few years, most hospital systems have been expanding into their communities with more non-acute facilities. These facilities all have equipment that need PMs, and most hospital biomedical departments are stretched to the limit and have trouble getting to off-campus facilities.

On top of all of that, many healthcare systems expanded their capacity due to Covid-19 which has increased the amount of equipment requiring PMs. Numerous US healthcare systems have needed to supplement their biomedical departments with outside agencies to comply with TJC requirements.

How to Be Prepared for Your Next TJC Inspection

There are a few things you can do to prepare for your next inspection. Here are a few suggestions:

  • Review all new requirements
  • Schedule a mock inspection
  • Order what you need as soon as you can
  • Find a reliable partner to supplement your biomedical team

CME Corp is the only national equipment-focused distributor in the US and can assist you in getting prepared for your next inspection. CME represents over 2,000 manufacturers and 2M+ products. Our trained account managers can help you choose the right products as well as give you some alternatives that have better lead times.

CME has biomedical technicians located strategically throughout the country that can augment your biomedical team when needed to get those inspections done in a timely fashion. Call CME at 800-338-2372 or visit our website for more information about our products and services.


About CME: With two corporate offices and 35+ service centers, our mission is to help healthcare facilities nationwide reduce the cost of the equipment they purchase, make their equipment specification, delivery, installation, and maintenance processes more efficient, and help them seamlessly launch, renovate and expand on schedule.

COVID-19