Testing Frequency Flexibility

If the required time frames can't be met to complete a task or function as specified in TJC's 2010 Hospital Accreditation Standards, what kind of leeway is there in completing them?


Within TJC's 2010 Hospital Accreditation Standards (HAS) manual is introductory information at the start of the Environment of Care (EC) chapter under Other Issues for Consideration #2, which states the following:
 
A number of elements of performance describe time frames for completing certain tasks or functions. The Joint Commission recognizes that it will not always be possible to meet the exact time frames cited in the requirements. For evaluation purposes, therefore, the following intervals are acceptable:

• Annually/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days
• Every 6 months = 6 months from the date of the last event, plus or minus 20 days
• Quarterly = 4 times a year, once in each quarter

In the 2010 HAS Glossary it shows the following:

• Weekly = Once every seven days, plus or minus two days