The Joint Commission is committed to improving health care safety. This commitment is inherent in its mission to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. At its heart, accreditation is a risk-reduction activity; compliance with standards is intended to reduce the risk of adverse outcomes. The Joint Commission demonstrates its commitment to patient safety through numerous efforts highlighted here.
Almost 50 percent of Joint Commission standards are directly related to safety, addressing such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security. These standards also include specific requirements for the response to adverse events; the prevention of accidental harm through the analysis and redesign of vulnerable patient systems (e.g. the ordering, preparation and dispensing of medications); and the organization’s responsibility to tell a patient about the outcomes of the care provided to the patient—whether good or bad.
The Joint Commission’s Sentinel Event Policy, implemented in 1996, is designed to help health care organizations identify sentinel events and take action to prevent their recurrence. A sentinel event is an unexpected death or serious physical—including loss of limb or function—or psychological injury, or the risk thereof. “Risk thereof” means that, although no harm occurred this time, any recurrence would carry a significant chance of a serious adverse outcome. Any time a sentinel event occurs, the health care organization is expected to complete a root cause analysis, make improvements to reduce risk, and monitor the effectiveness of those improvements. The root cause analysis is expected to drill down to underlying organization systems and processes that can be altered to reduce the likelihood of a failure in the future and to protect patients from harm when a failure does occur. The policy also encourages organizations to report to The Joint Commission sentinel events so “lessons learned” can be shared with other health care organizations. For more information, visit The Joint Commission Web site or call the Sentinel Event Hotline, (630) 792-3700.
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Sentinel Event Alert is a newsletter that identifies specific types of sentinel events, describes their common underlying causes, and recommends steps to prevent future occurrences. Information for an Alert comes from The Joint Commission’s sentinel event database, experts, and other organizations. The Joint Commission began publishing Sentinel Event Alert in 1998 in order to share “lessons learned” from its database and provide important information relating to the occurrence and management of sentinel events in health care organizations. Sentinel Event Alert has raised awareness in the health care community and the federal government about adverse events. Past issues are available on The Joint Commission Web site. Topics have included medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient suicides, infant abductions, and fatal falls.
In April 2002, The Joint Commission appointed a group of experienced physicians, nurses, pharmacists and others with special expertise in patient safety to advise The Joint Commission in the development and annual update of its National Patient Safety Goals. The Patient Safety Advisory Group conducts thorough reviews of all Alert recommendations and identifies those that are candidates for inclusion in the annual NPSGs. The NPSGs recommended by the Advisory Group are forwarded to The Joint Commission’s Board of Commissioners for approval.
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In July 2002, The Joint Commission approved its first set of National Patient Safety Goals with related specific requirements for improving the safety of patient care in health care organizations. All Joint Commission accredited health care organizations are surveyed for implementation of the NPSGs as appropriate to the services the organization provides. The NPSGs are prioritized from a “pool” of recommendations identified by the Patient Safety Advisory Group as evidence- or consensus-based, cost-effective and practical. Each year, new recommendations from Sentinel Event Alert newsletters published in the previous year and from other authoritative sources are added to the pool. In 2004, The Joint Commission began developing program-specific NPSGs for each of its accreditation and certification programs in order to make the goals and requirements more relevant to the non-hospital accreditation programs.
The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004, for all accredited hospitals, ambulatory care and office-based surgery facilities. The Universal Protocol drew upon, and expanded and integrated, a series of requirements under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. In July 2008, an updated Universal Protocol was approved by the Board, effective January 1, 2009. The revisions are based on feedback received at the Wrong Site Surgery Summit held in February 2007 to address concerns raised by a number of professional organizations regarding a continued increase in the occurrences of reported wrong site surgery cases to The Joint Commission and to other reporting systems. The three principal components of the Universal Protocol include: conducting a pre-procedure verification process; marking the procedure site; and performing a ‘time out’ immediately prior to starting the procedure. The Universal Protocol remains applicable to all non-surgical invasive procedures and all surgical procedures.
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The Joint Commission’s Office of Quality Monitoring evaluates complaints and reports of concerns about health care organizations relating to quality of care issues. Information comes from patients, their families, government agencies, the public, as well as from an organization’s own staff, and information from the media. The Office has a toll free hot line, (800) 994-6610, and receives written reports by mail or e-mail. Depending on the nature of the complaint, The Joint Commission will take one of the following actions:
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Conduct an unannounced, unscheduled on-site evaluation of the organization if the complaint raises serious concerns about a continuing threat to patient safety or continuing failure to comply with standards.
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Ask the organization to provide a written response to the complaint.
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Review the complaint and compliance with related standards at the time of the organization’s next accreditation survey or review, if it is scheduled in the near future.
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Incorporate the complaint into the quality monitoring database that is used to track health care organizations over time to identify trends or patterns in their performance.
The Joint Commission’s Division of Quality Measurement and Research addresses patient safety research from a variety of perspectives and works with external collaborators to advance the field of patient safety and adverse event reporting systems. Current initiatives include:
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Providing culturally and linguistically appropriate health care in hospitals.
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Developing an International Classification for Patient Safety to facilitate the global exchange and dissemination of information among users of disparate incident reporting systems.
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Developing strategies for implementing successful immunization programs for health care personnel.
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Identifying and disseminating promising and practical techniques for measuring compliance with hand hygiene guidelines through an educational monograph of best practices.
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Joint Commission Resources is a not-for-profit affiliate of The Joint Commission that offers patient safety education programs, publications, and multimedia products, as well as custom education and consultation. Topics include infection control and prevention, health and safety design, medication reconciliation, patient safety, environment of care, and medication safety, among others. JCR publishes Joint Commission Perspectives on Patient Safety, a monthly newsletter dedicated to providing information on the prevention of errors in health care settings. A bimonthly newsletter, Environment of Care News, focuses on patient and facility safety issues. For more information or to order, visit www.jcrinc.com, or call the JCR toll-free customer service line at (877) 223-6866.
In March 2002, The Joint Commission, together with the Centers for Medicare & Medicaid Services, launched a national program to urge patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. The program features brochures, posters and other materials on a variety of patient safety topics: surgical mistakes, living organ donation, infection prevention, medication mistakes, follow-up care, research studies, medical test mistakes, patient rights, health literacy and pain management. More patient safety topics will be addressed in the future. Speak up materials are available on The Joint Commission Web site.
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Quality Check®, at www.qualitycheck.org, is a comprehensive guide to the nearly 15,000 Joint Commission-accredited health care organizations and programs throughout the United States. In 2007, The Joint Commission began including organizations that are not accredited by The Joint Commission to Quality Check. Joint Commission accredited organizations are easily identified by The Joint Commission’s Gold Seal of Approval™. Visitors can search by city and state, name, zip code, and type of service. Quality Reports—which are only available for Joint Commission accredited organizations—help the public compare the performance of accredited health care organizations in a number of key areas. In 2006, The Joint Commission began providing hospital performance measure results to any external third party for free via Quality Check. This information allows for more flexibility in customizing performance measure results for use in performance improvement initiatives and quality of care reporting.
The Joint Commission continues to work with other health care and patient safety advocates and with Congressional Committees and other policymakers to urge the passage of legislation that promotes patient safety. For example, The Joint Commission testified on numerous occasions prior to the enactment of the 2005 Patient Safety and Quality Improvement Act, which promotes cultures of safety across health care settings by enabling health care providers to contract with Patient Safety Organizations and by establishing federal protections that encourage thorough, candid examinations of the causes of health care errors and the development of effective solutions to prevent their recurrence. Some recently introduced bills address issues that could further influence patient safety, such as mandatory reporting of health care-associated infections by hospitals and ambulatory surgery centers, staffing ratios and mandatory overtime limits for registered nurses in Medicare-participating hospitals, and measures to modernize the Quality Improvement Organization program. On the state level, The Joint Commission actively works with state regulatory and patient safety authorities to reduce duplicative expectations for accredited organizations subject to voluntary or mandatory reporting requirements. Recent issues addressed at the state level include the reuse of syringes/needles and mandatory reporting of adverse events.
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The Joint Commission is involved in coalitions with common interest in a number of issues affecting patient safety, including:
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The Joint Commission is a member of the World Health Organization’s (WHO) World Alliance for Patient Safety, launched in October 2004. The Joint Commission and Joint Commission International were both designated as a WHO Collaborating Center for Patient Safety Solutions – the purpose being to develop successful solutions for a variety of global patient safety issues. The Joint Commission also has a leading role in the other major Alliance initiatives, including developing an International Classification for Patient Safety to facilitate the global exchange and dissemination of information among users of disparate incident reporting systems, the WHO Global Challenges, and the Patient Safety Research action areas.
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The Joint Commission is involved with the WHO’s Action in Patient Safety (High 5s) initiative, established through the collaboration of the Commonwealth Fund, the WHO World Alliance for Patient Safety and the WHO Collaborating Centre for Patient Safety. The High 5s initiative’s goal is to implement innovative, standardized operating protocols for patient safety solutions that would broadly prevent avoidable catastrophic adverse events causing death or serious injury in hospitals and to measure the success of implementing these solutions within several countries.
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The Joint Commission helped form and is a member of the National Coordinating Council on Medication Error Reporting & Prevention, a coalition composed of 22 member organizations. NCC MERP developed principles for constructing patient safety reporting programs.
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The Joint Commission is a founding member and serves on the board of the National Patient Safety Foundation, which has a clearinghouse of information pertinent to issues in patient safety and funds innovative research dedicated to reducing risk. The Joint Commission’s former president is on the NPSF Board of Directors and the vice president and chief patient safety officer is on the NPSF Board of Governors.
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The Joint Commission is working with the National Quality Forum to create consensus around nationally agreed-upon measures for quality and safety. The NQF has a steering committee, on which The Joint Commission participates, that has identified a series of serious reportable events to be used by organizations that set up adverse event reporting systems. The Joint Commission also participates on the NQF Maintenance Committee for the “Safe Practices for Better Health Care,” which is striving to harmonize those safe practices with The Joint Commission’s National Patient Safety Goals. The Joint Commission is a member of the NQF National Priorities Partners.
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The Joint Commission is an affiliate of Consumers Advancing Patient Safety, a national consumer-led organization formed to be a collective voice for individuals, families and healers who suffer harm in health care encounters. The Joint Commission’s senior vice president is a member of the Founding Advisors Board of CAPS.
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The Joint Commission has convened a “Champions for Patient Safety” collaboration initiative with the leading United States patient safety organizations to begin harmonizing the numerous approaches to issues in patient safety.
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