The Joint Commission is committed to improving safety for patients and residents 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 in the following ways:
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 address a number of significant patient safety issues, including the implementation of patient safety programs; the response to adverse events when they occur; the prevention of accidental harm through the prospective analysis and redesign of vulnerable patient systems (for example, 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.
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The Joint Commission's Sentinel Event Policy, implemented in 1996, is designed to help health care organizations to identify sentinel events and take action to prevent their recurrence. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. Any time a sentinel event occurs, the health care organization is expected to complete a root cause analysis, implement 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 Sentinel Event Policy also encourages organizations to report to the Joint Commission sentinel events, along with their root causes and related preventive actions, so that the Joint Commission can learn about the underlying causes of the sentinel events, share "lessons learned" with other health care organizations, and reduce the risk of future sentinel event occurrences. The database includes the sentinel events that have been reported to the Joint Commission, the root causes of these events, and strategies that health care organizations have used to reduce risk to patients.
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Sentinel Event Alert is a periodic newsletter that identifies specific types of sentinel events, describes their common underlying causes, and recommends steps to prevent occurrences in the future. Information for Sentinel Event Alert comes mainly from the Joint Commission's sentinel event database, as well as from experts and other organizations. The Joint Commission began publishing Sentinel Event Alert in 1998 in order to share the most important "lessons learned" from its database and provide important information relating to the occurrence and management of sentinel events in health care organizations. Topics have included medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient suicides, infant abductions, fatal falls and operative/post-operative complications.
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In April 2002, the Joint Commission appointed a group of experienced physicians, nurses, pharmacists and other patient safety experts to advise the Joint Commission in the development of its first set of National Patient Safety Goals (NPSGs). The Sentinel Event Advisory Group conducts thorough reviews of all Sentinel Event 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 (NPSGs) 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 goals and requirements--or acceptable alternatives--as appropriate to the services the organization provides. The goals and requirements are drawn from a "pool" of recommendations identified by the Sentinel Event 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 are added to the pool. Future requirements will be drawn from the pool.
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In July 2003, the Joint Commission's Board of Commissioners approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™. The Universal Protocol was created to address the continuing occurrence of these tragic medical errors in Joint Commission accredited organizations. The Universal Protocol is applicable to all operative and other invasive procedures. The principal components of the Universal Protocol include: 1) the pre-operative verification process; 2) marking of the operative site; 3) taking a 'time out' immediately before starting the procedure; and 4) adaptation of the requirements to non-operating room settings, including bedside procedures. The protocol is endorsed by nearly 50 professional health care associations and organizations.
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The Joint Commission's Office of Quality Monitoring receives, evaluates and tracks complaints and reports of concerns about health care organizations relating to quality of care issues. Information often comes from patients, their families or the public, as well as from an organization's own staff, government agencies and others. The Office has a toll free hot line, (800) 994-6610, and also receives written reports by mail or e-mail. When a report is submitted, the Joint Commission reviews any past reports and the organization's most recent accreditation decision. Depending on the nature of the reported concern, the Joint Commission will take one of the following actions:
- Incorporate the reported concern into the quality monitoring database that is used to track health care organizations over time to identify trends or patterns in their performance.
- Ask the organization to provide a written response to the reported concern.
- Review the reported concern and compliance with related standards at the time of the organization's next accreditation survey, if it is scheduled in the near future.
- Conduct an unannounced on-site evaluation of the organization if the report raises serious concerns about a continuing threat to patient safety or continuing failure to comply with standards.
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The Joint Commission's Division of Research includes the Center for Patient Safety Research (PSR) that works with external collaborators and consultants to advance the field of patient safety research and adverse event reporting systems. Current initiatives include:
- Investigating adverse events in low English proficiency patients to determine the nature and preventability of such events and to implement intensive quality improvement interventions.
- Using health information technology to improve patient safety reporting, data analysis and learning from errors, and to promote a national reporting system for adverse events through the use of standardized patient safety taxonomy and ontology.
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Joint Commission Resources (JCR) is a not-for-profit subsidiary of the Joint Commission that provides services independently and confidentially, disclosing no information about its clients to the Joint Commission or others. JCR offers a number of seminars, programs, publications, web-based training, good practices, custom education and consultation on patient safety, including: environment of care, restraint and seclusion, failure mode and effects analysis, prevention of medical errors, medication use, preventing sentinel events, risk reduction strategies, and how to conduct root cause analyses. The Joint Commission website also provides information on sentinel events and the Sentinel Event Policy; how to complete root cause analyses; sentinel event reporting forms; and issues of Sentinel Event Alert.
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In March 2002, the Joint Commission 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 buttons on a variety of patient safety topics. Other Speak Up™ initiatives are:
- Help Prevent Errors in Your Care: For Surgical Patients
- Preparing to be a Living Organ Donor
- Three Things You Can Do To Prevent Infection
- Things You Can Do To Prevent Medication Mistakes
- Planning Your Recovery
- What You Should Know About Research Studies
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Quality Check®, at www.qualitycheck.org, is a comprehensive guide to more than 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—feature a user-friendly format with checks, pluses and minuses to 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.
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In March 2005, the Joint Commission and Joint Commission Resources (JCR) announced the establishment of the Joint Commission International Collaborating Center on Patient Safety, a virtual entity that draws upon the patient safety expertise, resources and knowledge of both the Joint Commission and JCR. The center will provide patient safety solutions to health care organizations worldwide. The mission of the center is:
To continuously improve patient safety by providing solutions, processes and procedures that help eliminate preventable adverse events in all health care settings.
The Patient Safety Center allows the Joint Commission and JCR to advance the entire continuum of patient safety including system design, product safety, safety of services, and environment of care, as well as offering proactive solutions for patient safety, whether based on empirical evidence, hard research or best practices.
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The Joint Commission believes that it is necessary to create a non-punitive environment in which medical/health care errors and patient safety information can be reported. Since 1997, the Joint Commission has advised Congress on the need for federal statutory protection of reported information--especially root cause analysis information--and has sought legislation that will facilitate the study and reporting of medical/health care error information by clinician and provider organizations, as well as provide adequate protection of that information from disclosure in civil law suits. Since 1998, the Joint Commission's sentinel event confidentiality language has been included in proposed legislation. While this language would provide for protection of medical/health care error reporting, final passage has not yet occurred. In 2004, both the House and Senate passed patient safety legislation, but the bills never went to conference. Nevertheless, because both chambers passed bills, the Joint Commission is optimistic that a bill will be passed in 2005.
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The Joint Commission is involved in coalitions with common interest in a number of issues affecting patient safety, including:
- The Joint Commission helped form the National Coordinating Council on Medication Error Reporting & Prevention, a coalition comprised of 22 member organizations, including the United States Pharmacopoeia, the American Medical Association and the American Hospital Association. NCC MERP has developed principles for constructing patient safety reporting programs.
- The Joint Commission is involved in a Medication Error Coalition whose efforts have resulted in the proposed Snowe-Graham legislation that seeks to secure adequate funding to employ the latest technology in hospitals and provide training to support that technology.
- The Joint Commission is an affiliate of Consumers Advancing Patient Safety (CAPS), 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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