The Joint Commission established its National Patient Safety Goals program in 2002 and the first set of Goals was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety. The development and annual updating of the NPSGs and requirements is overseen by an expert panel of widely recognized patient safety experts, as well as nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Each year, the Sentinel Event Advisory Group works with Joint Commission staff to undertake a systematic review of the literature and available databases to identify potential new Goals and requirements. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other parties of interest, the advisory group determines the highest priority Goals and requirements and makes its recommendations to The Joint Commission. In order to maintain the focus of accredited organizations on the most critical patient safety issues, the Sentinel Event Advisory Group may, as part of its annual review, recommend the retirement of selected requirements from the NPSGs. In such cases, they will usually continue as accreditation requirements under the relevant standards.
The Sentinel Event Advisory Group is charged with reviewing draft patient safety suggested actions for potential publication in The Joint Commission’s Sentinel Event Alert patient safety advisory. The Group also advises The Joint Commission as to the evidence for and face validity of these suggestions, as well as their practicality and cost of implementation. The Advisory Group’s recommendations for annual NPSGs and associated requirements are forwarded to The Joint Commission’s Board of Commissioners for approval prior to the year in which they are to be implemented. All Joint Commission accredited health care organizations and the Disease-Specific Care certified programs are surveyed for implementation of applicable Goals and requirements—or acceptable alternatives—as appropriate to the services the organization or program provides.
Submitting alternative approaches
An alternative approach to a NPSG requirement must be accepted by The Joint Commission based on the Sentinel Event Advisory Group’s review and recommendation that it is at least as effective as the published requirement in achieving the Goal. Organizations that wish to submit alternative approaches to the requirements associated with the NPSGs can do so by filling out a “Request for Review of an Alternative Approach to a NPSG Requirement” form. The form and instructions for submitting it are available on the Joint Commission website. Members of the Sentinel Event Advisory Group review and advise The Joint Commission on the acceptability of the alternative. If not accepted, the organization will be provided with the rationale and will need either to revise the alternative until it is approved, or to implement the requirement as issued by The Joint Commission. Surveyors will accept organizations’ use of approved alternatives and will evaluate the implementation of those alternatives and other relevant requirements associated with the NPSGs.
The National Patient Safety Goals for each program and more information are available on The Joint Commission website. Questions can be sent to the Standards Interpretation Group at (630) 792-5900 or via the Standards Online Question Submission Form.
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