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 website or call the Sentinel Event Hotline, (630) 792-3700.
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 website. 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 Sentinel Event 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.
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 prioritized 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 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.
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 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. It is applicable to all operative and other invasive procedures. The principal components of the Universal Protocol are: 1) the pre-operative verification process; 2) marking of the operative site; and 3) taking a ‘time out’ immediately before starting the procedure. The protocol is endorsed by more than 50 professional health care associations and organizations.
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.
- 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.
The Joint Commission’s Division of Research includes a focus on patient safety research from a variety of perspectives and works with external collaborators and consultants to advance the field of patient safety and adverse event reporting systems. Current initiatives include:
- 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.
- Developing an International Classification for Patient Safety to facilitate the global exchange and dissemination of information among users of disparate incident reporting systems.
- Developing Best Practices for Patient Safety, a collaboration with the Center for Health Policy and the Center for Primary Care and Outcomes Research at Stanford University. This project involves developing and implementing a survey of hospital organizational culture as a tool for assessing determinants of patient safety.
- Identifying and disseminating promising and practical techniques for measuring compliance with hand hygiene guidelines through an educational monograph of best practices.
Joint Commission Resources is a not-for-profit affiliate of The Joint Commission that offers patient safety seminars, programs, publications, web-based training, good practices, custom education and consultation. Topics include 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. 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, and medical test mistakes. More patient safety topics will be addressed in the future, including health literacy, pain management and stroke. Speak up materials are available on The Joint Commission website.
Quality Check, accessed at www.qualitycheck.org, is a guide to the nearly 15,000 Joint Commission-accredited health care organizations and programs throughout the United States. Visitors can search by city and state, name, zip code, and type of service. Quality Reports feature a user-friendly format with checks, pluses and minuses to help the public compare health care organization performance 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.
In March 2005, The Joint Commission and Joint Commission Resources established the Joint Commission International Center for Patient Safety. The Center is a natural extension of the well-established patient safety activities for which The Joint Commission and JCR are recognized. The Center leverages the expertise, resources and knowledge from both The Joint Commission and JCR. The mission of the center is: To continuously improve patient safety in all health care settings. The Center allows The Joint Commission and JCR to advance the entire continuum of patient safety including principles related to system design and re-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. For more information about the Center, visit www.jcipatientsafety.org.
The Joint Commission continues to work with other health care and patient safety advocates and with Congressional Committees to urge the passage of bills that promote 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 affect 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.
The Joint Commission is involved in coalitions with common interest in a number of issues affecting patient safety, including:
- The Joint Commission is a member of the World Health Organization’s World Alliance for Patient Safety, launched in October 2004. The Joint Commission has a leading role in the six major Alliance initiatives. The Joint Commission International Center for Patient Safety is the operational arm for this collaboration.
- 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.
- The Joint Commission was 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 is a member of the National Quality Forum. The Joint Commission serves on the NQF’s board and is committed to working with the NQF to find a common pathway for creating 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 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.
- The Joint Commission International Center for Patient Safety has convened a “Champions for Patient Safety” group to address “macro” issues in patient safety.