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Joint Commission Saves Lives Timeline

  • 1994

    First organization-specific performance reports released to public

  • 1995

    Multiple high-profile sentinel events

    A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm.

  • 1995

    Root Cause Analysis (RCA) introduced as required response

  • 1996

    Sentinel Event Policy established

    Formal policy to help health care organizations that experience serious adverse events improve and learn from those events. The policy explains how The Joint Commission partners with organizations to protect patients, improve systems and prevent further harm.

  • 1998

    Sentinel Event Policy revised

    Policy revised to promote self-reporting of medical errors and encourage health care providers to more closely examine the root causes of those events.

  • 1998

    First Sentinel Event Alert (SEA) published

    SEAs identify specific types of sentinel and adverse events and high-risk conditions, describe their underlying causes, and recommend steps to reduce risk and prevent future occurrences.

  • 1999

    Mission statement revised to explicitly reference patient safety

    Our mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

  • 1999

    Toll-free reporting hotline introduced

    Hotline provides channel for patients, their families, caregivers and others to share concerns regarding patient safety and quality issues at accredited organizations.

  • 1999

    National Patient Safety Goals® (NPSGs) established

    NPSGs help accredited organizations address specific areas of concern regarding patient safety and redirect focus to solving them.

  • 2003

    Universal Protocol effective

    Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery helps health care organizations identify the right patient, appropriate procedure and correct site of procedure.

  • 2005

    Sentinel Event Policy revised

    Policy revised to classify unintended retention of foreign objects, neonatal hyperbilirubinemia and radiation overdose as sentinel events.

  • 2006

    Onsite accreditation and certification reviews conducted on unannounced basis

    Holds facilities seeking to earn or renew accreditation or certification accountable for patient safety at all times.

  • 2007

    Improving America’s Hospitals: A Report on Quality and Safety publishes

    Annual Report provides aggregate performance data of accredited hospitals against The Joint Commission’s standardized national performance measures and NPSGs.

  • 2009

    The Joint Commission Center for Transforming Healthcare launches

    The mission of the Center is to transform health care into a high-reliability industry by developing highly effective, durable solutions to health care’s most critical safety and quality problems.

    Joint Commission Center for Transforming Healthcare
  • 2010

    The Center launches its first Targeted Solutions Tool® (TST®)

    The TST is an online application that guides health care organizations through a step-by-step process to accurately measure their organization’s true performance level, identify the causes of performance failures, and direct them to proven solutions that are customized to address their particular causes.


    Targeted Solutions Tool graphic
  • 2013

    Millbank Quarterly article on high reliability in health care

    Joint Commission President and CEO Mark R. Chassin, MD, FACP, MPP, MPH, and the late Jerod M. Loeb, PhD, detail a framework to help health care organizations achieve high reliability — extraordinarily high level of quality and safety over long periods of time with no or extremely few adverse or harm events despite operating in very hazardous conditions.

  • 2014

    Patient Safety Systems chapter introduced

    Chapter informs and educates hospital leaders about the importance and structure of an integrated patient-centered system that aims to improve patient safety and quality of care.

  • 2015

    The Center launches Oro® 2.0

    The assessment tool assists hospital leaders with evaluating their organization’s level of maturity in multiple components of high reliability and reaching the goal of zero harm.

    High Reliability Organizational Assessment and Resources 2.0 graphic
  • 2016

    Pioneers in Quality™ program launches

    Program provides education and support for hospitals as they strive to meet growing requirements for electronic clinical quality measures (eCQMs).

    Pioneers in Quality
  • 2017

    Updated emergency management standards effective

    Standards help health care organizations more effectively plan for disasters and coordinate with federal, state, tribal, regional and local emergency preparedness systems.

  • 2018

    Two NPSGs revised

    NPSGs to prevent suicide and to reduce harm associated with anticoagulant therapy are revised, effective July 1, 2019.