“The Power of A: Awareness, Assessment and Action” is the theme for this year’s Patient Safety Awareness Week (PSAW), March 9-15. The Joint Commission captured thoughts from our leaders and surveyors in videos about the importance of recognizing PSAW, and why patients should seek care at Joint Commission accredited organizations.
The introductory video features Ken Grubbs, The Joint Commission’s Executive Vice President for Accreditation and Certification Operations and Chief Nursing Officer; the other videos feature domestic and international surveyors representing The Joint Commission’s hospital, laboratory, behavioral healthcare and human services, and disease-specific care programs.
PSAW is sponsored by the Institute for Healthcare Improvement (IHI). IHI Vice President Patricia McGaffigan, RN, MS, CPPS, says, “It’s time for everyone in healthcare, in partnership with patients, families, and the communities we serve to leverage the power of ‘A’ [Awareness] and operationalize what matters for safety.”
See The Joint Commission’s Patient Safety Awareness Week videos:
Ascension reduced risk-adjusted mortality by more than 20% across 88 hospitals through its Recognize and Rescue initiative. This major breakthrough in patient care is reported in the March issue of The Joint Commission Journal on Quality and Patient Safety. Over a three-year period, the program prevented more than 4,000 deaths, focusing on standardizing processes, feedback on performance, and accountability.
Ascension’s approach of standardizing care and mitigating risk for events (Recognize) and prompt management of the decompensating patient (Rescue) provides a foundation for anchoring standardized processes in care, reducing variation, and promoting optimal outcomes through a multidisciplinary approach that included physicians, nursing, and other medical professionals. Under the Rescue work, the authors promoted teamwork, enhanced the function of rapid response teams to a proactive role to avert significant patient deterioration, and established a clear approach to escalation of care and resuscitation.
This systemwide initiative and was associated with sustainable improvements in mortality and a reduction in infectious and safety events, specifically:
- Overall mortality improved from the baseline of 0.97 in 2021 to 0.74 in 2023
- Standardized infection ratio declined (in 2023 compared to 2021) for:
- Central line-associated blood stream infections by 24.8%
- Catheter-associated urinary tract infections by 30.6%
- Hospital onset (HO) methicillin-resistant Staphylococcus aureus bacteremia by 29.0%
- HO Clostridioides difficile infection by 35.1%
- HO acute kidney injury (AKI) episodes dropped by 6.2%
- Patient-days with hypoglycemia and severe hyperglycemia decreased by 5.8% and 22.8%, respectively
Significant improvements in healthcare-associated infections were noted for both 2022 and 2023. Ascension markedly exceeded the U.S. national performance for the four healthcare-associated infections. The successful outcomes were related to promoting healthcare worker competencies to mitigate device harm of peripheral and central venous catheters and urinary catheters and promoting diagnostic stewardship.
Ascension has seen improvements in all of its 11 geographically distinct markets, reflecting the feasibility of implementing such effort in other systems. Many of Ascension’s markets have different cultures, environments, and resources.
Read the Becker’s Clinical Leadership article highlighting the study
Sharps injuries are up 16% over the last decade – meaning a focus on safe handling is needed to help keep healthcare workers safe from injuries and healthcare acquired infections. A new article in the March 5, 2025, issue of OR Manager, features commentary from Joint Commission Vice President and Chief Medical Officer Elizabeth Mort, MD, MPH. Dr. Mort offers insight into what Joint Commission surveyors look for during surveys to ensure safe handling and disposal of sharps.
Read the article: “Fresh tools, talking points drive sharps safety culture shift”
Effective March 30, 2025, a new Accreditation Participation Requirement (APR) requires Joint Commission-accredited assisted living communities, behavioral health care and human services organizations, and nursing care centers to meet the minimum requirements necessary for quality and/or safety, as determined by the sole discretion of The Joint Commission. Failure to meet this requirement may trigger a new decision rule, resulting in an immediate denial of accreditation (DA).
Examples of situations that may result in denial of accreditation include providing care, treatment, or services in a manner unfit to meet the basic needs of patients, residents, or individuals served or pervasive patterns of patient rights violations that have not been addressed by leadership through analysis and implementation of sustainable actions.
The new element of performance (EP) in the APR chapter is underlined below.
Standard APR.09.04.01: The organization provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety.”
Element of Performance 2 for APR.09.04.01: As determined by the sole discretion of The Joint Commission, the organization provides care, treatment, services, and/or a safe environment that meets minimal accreditation requirements of quality and/or safety of individuals served and/or staff.
The new decision rules are:
DA13 — For Organizations Seeking Initial Accreditation
DA08 — For Organizations Seeking Reaccreditation
The new requirement and decision rules will publish online in the spring interim 2025 E-dition® update to the manuals for assisted living communities, behavioral health care and human services, and nursing care centers.
For more information, please contact The Joint Commission’s Department of Standards and Survey Methods.
The deadline for submitting calendar year (CY) 2024 ORYX® Electronic Clinical Quality Measure (eCQM) data is extended from March 17, 2025, to April 16, 2025, at 11:59 p.m. CT, for Joint Commission accredited hospitals required or choosing to submit eCQM data for CY 2024 to meet their ORYX Performance Measurement requirements. The deadline for submitting fourth quarter 2024 chart-abstracted data to The Joint Commission via the Direct Data Submission Platform (DDSP) has not changed; that deadline is still March 31, 2025, at 11:59 p.m. CT.
Additional information on submitting data:
- The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are separate entities with separate requirements and platforms; submission of data to one does not meet the requirements of the other.
- Information on how to verify your organization’s ORYX requirements and data submission is available via the DDSP at “Need Help?”
- Once data submission is complete, download the Submission Report from the Home page on the DDSP, which provides a summary/proof of submission of the data received from your organization.
- Organizations are responsible for managing user’s access to the DDSP. To manage staff with access to the DDSP log in via The Joint Commission website.
- See the CY 2024 ORYX Performance Measurement requirements.
- We strongly encourage organizations to submit their data well in advance of the deadline.
If you need assistance or have questions with any portion of the DDSP, please submit a support ticket via the DDSP “Need Help?” button. If you have non-DDSP questions, please contact hcooryx@jointcommission.org and include your HCO ID in the subject line.