JCAHO Safety Goals

The Joint Commission (formerly JCAHO, now TJC) is an accreditation agency. A hospital or healthcare organization may apply for Joint Commission accreditation. To achieve accredited status, the organization must demonstrate they comply with the highest standards of practice, set forth by TJC. The goal of the Joint Commission is to ensure hospitals, healthcare facilities and practices are following their guidelines to ensure quality and patient safety. This is done throughout periodic unannounced surveys of the participating site.

Background: National Patient Safety Goals

• In 2003, the Joint Commission launched its National Patient Safety Goals (NPSGs). Accredited hospitals and those applying for accreditation are required to comply with all goals. The current NPSG list contains ten requirements and each one has sub-requirements with several elements of performance by which to measure the organizations compliance.

Goals 1, 2, 3 and 7 Synopses

• Goal 1: "Improve the accuracy of patient identification". TJC requires at least two different patient identifiers when providing patient care. Examples of patient identifiers can be the patient's full name and date of birth. The goal is to provide accurate care to the correct patient. A sub-requirement is to "eliminate errors related to transfusions and patient misidentification". In addition to using two patient identifiers, organizations must also conduct a side-be-side double check of this information, at the bedside.

  Goal 2: "Improve the effectiveness of communication among caregivers"
  Organizations are required to "read back" verbal or telephone orders and test results, to ensure accuracy. A sub-requirement is that the hospital must maintain a list of unacceptable abbreviations, doses, acronyms and symbols that are not allowed because of the potential for error when used. An additional sub-requirement is that the organization report critical test results within a given time frame to the responsible caregiver. Additionally, the organization must standardize and implement a process for "hand-off communication". Staff should feel encouraged and empowered to respond to and ask questions when handing off patients at end of shift.

  Goal 3: "Improve the safety of using medications"
  Among the requirements for this goal is that the organization populate and review annually a list of look-alike/sound-alike drugs and identify the measures taken to prevent medication errors with those drugs. Medication and medication containers (i.e. syringes) must be labeled "on and off the sterile field". In 2009, TJC added a new sub-requirement for NPSG 3, which requires organizations to reduce the chance of patient harm associated with anticoagulants (i.e. Coumadin, Heparin, Lovenox and Arixtra).

  Goal 7: "Reduce the risk of health care-associated infections."
  Organizations are expected to comply with World Health Organization (WHO) Hand Hygiene Guidelines or Center for Disease Control and Prevention guidelines. A sub-requirement is to identify and manage adverse events including loss of life or function, due to infections resulting from a patient's hospital stay.

Goals 8, 9, 13, 15 and 16: Synopses

• Goal 8: "Accurately and completely reconcile medications across the continuum of care."
  To comply with this goal, organizations must have a process in place to accurately and effectively reconcile patient's medications. This list must be communicated to the next care provider if the patient is transferred within or outside the facility. The patient should also receive a copy of their medication list, including doses, when they are discharged.

  Goal 9: "Reduce the risk of patient harm resulting from falls."
  Organizations are responsible for developing and managing an effective process for assessing patients for their fall risk. Typically, patients who receive any kind of sedation would be included. Whatever processes the organization implements, they must measure the effectiveness.

  Goal 13: "Encourage patients' active involvement in their own care as a patient safety strategy."
  Organizations are required to educate patients on how to report concerns they have about their care or the care of a family member.

  Goal 15: "The organization identifies safety risks inherent in its patient population." This goal is mainly for hospitals that deal with psychiatric care. It requires all patients be assessed for suicidal risk.

  Goal 16: "Improve recognition and response to changes in a patient's condition."
  Organizations are required to develop and manage a system in which trained personnel respond to calls for help and assistance in the event of an emergency or when a patient's condition is deteriorating.

Universal Protocol

• The Universal Protocol developed by the Joint Commission, is an additional set of requirements that they have combined with the National Patient Safety Goals.

  The Universal Protocol requires organizations that provide surgical procedures to take certain steps to ensure the safety of the patient. The organization must have a pre-procedure verification process in place. The process should require all surgical staff to stop and double check the patient identification and surgery site just prior to the start of the procedure.

  The Universal Protocol also requires the surgeon to mark the operative site prior to procedure.

Considerations

• For an organization to attain Joint Commission accreditation, it must comply with all of the above in addition to hundreds of other standards. If an organization is found to lack compliance at the time of their unannounced Joint Commission survey, they risk losing that accreditation and as a result, their current reimbursement rates. Insurance companies will reimburse an organization at a higher rate than unaccredited places because they have demonstrated a dedication to patient safety and well-being.