How to Comply With the Joint Commission's National Patient Safety Goals

The Joint Commission, one of the United States pre-eminent health care accreditation agencies, promotes patient safety through its requirements and initiatives, including the National Patient Safety Goals. They address patient safety, including medication management, pre-operative assessments, infection control and patient identification. Accredited organizations must submit yearly reports indicating their compliance rates with each goal. On-site surveys are conducted every three years and are unannounced; therefore, each accredited organization must be in a constant state of readiness.

Instructions

Compliance Readiness

• 1

  Assign each National Patient Safety Goal to a team leader, charged with developing multi-disciplinary teams to have regular, focused meetings to address their specific goal. These teams will meet monthly at the least to assess status.

• 2

  Teams will set their own compliance targets for each goal (i.e., 90 percent or above compliance) which should be equal to or higher than the set targets from the Joint Commission.

• 3

  Staff education on each goal is conducted on a regular basis to help maintain staff awareness and to keep information fresh. This education is conducted on each unit/floor/patient-care area.

• 4

  Assess compliance weekly or monthly by conducting random staff surveys, asking questions and observing patient-care techniques.

• 5

  Teams will measure their respective goals compliance through direct observation of staff activities or by asking staff directly. Based on these results, the team will develop action plans for goals falling out of compliance.

• 6

  Teams will document the progress of any and all action plans and outcomes.