Joint Commission 101

Environment of Care basics

September 28, 2014

Joint Commission 101

Patient Safety - Joint Commission, National Patient Safety Goals (NPSGs)

The Joint Commission

The Joint Commission is an independent (not government), not-for-profit organization which accredits and certifies more than 20,500 health care organizations and programs, including hospitals, doctors’ offices, nursing homes, behavioral health facilities, office-based surgery centers and home-care services.

The purposes of The Joint Commission include helping health care operations improve the quality and safety of the care they provide, as well as reduce the risk of adverse outcomes.

In 2002, in keeping with its mission to continuously improve health care for the public, The Joint Commission launched a National Patient Safety Goals (NPSGs) program to address specific safety concerns.

The Patient Safety Advisory Group

A Patient Safety Advisory Group was formed – a panel of prominent safety experts composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals with hands-on experience addressing patient safety concerns in a variety of clinical settings. The panel’s purpose is to advise the Joint Commission on the development and updating of the NPSGs, the first of which became effective January 1, 2003.

The Patient Safety Advisory Group works with the Joint Commission to identify emerging safety concerns. They seek input from practitioners, care-providing institutions, consumer groups and other entities invested in patient safety. The Patient Safety Advisory Group uses the information to advise the Joint Commission in the effective use of NPSGs, standards, surveys, performance measures, educational materials, Sentinel Event Alerts and The Joint Commission Center for Transforming Healthcare (to be discussed.)

2014 National Patient Safety Goals (NPSGs)

There are different sets of NPSGs for particular settings, including:

  • Ambulatory Health Care
  • Laboratory Services
  • Behavioral Health Care
  • Nursing Care Centers
  • Critical Access Hospitals
  • Long Term Care (Medicare/Medicaid)
  • Home Care
  • Office-Based Surgery
  • Hospitals

Some of the goals are applicable to all settings. The full text containing the NPSGs can be purchased from Joint Commission Resources,

Sentinel Event Alerts

An additional safety operation of The Joint Commission is the management of what the commission calls sentinel events; reports of the events are called Sentinel Event Alerts.

A sentinel event is an unintentional, unexpected, occurrence which results in death, serious physical and/or psychological injury, or confers the risk of serious adverse outcome if the event were to recur. These events are not related to the natural course of the patient’s disease or condition. Inherent to the definition of adverse outcomes is loss of life, limb or function.

Such events demand immediate attention and responses. They differ from medical errors, although some errors may trigger sentinel events, and sentinel events can increase the risk that medical errors will occur.

The Joint Commission, during the accreditation process, critiques the organization’s response to sentinel events. Already accredited organizations will have periodic, scheduled reviews, as well as random, unannounced reviews and for-cause investigations.
Accredited organizations are expected to respond appropriately with timely, credible analysis, to find the root cause of the adverse event. The analysis focuses on procedures and systems, not on individuals. The organization then must develop a plan for action, to reduce the risk of recurrences.

Some of the sentinel events that are reviewable under The Joint Commission’s Sentinel Events Policy include (not all inclusive):

  • Any patient death, paralysis, coma, or other major loss of function associated with a medication error
  • Invasive procedures, including surgery, on the wrong patient, wrong site, or the wrong procedure
  • A foreign body, such as surgical instruments, left in a patient after conclusion of the surgery
  • A hemolytic transfusion reaction involving blood-type incompatibilities
  • A patient fall that results in death or serious loss of function as a result of the fall
  • A patient abducted from the organization which provides care
  • Prolonged fluoroscopy to a single region of the body to a cumulative dose of > 1,500 rads or to the wrong body region
  • Assault, homicide, or other crime that results in death or permanent loss of function of a staff member, visitor, vendor, independent practitioner or patient.

Examples of sentinel events which are not reviewable, under the same Joint Commission policy include (not all inclusive):

  • Any sentinel event that has not affected patient well-being
  • Medication errors which do not result in death or permanent loss of function
  • Minor degrees of hemolysis not caused by blood-type incompatibility and without residual clinical effect
  • Full or expected return of limb or bodily function to the same level as prior to the adverse event
  • Death or loss of function following a patient leaving an organization against medical advice

Procedures for Implementing the Sentinel Event Policy

The Joint Commission staff will determine whether an event is reviewable based on available information they received about the event. Urgent threats to health or safety are referred to Joint Commission Executive Leadership for authorization to conduct an immediate, unannounced for-cause survey. The organization of interest must submit the complete root analysis and the action plan within 45 days from the date the event was reported.

The Joint Commission staff assess the acceptability of the organization’s response to the reviewable sentinel event. If the root cause analysis information and action plan are deemed to be thorough and credible, the organization is assigned one or more Sentinel Event Measures of Success (SE MOS). An MOS is a numerical or quantifiable measure that determines if a planned action was effective and sustained.

If the response is unacceptable, Joint Commission staff will provide consultation to the organization on the unmet criteria and extend an additional 15 calendar days beyond the original submission date for the organization to demonstrate acceptable analysis and an appropriate plan for action.

If the amended report does not meet established criteria, or The Joint Commission determines that the organization has not made serious improvement efforts, accreditation may be affected.
If the report is acceptable, The Joint Commission determines appropriate follow-up – usually reassessment in four months.

Universal Protocol for Preventing Wrong-site, Wrong-procedure, Wrong-person Events

The Joint Commission’s Universal Protocol applies to all invasive procedures. Those which place the patient at the most risk involve general anesthesia or deep sedation. The protocol is based on the following principles:

  • Wrong-person, wrong-site, wrong-procedure events can and must be prevented.
  • Diligence and vigilance are necessary.
  • Proactive use of effective methods of communication should be established.
  • The patient must be involved to whatever extent possible.
  • Consistent use of a standardized protocol throughout an organization is best for patient and healthcare worker safety.

The Universal Protocol is most effective in environments which promote teamwork, and all members are empowered to pursue patient safety.
Timing and location of preprocedure verification of patient identity and site marking must be determined by an individual organization. The frequency and scope of preprocedure verification is determined by the type and complexity of the procedure. Preprocedure verification, site marking, and time-out procedures must be as consistent as possible throughout the organization. Site marking is not required when the person performing the procedure is with the patient from the time the decision to do the procedure is made, through to completion of the procedure.

Joint Commission Center for Transforming Healthcare

The Joint Commission, in 2008, created a Center for Transforming Healthcare, to tackle the most critical healthcare quality and patient safety problems. With the NPSGs, core measures, and high standards for accreditation, hospitals and other organizations that deliver healthcare can determine where to focus their resources, to have the greatest impact on quality and safety. However, some major shortcomings in quality and patient safety persist, despite considerable efforts to find solutions, including hand hygiene, wrong-site surgery and hand-off communication. The demand is great for more specific, effective and durable solutions.

The Center participants – some of the nation’s leading hospitals and health systems - are using a systematic approach to analyze the underlying causes of dangerous breakdowns in care, and to develop proven solutions to the more complex problems.

The Joint Commission makes available the proven solutions to the more than 20,500 healthcare organizations it accredits and certifies. With the proven solutions, significant advances in safety for all have been made in health systems and processes of care.

In September 2010, the Targeted Solutions Tool (TST) was introduced. The Joint Commission Center for Transforming Healthcare developed the application. It guides healthcare organizations through a step-by-step process to accurately measure their organizations’ performance, identify the barriers to excellent performance, and direct them to proven solutions that are customized to address the particular barriers of each organization.
The TST currently provides targeted solutions for hand hygiene, wrong-site surgery, and hand-off communications. Targeted solutions for surgical site infections, heart failure hospitalizations, patient falls, sepsis and others will be incorporated into the TST as the center completes their development.

National Patient Safety Foundation

The National Patient Safety Foundation (NPSF) is a not-for-profit organization dedicated to identifying problems in safety and creating solutions for both patients and healthcare workers. The NPSF, although it has a similar mission to that of The Joint Commission, it is entirely independent, with no affiliation to the commission.
The NPSF partners with patients, families, communities, healthcare workers and institutions to address safety issues, solve problems, and provide education in regard to patient and healthcare worker safety.
Among its educational resources is the NPSF On-line Patient Safety Curriculum. The 10 – module course is approved for continuing education credit by the Joint Commission and the American Board of Medical Specialties. The NPSF can be reached at (617) 391-9900 and


Institute of Medicine:

The Joint Commission:

The Joint Commission Sentinel Events:

The Joint Commission: Patient Safety:

The Joint Commission Resources:

The National Patient Safety Foundation:

The Center for Transforming Healthcare – Joint Commission:

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