Patient Safety Systems (PS) : Source: Committee To Design A Strategy For Quality Review and Assurance in

Patient Safety Systems (PS)
Introduction
The quality of care and the safety of patients are core values of The Joint Commission
accreditation process. This is a commitment The Joint Commission has made to
patients, families, health care practitioners, staff, and health care organization leaders.
This chapter exemplifies that commitment.
The intent of this “Patient Safety Systems” (PS) chapter is to provide health care
organizations with a proactive approach to designing or redesigning a patient-centered
system that aims to improve quality of care and patient safety, an approach that aligns
with the Joint Commission’s mission and its standards.
The Joint Commission partners with accredited health care organizations to improve
health care systems to protect patients. The first obligation of health care is to “do no
harm.” Therefore, this chapter is focused on the following three guiding principles:
1. Aligning existing Joint Commission standards with daily work in order to engage
patients and staff throughout the health care system, at all times, on reducing harm.
2. Assisting health care organizations with advancing knowledge, skills, and com-
petence of staff and patients by recommending methods that will improve quality
and safety processes.
3. Encouraging and recommending proactive quality and patient safety methods that
will increase accountability, trust, and knowledge while reducing the impact of fear
and blame.
Quality* and safety are inextricably linked. Quality in health care is the degree to which
its processes and results meet or exceed the needs and desires of the people it serves.1,2
Those needs and desires include safety.
The components of a quality management system should include the following:
n Ensuring reliable processes
*
The Institute of Medicine defines quality as the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current
professional knowledge. Source: Committee to Design a Strategy for Quality Review and Assurance in
Medicare, Institute of Medicine. Medicare: A Strategy for Quality Assurance, vol. 1. Lohr KN, editor.
Washington, DC: The National Academies Press, 1990.
Shading indicates a change effective January 1, 2016, unless otherwise noted in the What's New.
CAMH Update 2, January 2016 PS – 1
◤Comprehensive Accreditation Manual for Hospitals
n Decreasing variation and defects (waste)
n Focusing on achieving better outcomes
n Using evidence to ensure that a service is satisfactory
Patient safety emerges as a central aim of quality. Patient safety, as defined by the World
Health Organization, is the prevention of errors and adverse effects to patients that are
associated with health care. Safety is what patients, families, staff, and the public expect
from Joint Commission–accredited organizations. While patient safety events may not
be completely eliminated, harm to patients can be reduced, and the goal is always zero
harm. This chapter describes and provides approaches and methods that may be adapted
by a health care organization that aims to increase the reliability of its complex systems
while making visible and removing the risk of patient harm. Joint Commission–
accredited organizations should be continually focused on eliminating systems failures
and human errors that may cause harm to patients, families, and staff.1,2
The ultimate purpose of The Joint Commission’s accreditation process is to enhance
quality of care and patient safety. Each requirement or standard, the survey process, the
Sentinel Event Policy, and other Joint Commission initiatives are designed to help
organizations reduce variation, reduce risk, and improve quality. Hospitals should have
an integrated approach to patient safety so that high levels of safe patient care can be
provided for every patient in every care setting and service.
Hospitals are complex environments that depend on strong leadership to support an
integrated patient safety system that includes the following:
n Safety culture
n Validated methods to improve processes and systems
n Standardized ways for interdisciplinary teams to communicate and collaborate
n Safely integrated technologies
In an integrated patient safety system, staff and leaders work together to eliminate
complacency, promote collective mindfulness, treat each other with respect and
compassion, and learn from their patient safety events, including close calls and other
system failures that have not yet led to patient harm.
What Does This Chapter Contain?

The “Patient Safety Systems” (PS) chapter is intended to help inform and educate
hospitals about the importance and structure of an integrated patient safety system.
While this chapter does not include new accreditation requirements, it describes how
PS – 2 CAMH Update 2, January 2016
Patient Safety Systems ◥
existing requirements can be applied to achieve improved patient safety. It is also
intended to help all health care workers understand the relationship between Joint
Commission accreditation and patient safety.
This chapter does the following:
n Describes an integrated patient safety system
n Discusses how hospitals can develop into learning organizations
n Explains how hospitals can continually evaluate the status and progress of their
patient safety systems
n Describes how hospitals can work to prevent or respond to patient safety events
(Sidebar 1, below, defines key terminology)
n Serves as a framework to guide hospital leaders as they work to improve patient
safety in their hospitals
n Contains a list of standards and requirements related to patient safety systems
(which will be scored as usual in their original chapters)
n Contains references that were used in the development of this chapter
This chapter refers to a number of Joint Commission standards. Standards cited in this
chapter are formatted with the standard number in boldface type (for example,
“Standard RI.01.01.01
RI.01.01.01”) and are accompanied by language that summarizes the
standard. For the full text of a standard and its element(s) of performance (EP), please
see the Appendix beginning on page PS-23.
Sidebar 1. Key Terms to Understand
n Patient safety event: An event, incident, or condition that could have resulted or
did result in harm to a patient.
n Adverse event: A patient safety event that resulted in harm to a patient.
n Sentinel event:† A subcategory of Adverse Events, a Sentinel Event is a patient
safety event (not primarily related to the natural course of the patient’s illness or
underlying condition) that reaches a patient and results in any of the following:
o Death
o Permanent harm
o Severe temporary harm
†
For a list of specific patient safety events that are also considered sentinel events, see page SE-1 in the
“Sentinel Events” (SE) chapter of this manual.
n Close call (or “near miss,” “no harm,” or “good catch”): A patient safety event
that did not cause harm as defined by the term sentinel event.
n Hazardous (or “unsafe”) condition(s): A circumstance (other than a patient’s
own disease process or condition) that increases the probability of an adverse
event.
Note: It is impossible to determine if there are practical prevention or mitigation

countermeasures available without first doing an event analysis. An event analysis
will identify systems-level vulnerabilities and weaknesses and the possible remedial
or corrective actions that can be implemented.
Becoming a Learning Organization

The need for sustainable improvement in patient safety and the quality of care has never
been greater. One of the fundamental steps to achieving and sustaining this
improvement is to become a learning organization. A learning organization is one in
which people learn continuously, thereby enhancing their capabilities to create and
innovate.3 Learning organizations uphold five principles: team learning, shared visions
and goals, a shared mental model (that is, similar ways of thinking), individual
commitment to lifelong learning, and systems thinking.3 In a learning organization,
patient safety events are seen as opportunities for learning and improvement.4 Therefore,
leaders in learning organizations adopt a transparent, nonpunitive approach to reporting
so that the organization can report to learn and can collectively learn from patient safety
events. In order to become a learning organization, a hospital must have a fair and just
safety culture, a strong reporting system, and a commitment to put that data to work by
driving improvement. Each of these require the support and encouragement of hospital
leaders.
Leaders, staff, licensed independent practitioners, and patients in a learning organization
realize that every patient safety event (from close calls to events that cause major harm to
patients) must be reported.4-8 When patient safety events are continuously reported,
experts within the hospital can define the problem, identify solutions, achieve
sustainable results, and disseminate the changes or lessons learned to the rest of the
hospital.4-8 In a learning organization, the hospital provides staff with information
regarding improvements based on reported concerns. This helps foster trust that
encourages further reporting.
The Role of Hospital Leaders in Patient
Safety
Hospital leaders provide the foundation for an effective patient safety system by doing
the following:9
n Promoting learning
n Motivating staff to uphold a fair and just safety culture
n Providing a transparent environment in which quality measures and patient harms
are freely shared with staff
n Modeling professional behavior
n Removing intimidating behavior that might prevent safe behaviors
n Providing the resources and training necessary to take on improvement initiatives
For these reasons, many of the standards that are focused on the hospital’s patient safety
system appear in the Joint Commission’s Leadership (LD) standards, including Standard
LD.04.04.05 (which focuses on having an organizationwide, integrated patient safety
program within performance improvement activities).
Without the support of hospital leaders, hospitalwide changes and improvement
initiatives are difficult to achieve. Leadership engagement in patient safety and quality
initiatives is imperative because 75% to 80% of all initiatives that require people to
change their behaviors fail in the absence of leadership managing the change.4 Thus,
leadership should take on a long-term commitment to transform the hospital.10
Safety Culture
A strong safety culture is an essential component of a successful patient safety system
and is a crucial starting point for hospitals striving to become learning organizations. In
a strong safety culture, the hospital has an unrelenting commitment to safety and to do
no harm. Among the most critical responsibilities of hospital leaders is to establish and
maintain a strong safety culture within their hospital. The Joint Commission’s standards
address safety culture in Standard LD.03.01.01
LD.03.01.01, which requires leaders to create and
maintain a culture of safety and quality throughout the hospital.
The safety culture of a hospital is the product of individual and group beliefs, values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
organization’s commitment to quality and patient safety. Hospitals that have a robust
safety culture are characterized by communications founded on mutual trust, by shared
perceptions of the importance of safety, and by confidence in the efficacy of preventive
measures.11 Organizations will have varying levels of safety culture, but all should be
working toward a safety culture that has the following qualities:
n Staff and leaders that value transparency, accountability, and mutual respect.4
n Safety as everyone’s first priority.4
n Behaviors that undermine a culture of safety are not acceptable, and thus should be
reported to organizational leadership by staff, patients, and families for the purpose
of fostering risk reduction.4,10,12
n Collective mindfulness is present, wherein staff realize that systems always have the
potential to fail and staff are focused on finding hazardous conditions or close calls
at early stages before a patient may be harmed.10 Staff do not view close calls as
evidence that the system prevented an error but rather as evidence that the system
needs to be further improved to prevent any defects.10,13
n Staff who do not deny or cover up errors but rather want to report errors to learn
from mistakes and improve the system flaws that contribute to or enable patient
safety events.6 Staff know that their leaders will focus not on blaming providers
involved in errors but on the systems issues that contributed to or enabled the
patient safety event.6,14
n By reporting and learning from patient safety events, staff create a learning
organization.
A safety culture operates effectively when the hospital fosters a cycle of trust, reporting,
and improvement.10,15 In hospitals that have a strong safety culture, health care providers
trust their coworkers and leaders to support them when they identify and report a
patient safety event.10 When trust is established, staff are more likely to report patient
safety events, and hospitals can use these reports to inform their improvement efforts. In
the trust-report-improve cycle, leaders foster trust, which enables staff to report, which
enables the hospital to improve.10 In turn, staff see that their reporting contributes to
actual improvement, which bolsters their trust. Thus, the trust-report-improve cycle
reinforces itself.10 (See Figure 1 on page PS-7.)
Leadership
High
Reliability
y
Trust
RPI
Improve Report
Health
Care
Safety Culture
Figure 1. The Trust-Report-Improve Cycle
In the trust-report-improve cycle, trust promotes reporting, which leads to improve-

ment, which in turn fosters trust.
Leaders need to ensure that intimidating or unprofessional behaviors within the hospital
are addressed, so as not to inhibit others from reporting safety concerns.16 Leaders should
both educate staff and hold them accountable for professional behavior. This includes
the adoption and promotion of a code of conduct that defines acceptable behavior as
well as behaviors that undermine a culture of safety. The Joint Commission’s Standard
LD.03.01.01
LD.03.01.01, EP 4, requires that leaders develop such a code.
Intimidating and disrespectful behaviors disrupt the culture of safety and prevent
collaboration, communication, and teamwork, which is required for safe and highly
reliable patient care.17 Disrespect is not limited to outbursts of anger that humiliate a
member of the health care team; it can manifest in many forms, including the
following:4,12,17
n Inappropriate words (profane, insulting, intimidating, demeaning, humiliating, or
abusive language)
n Shaming others for negative outcomes
n Unjustified negative comments or complaints about another provider’s care
n Refusal to comply with known and generally accepted practice standards, the refusal
of which may prevent other providers from delivering quality care
n Not working collaboratively or cooperatively with other members of the interdisci-
plinary team
n Creating rigid or inflexible barriers to requests for assistance or cooperation
n Not returning pages or calls promptly
These issues are still occurring in hospitals nationwide. Of 4,884 respondents to a 2013
survey by the Institute for Safe Medication Practices (ISMP), 73% reported encoun-
tering negative comments about colleagues or leaders during the previous year. In
addition, 68% reported condescending language or demeaning comments or insults;
while 77% of respondents said they had encountered reluctance or refusal to answer
questions or return calls.18 Further, 69% report that they had encountered impatience
with questions or the hanging up of the phone.
Nearly 50% of the respondents indicated that intimidating behaviors had affected the
way they handle medication order clarifications or questions, including assuming that an
order was correct in order to avoid interaction with an intimidating coworker.18
Moreover, 11% said they were aware of a medication error during the previous year in
which behavior that undermines a culture of safety was a contributing factor. The
respondents included nurses, physicians, pharmacists, and quality/risk management
personnel.
Only 50% of respondents indicated that their organizations had clearly defined an
effective process for handling disagreements with the safety of an order. This is down
from 60% of respondents to a similar ISMP survey conducted in 2003, which suggests
that this problem is worsening.18 While these data are specific to medication safety, their
lessons are broadly applicable: Behaviors that undermine a culture of safety have an
adverse effect on quality and patient safety.
A Fair and Just Safety Culture

A fair and just safety culture is needed for staff to trust that they can report patient safety
events without being treated punitively.2,8 In order to accomplish this, hospitals should
provide and encourage the use of a standardized reporting process for staff to report
patient safety events. This is also built into the Joint Commission’s standards at
Standard LD.04.04.05
LD.04.04.05, EP 6, which requires leaders to provide and encourage the use of
systems for blame-free reporting of a system or process failure or the results of proactive
risk assessments. Reporting enables both proactive and reactive risk reduction. Proactive
risk reduction solves problems before patients are harmed, and reactive risk reduction
attempts to prevent the recurrence of problems that have already caused patient harm.10,15
A fair and just culture takes into account that individuals are human, fallible, and
capable of mistakes, and that they work in systems that are often flawed. In the most
basic terms, a fair and just culture holds individuals accountable for their actions but
does not punish individuals for issues attributed to flawed systems or processes.14,18,19
Refer to Standard LD.04.01.05
LD.04.01.05, EP 4, which requires that staff are held accountable for
their responsibilities.
It is important to note that for some actions for which an individual is accountable, the
individual should be held culpable and some disciplinary action may then be necessary.
(See Sidebar 2, below, for a discussion of tools that can help leaders determine a fair and
just response to a patient safety event.) However, staff should never be punished or
ostracized for reporting the event, close call, hazardous condition, or concern.
Sidebar 2. Assessing Staff Accountability
The aim of a safety culture is not a “blame-free” culture but one that balances
learning with accountability. To achieve this, it is essential that leaders assess errors
and patterns of behavior in a manner that is applied consistently, with the goal of
eliminating behaviors that undermine a culture of safety. There has to exist within the
hospital a clear, equitable, and transparent process for recognizing and separating
the blameless errors that fallible humans make daily from the unsafe or reckless acts
that are blameworthy.1–8
There are a number of sources for information (some of which are listed immediately
below) that provide rationales, tools, and techniques that will assist an organization
in creating a formal decision process to determine what events should be considered
blameworthy and require individually directed action in addition to systems-level
corrective actions. The use of a formal process will reinforce the culture of safety and
demonstrate the organization’s commitment to transparency and fairness.
Reaching answers to these questions requires an initial investigation into the patient
safety event to identify contributing factors. The use of the Incident Decision Tree
(adapted by the United Kingdom’s National Patient Safety Agency from James
Reason’s culpability matrix) or other formal decision process can help make
determinations of culpability more transparent and fair.5
References
1. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel
Event Alert, No. 40, Jul 9, 2009. Accessed Sep 3, 2013. http://
www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_
that_undermine_a_culture_of_safety/
2. The Joint Commission. Leadership committed to safety. Sentinel Event Alert.
Aug 27, 2009. Accessed Sep 8, 2013. http://www.jointcommission.org/
sentinel_event_alert_issue_43_leadership_committed_to_safety
3. Marx D. How building a ‘just culture’ helps an organization learn from errors. OR
Manager. 2003 May;19(5):1, 14–15, 20.
4. Reason J; Hobbs A. Managing Maintenance Error. Farnham, Surrey, United
Kingdom: Ashgate Publishing, 2003.
5. Vincent C. Patient Safety, 2nd ed. Hoboken, NJ: Wiley-Blackwell, 2010.
6. National Patient Safety Agency. Incident Decision Tree. Accessed Sep 7, 2013.
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59900
7. Bagian JP, et al. Developing and deploying a patient safety program in a large
health care delivery system: You can’t fix what you don’t know about. Jt Com J
Qual Patient Saf. 2001 Oct;27(10):522–532.
8. National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and
Actions to Prevent Harm. Jun 16, 2015. Accessed Jun 23, 2015. http://
www.npsf.org/?page=RCA2
Data Use and Reporting Systems

An effective culture of safety is evidenced by a robust reporting system and use of
measurement to improve. When hospitals adopt a transparent, nonpunitive approach to
reports of patient safety events or other concerns, the hospital begins reporting to
learn—and to learn collectively from adverse events, close calls, and hazardous
conditions. This section focuses on data from reported patient safety events. Hospitals
should note that this is but one type of data among many that should be collected and
used to drive improvement.
When there is continuous reporting for adverse events, close calls, and hazardous
conditions, the hospital can analyze the patient safety events, change the process or
system to improve safety, and disseminate the changes or lessons learned to the rest of
the organization.20–24
In addition to those mentioned earlier in this chapter, a number of standards relate to
the reporting of safety information, including Performance Improvement (PI) Standard
PI.01.01.01
PI.01.01.01, which requires hospitals to collect data to monitor their performance, and
LD.03.02.01, which requires hospitals to use data and information to guide
decisions and to understand variation in the performance of processes supporting safety
and quality.
Hospitals can engage frontline staff in internal reporting in a number of ways, including
the following:
n Create a nonpunitive approach to patient safety event reporting
n Educate staff on identifying patient safety events that should be reported
n Provide timely feedback regarding actions taken on patient safety events
Effective Use of Data

Collecting Data
When hospitals collect data or measure staff compliance with evidence-based care
processes or patient outcomes, they can manage and improve those processes or
outcomes and, ultimately, improve patient safety.25 The effective use of data enables
hospitals to identify problems, prioritize issues, develop solutions, and track to
determine success.9 Objective data can be used to support decisions, influence people to
change their behaviors, and to comply with evidence-based care guidelines.9,26
The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) both
require hospitals to collect and use data related to certain patient care outcomes and
patient harms. Some key Joint Commission standards related to data collection and use
require hospitals to do the following:
n Collect information to monitor conditions in the environment (Standard
EC.04.01.01
EC.04.01.01)
n Identify risks for acquiring and transmitting infections (Standard IC.01.03.01 )
n Use data and information to guide decisions and to understand variation in the
performance of processes supporting safety and quality (Standard LD.03.02.01
LD.03.02.01)
n Have an organizationwide, integrated patient safety program within their perform-
ance improvement activities (Standard LD.04.04.05
LD.04.04.05)
n Evaluate the effectiveness of their medication management system (Standard
MM.08.01.01
MM.08.01.01)
n Report (if using Joint Commission accreditation for deemed status purposes) deaths
associated with the use of restraint and seclusion (Standard PC.03.05.19
PC.03.05.19)
n Collect data to monitor their performance (Standard PI.01.01.01
PI.01.01.01)
n Improve performance on an ongoing basis (Standard PI.03.01.01
PI.03.01.01)
Analyzing Data
Effective data analysis can enable a hospital to “diagnose” problems within its system
similar to the way one would diagnose a patient’s illness based on symptoms, health
history, and other factors. Turning data into information is a critical competency of a
learning organization and of effective management of change. When the right data are
collected and appropriate analytic techniques are applied, it enables the hospital to
monitor the performance of a system, detect variation, and identify opportunities to
improve. This can help the hospital not only understand the current performance of
hospital systems but also can help it predict its performance going forward.23
Analyzing data with tools such as run charts, statistical process control (SPC) charts, and
capability charts helps a hospital determine what has occurred in a system and provides
clues as to why the system responded as it did.23 Table 1, following, describes and
compares examples of these tools. Please note that several types of SPC charts exist; this
discussion focuses on the XmR chart, which is the most commonly used.
Table 1. Defining and Comparing Analytical Tools
Tool When to Use Example

Run Chart1 n When the hospital needs
to identify variation within
a system
n When the hospital needs
a simple and straightfor-
ward analysis of a system
n As a precursor to an SPC
chart
Statistical Process
Control Chart n When the hospital needs
to identify variation within
a system and find indi-
cators of why the variation
occurred
n When the hospital needs
a more detailed and in-
depth analysis of a sys-
tem
Capability Chart2 n When the hospital needs
to determine whether a
process will function as
expected, according to re-
quirements or specifi-
cations
In the example above, the curve at the top of

the chart indicates a process that is only
partly capable of meeting requirements. The
curve at the bottom of the chart shows a
process that is fully capable.
Sources:
1. Agency for Healthcare Research and Quality. Advanced Methods in Delivery System
Research—Planning, Executing, Analyzing, and Reporting Research on Delivery System
Improvement. Webinar #2: Statistical Process Control. Jul 2013. Accessed Aug 21, 2015. http://
www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar02/
index.html. (Example 2, above).
2. George ML, et al. The Lean Six Sigma Pocket Toolbook: A Quick Reference Guide to Nearly
100 Tools for Improving Process Quality, Speed, and Complexity. New York: McGraw-Hill,
2005. Used with permission.
Using Data to Drive Improvement
After data has been turned into information, leadership should ensure the following (per
the requirements shown):27–29
n Information is presented in a clear manner (Standard LD.03.04.01
LD.03.04.01, EP 3)
n Information is shared with the appropriate groups throughout the organization
(from the front line to the board) (Standards LD.03.04.01
LD.03.04.01, LD.04.04.05
LD.04.04.05)
n Opportunities for improvement and actions to be taken are clearly articulated
(Standards LD.03.05.01
LD.03.05.01, EP 4; LD.04.04.01
LD.04.04.01)
n Leadership provides staff with time, resources, and opportunities for participating in
improvement efforts as part of daily work (Standard LD.03.01.01
LD.03.01.01, EP 3)
n Improvements are celebrated or recognized
A Proactive Approach to Preventing Harm

Proactive risk reduction prevents harm before it reaches the patient. By engaging in
proactive risk reduction, a hospital can correct process problems in order to reduce the
likelihood of experiencing adverse events.
In a proactive risk assessment the hospital evaluates a process to see how it could
potentially fail, to understand the consequences of such a failure, and to identify parts of
the process that need improvement. A proactive risk assessment increases understanding
within the organization about the complexities of process design and management—and
what could happen if the process fails.
When conducting a proactive risk assessment, organizations should prioritize high-risk,
high-volume areas. Areas of risk are identified from internal sources such as ongoing
monitoring of the environment, results of previous proactive risk assessments, from
results of data collection activities. Risk assessment tools should be accessed from
credible external sources such as a Sentinel Event Alert, nationally recognized risk
assessment tools, and peer review literature. Benefits of a proactive approach to patient
safety includes increased likelihood of the following:
n Identification of actionable common causes
n Avoidance of unintended consequences
n Identification of commonalities across departments/services/units
n Identification of system solutions
Hazardous (or unsafe) conditions provide an opportunity for a hospital to take a
proactive approach to reduce harm. Hospitals also benefit from identifying hazardous
conditions while designing any new process that could impact patient safety. A
hazardous condition is defined as any circumstance that increases the probability of a
patient safety event. A hazardous condition may be the result of a human error or
violation, may be a design flaw in a system or process, or may arise in a system or process
in changing circumstances.‡ A proactive approach to such conditions should include an
analysis of the systems and processes in which the hazardous condition is found, with a
focus on conditions that preceded the hazardous condition. (See Sidebar 3, below.)
A proactive approach to hazardous conditions should include an analysis of the related
systems and processes, including the following aspects:30
n Preconditions. Examples include hazardous (or unsafe) conditions in the environ-
ment of care (such as noise, clutter, wet floors and so forth), inadequate staffing
levels, an operator who is impaired or inadequately trained.
n Supervisory influences. Examples include inadequate supervision, planned inappro-
priate operations, failure to address a known problem, authorization of activities
that are known to be hazardous.
n Organizational influences. Examples include inadequate staffing, inadequate poli-
cies, lack of strategic risk assessment.
The Joint Commission addresses proactive risk assessments at Standard LD.04.04.05
LD.04.04.05,
EP 10, which requires hospitals to select one high-risk process and conduct a proactive
risk assessment at least every 18 months.
Hospitals should recognize that this standard represents a minimum requirement.
Hospitals working to become learning organizations are encouraged to exceed this
requirement by constantly working to proactively identify risk.
Sidebar 3. Strategies for an Effective Risk

Assessment
Although several methods could be used to conduct a proactive risk assessment, the
following steps comprise one approach:
n Describe the chosen process (for example, through the use of a flowchart).
‡
Human errors are typically skills based, decision based, or knowledge based; whereas violations could
be either routine or exceptional (intentional or negligent). Routine violations tend to include habitual
“bending of the rules,” often enabled by management. A routine violation may break established rules
or policies, and yet be a common practice within an organization. An exceptional violation is a willful
behavior outside the norm that is not condoned by management, engaged in by others, and not part of
the individual’s usual behavior. Source: Diller T, et al. The human factors analysis classification system
(HFACS) applied to health care. Am J Med Qual.2014 May–Jun;29(3)181–190.
n Identify ways in which the process could break down or fail to perform its
desired function, which are often referred to as “failure modes.”
n Identify the possible effects that a breakdown or failure of the process could
have on patients and the seriousness of the possible effects.
n Prioritize the potential process breakdowns or failures.
n Determine why the prioritized breakdowns or failures could occur, which may
involve performing a hypothetical root cause analysis.
n Design or redesign the process and/or underlying systems to minimize the risk
of the effects on patients.
n Test and implement the newly designed or redesigned process.
n Monitor the effectiveness of the newly designed or redesigned process.
Tools for Conducting a Proactive Risk Assessment

A number of tools are available to help organizations conduct a proactive risk
assessment. One of the best known of these tools is the Failure Modes and Effects
Analysis (FMEA). An FMEA is used to prospectively examine how failures could occur
during high-risk processes and, ultimately, how to prevent them. The FMEA asks
“What if?” to explore what could happen if a failure occurs at particular steps in a
process.31
Hospitals have other tools they can consider using in their proactive risk assessment.
Some examples include the following:
n Institute for Safe Medication Practices Medication Safety Risk Assessment: This
tool is designed to help reduce medication errors. Visit https://www.ismp.org/
selfassessments/default.asp for more information.
n Contingency diagram: The contingency diagram uses brainstorming to generate a
list of problems that could arise from a process. Visit http://healthit.ahrq.gov/
health-it-tools-and-resources/workflow-assessment-health-it-toolkit/all-workflow-
tools/contingency-diagram for more information.
n Potential problem analysis (PPA) is a systematic method for determining what
could go wrong in a plan under development. The problem causes are rated
according to their likelihood of occurrence and the severity of their consequences.
Visit http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-
health-it-toolkit/all-workflow-tools/potential-problem-analysis for more infor-
mation.
n Process decision program chart (PDPC) provides a systematic means of finding
errors with a plan while it is being created. After potential issues are found,
preventive measures are developed, allowing the problems to either be avoided or a
contingency plan to be in place should the error occur. Visit http://
healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it
-toolkit/all-workflow-tools/process-decision-program-chart.
Encouraging Patient Activation

To achieve the best outcomes, patients and families must be more actively engaged in
decisions about their health care and must have broader access to information and
support. Patient activation is inextricably intertwined with patient safety. Activated
patients are less likely to experience harm and unnecessary hospital readmissions.
Patients who are less activated suffer poorer health outcomes and are less likely to follow
their provider’s advice.32,33
A patient-centered approach to care can help hospitals assess and enhance patient
activation. Achieving this requires leadership engagement in the effort to establish
patient-centered care as a top priority throughout the hospital. This includes adopting
the following principles:34
n Patient safety guides all decision making.
n Patients and families are partners at every level of care.
n Patient- and family-centered care is verifiable, rewarded, and celebrated.
n The licensed independent practitioner responsible for the patient’s care, or his or
her designee, discloses to the patient and family any unanticipated outcomes of care,
treatment, and services.
n Though Joint Commission standards do not require apology, evidence suggests that
patients benefit—and are less likely to pursue litigation—when physicians disclose
harm, express sympathy, and apologize.
n Staffing levels are sufficient, and staff has the necessary tools and skills.
n The hospital has a focus on measurement, learning, and improvement.
n Staff and licensed independent practitioners must be fully engaged in patient- and
family-centered care as demonstrated by their skills, knowledge, and competence in
compassionate communication.
Hospitals can adopt a number of strategies to support and improve patient activation,
including promoting culture change, adopting transitional care models, and leveraging
health information technology capabilities.34
A number of Joint Commission standards address patient rights and provide an excellent
starting point for hospitals seeking to improve patient activation. These standards
require that hospitals do the following:
n Respect, protect, and promote patient rights (Standard RI.01.01.01
RI.01.01.01)
n Respect the patient’s right to receive information in a manner he or she understands
(Standard RI.01.01.03
RI.01.01.03)
n Respect the patient’s right to participate in decisions about his or her care,
treatment, and services (Standard RI.01.02.01
RI.01.02.01)
n Honor the patient’s right to give or withhold informed consent (Standard
RI.01.03.01
RI.01.03.01)
n Address patient decisions about care, treatment, and services received at the end of
life (Standard RI.01.05.01
RI.01.05.01)
n Inform the patient about his or her responsibilities related to his or her care,
treatment, and services (Standard RI.02.01.01
RI.02.01.01)
Beyond Accreditation: The Joint

Commission Is Your Patient Safety Partner
To assist hospitals on their journey toward creating highly reliable patient safety systems,
The Joint Commission provides many resources, including the following:
n Office of Quality and Patient Safety: An internal Joint Commission department that
offers hospitals guidance and support when they experience a sentinel event.
Organizations can call the Sentinel Event Hotline (630-792-3700) to clarify
whether a patient safety event is considered to be a sentinel event (and therefore
reviewable) or to discuss any aspect of the Sentinel Event Policy. The Office of
Quality and Patient Safety assesses the thoroughness and credibility of a hospital’s
comprehensive systematic analysis as well as the action plan to help the hospital
prevent the hazardous or unsafe conditions from occurring again.
n Joint Commission Center for Transforming Healthcare: A Joint Commission not-for-
profit affiliate that offers highly effective, durable solutions to health care’s most
critical safety and quality problems to help hospitals transform into high reliability
organizations. For specific quality and patient problems, the Center’s Targeted
Solutions Tool® (TST®) guides health care organizations through a step-by-step
process to measure their organization’s performance, identify barriers to excellence,
and direct them to proven solutions. To date, a TST has been developed for each of
the following: hand hygiene, hand-off communications, and wrong-site surgery. For
more information, visit http://www.centerfortransforminghealthcare.org.
n Standards Interpretation Group: An internal Joint Commission department that
helps organizations with their questions about Joint Commission standards. First,
organizations can see if other organizations have asked the same question by
accessing the Standards FAQs at http://www.jointcommission.org/
standards_information/jcfaq.aspx. Thereafter, organizations can submit questions
about standards to the Standards Interpretation Group by completing an online
form at https://web.jointcommission.org/sigsubmission/sigonlineform.aspx.
n National Patient Safety Goals: The Joint Commission’s yearly patient safety
requirements based on data obtained from the Joint Commission’s Sentinel Event
Database and recommended by a panel of patient safety experts. (For a list of the
current National Patient Safety Goals, go to http://www.jointcommission.org/
standards_information/npsgs.)
n Sentinel Event Alert: The Joint Commission’s periodic alerts with timely infor-
mation about similar, frequently reported sentinel events, including root causes,
applicable Joint Commission requirements, and suggested actions to prevent a
particular sentinel event. (For archives of previously published Sentinel Event Alert,
go to http://www.jointcommission.org/sentinel_event.)
n Quick Safety: Quick Safety is a monthly newsletter that outlines an incident, topic,
or trend in health care that could compromise patient safety. http://
www.jointcommission.org/quick_safety.aspx?archieve=y
n Core Measure Solution Exchange®: Available for accredited or certified organizations
through the Joint Commission Connect™ extranet, organizations can search a database
of over two hundred success stories from accredited hospitals that have attained
excellent performance on core measures, including accountability measures.
n Joint Commission Resources: A Joint Commission not-for-profit affiliate that
produces books and periodicals, holds conferences, provides consulting services, and
develops software products (including AMP®, Tracers with AMP®, E-dition®, ECM
Plus®, CMSAccess®, and JCAccess®) for accreditation and survey readiness. (For
more information, visit http://www.jcrinc.com.)
n Webinars and podcasts: The Joint Commission and its affiliate, Joint Commission
Resources, offer free webinars and podcasts on various accreditation and patient
safety topics.
n Speak Up™ program: The Joint Commission’s campaign to educate patients about
health care processes and potential safety issues and encourage them to speak up
whenever they have questions or concerns about their safety. (For more information
and patient education resources, go to http://www.jointcommission.org/speakup.)
n Standards BoosterPaks™: Available for accredited or certified organizations through
Joint Commission Connect, organizations can access BoosterPaks that provide
detailed information about a single standard or topic area that has been associated
with a high volume of inquiries or noncompliance scores. Recent standards
BoosterPak topics have included credentialing and privileging in nonhospital
settings, waived testing, restraint and seclusion, management of hazardous waste,
environment of care (including Standards EC.04.01.01
EC.04.01.01, EC.04.01.03
EC.04.01.03, and
EC.04.01.05
EC.04.01.05), and sample collection.
n Leading Practice Library: Available for accredited or certified organizations through
Joint Commission Connect, organizations can access an online library of solutions to
help improve safety. The searchable documents in the library are actual solutions
that have been successfully implemented by hospitals and reviewed by Joint
Commission standards experts.
n Joint Commission web portals: Through The Joint Commission website, organiza-
tions can access web portals with a repository of resources from The Joint
Commission, the Joint Commission Center for Transforming Healthcare, Joint
Commission Resources, and Joint Commission International on the following
topics:
o Transitions of care: http://www.jointcommission.org/toc.aspx
o High reliability: http://www.jointcommission.org/highreliability.aspx
o Infection prevention and health care–associated infections (HAI): http://
www.jointcommission.org/hai.aspx
o Emergency management: http://www.jointcommission.org/
emergency_management.aspx
References
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2010.
2. American Society for Quality. Glossary and Tables for Statistical Quality Control, 4th
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3. Senge PM. The Fifth Discipline: The Art and Practice of the Learning Organization,
2nd ed. New York: Doubleday, 2006.
4. Leape L, et al. A culture of respect, part 2: Creating a culture of respect. Academic
Medicine. 2012 Jul;87(7):853–858.
5. Wu A, ed. The Value of Close Calls in Improving Patient Safety: Learning How to
Avoid and Mitigate Patient Harm. Oak Brook, IL: Joint Commission Resources,
2011.
6. Agency for Healthcare Research and Quality. Becoming a High Reliability Organiza-
tion: Operational Advice for Hospital Leaders. Rockville, MD: AHRQ, 2008.
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8. Massachusetts Coalition of the Prevention of Medical Errors: When Things Go
Wrong: Responding to Adverse Events. Mar 2006. Accessed Sep 30, 2013. http://
www.macoalition.org/documents/respondingToAdverseEvents.pdf
9. The Joint Commission. The Joint Commission Leadership Standards. Oak Brook, IL:
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10. Chassin MR, Loeb JM. High-reliability healthcare: Getting there from here.
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11. Advisory Committee on the Safety of Nuclear Installations. Study Group on Human
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12. Leape L, et al. A culture of respect, part 1: The nature and causes of disrepectful
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Bass, 2007.
14. Reason J, Hobbs A. Managing Maintenance Error: A Practical Guide. Aldershot, UK:
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15. Association for the Advancement of Medical Instrumentation. Risk and Reliability in
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16. Reason J. Human error: Models and management. BMJ. 2000 Mar 13;320(3):768–
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sentinel_event_alert_issue_43_leadership_committed_to_safety
27. Nelson EC, et al. Microsystems in health care: Part 2. Creating a rich information
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-insurance/info-03-2009/beyond_50_hcr.html
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Conceptualizing and measuring activation in patients and consumers. Health Serv
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Appendix. Key Patient Safety Requirements
A number of Joint Commission standards have been discussed in the “Patient Safety
Systems” (PS) chapter. However, many Joint Commission requirements address issues
related to the design and management of patient safety systems, including the following
examples:
Accreditation Participation Requirements

(APR)
Standard APR.09.01.01
The hospital notifies the public it serves about how to contact its hospital management
and The Joint Commission to report concerns about patient safety and quality of care.
Note: Methods of notice may include, but are not limited to, distribution of information
about The Joint Commission, including contact information in published materials such as
brochures and/or posting this information on the hospital’s website.
Elements of Performance for APR.09.01.01

A 1. The hospital informs the public it serves about how to contact its management to
report concerns about patient safety and quality of care.
A 2. The hospital informs the public it serves about how to contact The Joint
Commission to report concerns about patient safety and quality of care.
Standard APR.09.02.01
Any individual who provides care, treatment, and services can report concerns about
safety or the quality of care to The Joint Commission without retaliatory action from
the hospital.
Elements of Performance for APR.09.02.01

A 1. The hospital educates its staff, medical staff, and other individuals who provide
care, treatment, and services that concerns about the safety or quality of care
provided in the organization may be reported to The Joint Commission.
A 2. The hospital informs its staff and medical staff that it will take no disciplinary or
punitive action because an employee, physician, or other individual who provides
care, treatment, and services reports safety or quality-of-care concerns to The
Joint Commission.
A 3. The hospital takes no disciplinary or punitive action against employees,
physicians, or other individuals who provide care, treatment, and services when
they report safety or quality-of-care concerns to The Joint Commission.
Environment of Care (EC)

Standard EC.04.01.01
The hospital collects information to monitor conditions in the environment.
Elements of Performance for EC.04.01.01

A 1. The hospital establishes a process(es) for continually monitoring, internally
reporting, and investigating the following:
n Injuries to patients or others within the hospital’s facilities
n Occupational illnesses and staff injuries
n Incidents of damage to its property or the property of others
n Security incidents involving patients, staff, or others within its facilities
n Hazardous materials and waste spills and exposures
n Fire safety management problems, deficiencies, and failures
n Medical or laboratory equipment management problems, failures, and use
errors
n Utility systems management problems, failures, or use errors
Note 1: All the incidents and issues listed above may be reported to staff in quality
assessment, improvement, or other functions. A summary of such incidents may also be
shared with the person designated to coordinate safety management activities.
Note 2: Review of incident reports often requires that legal processes be followed to
preserve confidentiality. Opportunities to improve care, treatment, or services, or to
prevent similar incidents, are not lost as a result of following the legal process.
Based on its process(es), the hospital reports and investigates the following:
C 3. Injuries to patients or others in the hospital’s facilities. (See also
EC.04.01.03, EP 1)
C 4. Occupational illnesses and staff injuries. (See also EC.04.01.03, EP 1)
C 5. Incidents of damage to its property or the property of others. (See also

EC.04.01.03, EP 1)
C 6. Security incidents involving patients, staff, or others within its facilities.
(See also EC.04.01.03, EP 1)
C 8. Hazardous materials and waste spills and exposures. (See also EC.04.01.03,
EP 1)
C 9. Fire safety management problems, deficiencies, and failures. (See also
EC.04.01.03, EP 1)
C 10. Medical/laboratory equipment management problems, failures, and use
errors. (See also EC.04.01.03, EP 1)
C 11. Utility systems management problems, failures, or use errors. (See also
EC.04.01.03, EP 1)
A 12. The hospital conducts environmental tours every six months in patient care areas
to evaluate the effectiveness of previously implemented activities intended to
minimize or eliminate environment of care risks. (See also EC.04.01.03, EP 1)
C 13. The hospital conducts annual environmental tours in nonpatient care areas to
evaluate the effectiveness of previously implemented activities intended to
minimize or eliminate risks in the environment. (See also EC.04.01.03, EP 1)
A 14. The hospital uses its tours to identify environmental deficiencies, hazards, and
unsafe practices. (See also EC.02.01.01, EP 1; EC.04.01.03, EP 1)
A 15. Every 12 months, the hospital evaluates each environment of care management
plan, including a review of the plan’s objectives, scope, performance, and
effectiveness. (See also EC.01.01.01, EPs 3-8; EC.04.01.03, EP 1)
Human Resources (HR)

Standard HR.01.05.03
Staff participate in ongoing education and training.
Elements of Performance for HR.01.05.03
C 7. Staff participate in education and training that includes information about the
need to report unanticipated adverse events and how to report these events. Staff
participation is documented.
C 8. Staff participate in education and training on fall reduction activities. Staff
participation is documented.
C 13. The hospital provides education and training that addresses how to identify
early warning signs of a change in a patient’s condition and how to respond to a
deteriorating patient, including how and when to contact responsible clinicians.
Education is provided to staff and licensed independent practitioners who may
request assistance and those who may respond to those requests. Participation in
this education is documented.
Infection Prevention and Control (IC)

Standard IC.01.03.01
The hospital identifies risks for acquiring and transmitting infections.
Elements of Performance for IC.01.03.01

The hospital identifies risks for acquiring and transmitting infections based on the
following:
A 1. Its geographic location, community, and population served. (See also
NPSG.07.03.01, EP 1)
A 2. The care, treatment, and services it provides. (See also NPSG.07.03.01,
EP 1)
A 3. The analysis of surveillance activities and other infection control data. (See
also NPSG.07.03.01, EP 1; TS.03.03.01, EP 2)
A 4. The hospital reviews and identifies its risks at least annually and whenever
significant changes occur with input from, at a minimum, infection control
personnel, medical staff, nursing, and leadership. (See also NPSG.07.03.01, EP 1)
A 5. The hospital prioritizes the identified risks for acquiring and transmitting
infections. These prioritized risks are documented. (See also NPSG.07.03.01,
EP 1)
Leadership (LD)
The mission, vision, and goals of the hospital support the safety and quality of care,
Elements of Performance for LD.02.01.01

A 1. The governing body, senior managers, and leaders of the organized medical staff
work together to create the hospital’s mission, vision, and goals. (See also
NR.01.01.01, EP 2)
A 2. The hospital’s mission, vision, and goals guide the actions of leaders.
A 3. Leaders communicate the mission, vision, and goals to staff and the population(s)
the hospital serves.
The governing body, senior managers, and leaders of the organized medical staff
regularly communicate with one another on issues of safety and quality.

A 1. Leaders discuss issues that affect the hospital and the population(s) it serves,
including the following:
n Performance improvement activities
n Reported safety and quality issues
n Proposed solutions and their impact on the hospital’s resources
n Reports on key quality measures and safety indicators
n Safety and quality issues specific to the population served
n Input from the population(s) served
(See also NR.01.01.01, EP 3)

A 2. The hospital establishes time frames for the discussion of issues that affect the
hospital and the population(s) it serves.
The hospital manages conflict between leadership groups to protect the quality and
safety of care.

A 1. Senior managers and leaders of the organized medical staff work with the
governing body to develop an ongoing process for managing conflict among
leadership groups.
A 2. The governing body approves the process for managing conflict among leadership
groups.
A 4. The conflict management process includes the following:
n Meeting with the involved parties as early as possible to identify the conflict
n Gathering information regarding the conflict
n Working with the parties to manage and, when possible, resolve the conflict
n Protecting the safety and quality of care
A 5. The hospital implements the process when a conflict arises that, if not managed,
could adversely affect patient safety or quality of care.
Leaders create and maintain a culture of safety and quality throughout the hospital.

A 1. Leaders regularly evaluate the culture of safety and quality using valid and reliable
tools.
A 2. Leaders prioritize and implement changes identified by the evaluation.
A 3. Leaders provide opportunities for all individuals who work in the hospital to
participate in safety and quality initiatives.
A 4. Leaders develop a code of conduct that defines acceptable behavior and
behaviors that undermine a culture of safety.
A 5. Leaders create and implement a process for managing behaviors that undermine a
culture of safety.
A 6. Leaders provide education that focuses on safety and quality for all individuals.
A 7. Leaders establish a team approach among all staff at all levels.

A 8. All individuals who work in the hospital, including staff and licensed indepen-
dent practitioners, are able to openly discuss issues of safety and quality. (See also
LD.04.04.05, EP 6)
A 9. Literature and advisories relevant to patient safety are available to all individuals
who work in the hospital.
A 10. Leaders define how members of the population(s) served can help identify and
manage issues of safety and quality within the hospital.
The hospital uses data and information to guide decisions and to understand variation in
the performance of processes supporting safety and quality.

A 1. Leaders set expectations for using data and information to improve the safety and
quality of care, treatment, and services.
A 3. The hospital uses processes to support systematic data and information use.
A 4. Leaders provide the resources needed for data and information use, including
staff, equipment, and information systems.
A 5. The hospital uses data and information in decision making that supports the
safety and quality of care, treatment, and services. (See also NR.02.01.01, EPs 3
and 6; PI.02.01.01, EP 8)
A 6. The hospital uses data and information to identify and respond to internal and
external changes in the environment.
A 7. Leaders evaluate how effectively data and information are used throughout the
hospital.
Leaders use hospitalwide planning to establish structures and processes that focus on
safety and quality.

A 1. Planning activities focus on improving patient safety and health care quality.
A 3. Planning is systematic, and it involves designated individuals and information
sources.
A 4. Leaders provide the resources needed to support the safety and quality of care,
A 5. Safety and quality planning is hospitalwide.
A 6. Planning activities adapt to changes in the environment.
A 7. Leaders evaluate the effectiveness of planning activities.
The hospital communicates information related to safety and quality to those who need
it, including staff, licensed independent practitioners, patients, families, and external
interested parties.

A 1. Communication processes foster the safety of the patient and the quality of care.
A 3. Communication is designed to meet the needs of internal and external users.
A 4. Leaders provide the resources required for communication, based on the needs of
patients, the community, physicians, staff, and management.
A 5. Communication supports safety and quality throughout the hospital. (See also
LD.04.04.05, EPs 6 and 12)
A 6. When changes in the environment occur, the hospital communicates those
changes effectively.
A 7. Leaders evaluate the effectiveness of communication methods.
Leaders implement changes in existing processes to improve the performance of the
hospital.

A 1. Structures for managing change and performance improvements exist that foster
the safety of the patient and the quality of care, treatment, and services.
A 3. The hospital has a systematic approach to change and performance improvement.
A 4. Leaders provide the resources required for performance improvement and change
management, including sufficient staff, access to information, and training.
A 5. The management of change and performance improvement supports both safety
and quality throughout the hospital.
A 6. The hospital’s internal structures can adapt to changes in the environment.
A 7. Leaders evaluate the effectiveness of processes for the management of change and
performance improvement. (See also PI.02.01.01, EP 13)
Those who work in the hospital are focused on improving safety and quality.

A 1. Leaders design work processes to focus individuals on safety and quality issues.
A 3. Leaders provide for a sufficient number and mix of individuals to support safe,
quality care, treatment, and services. (See also IC.01.01.01, EP 3)
Note: The number and mix of individuals is appropriate to the scope and complexity
of the services offered.
A 4. Those who work in the hospital are competent to complete their assigned
responsibilities.
A 5. Those who work in the hospital adapt to changes in the environment.
A 6. Leaders evaluate the effectiveness of those who work in the hospital to promote
safety and quality.
The hospital complies with law and regulation.

A 1. The hospital is licensed, is certified, or has a permit, in accordance with law
and regulation, to provide the care, treatment, or services for which the hospital
is seeking accreditation from The Joint Commission.
Note: Each service location that performs laboratory testing (waived or nonwaived)
must have a Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88)
certificate§ as specified by the federal CLIA regulations (42 CFR 493.55 and 493.3)
and applicable state law. (See also WT.01.01.01, EP 1; WT.04.01.01, EP 1)
A 2. The hospital provides care, treatment, and services in accordance with licensure
requirements, laws, and rules and regulations.
A 3. Leaders act on or comply with reports or recommendations from external
authorized agencies, such as accreditation, certification, or regulatory bodies.
A 16. For psychiatric hospitals that use Joint Commission accreditation for deemed
status purposes:
n The psychiatric hospital is primarily engaged in providing, by or under the
supervision of a doctor of medicine or osteopathy, psychiatric services for the

diagnosis and treatment of mentally ill persons.
n The psychiatric hospital meets the hospital conditions of participation
specified in 42 CFR 482.1 through 482.23, and 42 CFR 482.25 through

482.57.
n The psychiatric hospital maintains clinical records on all patients to
determine the degree and intensity of treatments, as specified in 42 CFR

482.61.
n The psychiatric hospital meets the staffing requirements specified in 42 CFR
482.62.
A 17. For hospitals that use Joint Commission accreditation for deemed status
purposes: The hospital has a utilization review plan consistent with 42 CFR
482.30 that provides for review of services furnished by the hospital and the
medical staff to patients entitled to benefits under the Medicare and Medicaid
programs.
Note 1: The hospital does not need to have a utilization review plan if either a
Quality Improvement Organization (QIO) has assumed binding review for the
hospital or the Centers for Medicare & Medicaid Services (CMS) has determined that
the utilization review procedures established by the state under title XIX of the Social
§
For more information on how to obtain a CLIA certificate, see http://www.cms.gov/Regu-
lations-and-Guidance/Legislation/CLIA/
How_to_Apply_for_a_CLIA_Certificate_International_Laboratories.html.
Security Act are superior to the procedures required in this section, and has required
hospitals in that state to meet the utilization review plan requirements under 42 CFR
456.50 through 42 CFR 456.245.
Note 2: For guidance regarding the requirements at 42 CFR 482.30, refer to the
“Medicare Requirements for Hospitals” appendix.
purposes: Utilization review activities are implemented by the hospital in
accordance with the plan.
Note 1: The hospital does not need to implement utilization review activities itself if
either a Quality Improvement Organization (QIO) has assumed binding review for
the hospital or the Centers for Medicare & Medicaid Services (CMS) has determined
that the utilization review procedures established by the state under title XIX of the
Social Security Act are superior to the procedures required in this section, and has
required hospitals in that state to meet the utilization review plan requirements under
42 CFR 456.50 through 42 CFR 456.245.
Note 2: For guidance regarding the requirements at 42 CFR 482.30, refer to the
“Medicare Requirements for Hospitals” appendix.
The hospital effectively manages its programs, services, sites, or departments.

A 4. Staff are held accountable for their responsibilities.
Leaders establish priorities for performance improvement. (Refer to the “Performance
Improvement” [PI] chapter.)

A 1. Leaders set priorities for performance improvement activities and patient health
outcomes. (See also PI.01.01.01, EPs 1 and 3)
A 2. Leaders give priority to high-volume, high-risk, or problem-prone processes for
performance improvement activities. (See also PI.01.01.01, EPs 4, 6-8, 11-12,
and 14-15)
A 3. Leaders reprioritize performance improvement activities in response to changes in
the internal or external environment.
A 4. Performance improvement occurs hospitalwide.
A 5. For hospitals that elect The Joint Commission Primary Care Medical Home
option: Ongoing performance improvement occurs hospitalwide for the purpose
of demonstrably improving the quality and safety of care, treatment, or services.
option: The interdisciplinary team actively participates in performance improve-
ment activities.
option: Leaders involve patients in performance improvement activities.
Note: Patient involvement may include activities such as participating on a quality
committee or providing feedback on safety and quality issues.
A 25. Senior hospital leadership directs implementation of selected hospitalwide
improvements in emergency management based on the following:
n Review of the annual emergency management planning reviews (See also
EM.03.01.01, EP 4)
n Review of the evaluations of all emergency response exercises and all responses
to actual emergencies (See also EM.03.01.03, EP 15)

n Determination of which emergency management improvements will be
prioritized for implementation, recognizing that some emergency manage-

ment improvements might be a lower priority and not taken up in the near
term
The hospital has an organizationwide, integrated patient safety program within its
performance improvement activities.

A 1. The leaders implement a hospitalwide patient safety program.
A 2. One or more qualified individuals or an interdisciplinary group manages the

safety program.
A 3. The scope of the safety program includes the full range of safety issues, from
potential or no-harm errors (sometimes referred to as near misses, close calls, or
good catches) to hazardous conditions and sentinel events.
A 4. All departments, programs, and services within the hospital participate in the
safety program.
A 5. As part of the safety program, the leaders create procedures for responding to
system or process failures.
Note: Responses might include continuing to provide care, treatment, and services to
those affected, containing the risk to others, and preserving factual information for
subsequent analysis.
A 6. The leaders provide and encourage the use of systems for blame-free internal
reporting of a system or process failure, or the results of a proactive risk
assessment. (See also LD.03.01.01, EP 8; LD.03.04.01, EP 5; LD.04.04.03,
EP 3; PI.01.01.01, EP 8)
Note: This EP is intended to minimize staff reluctance to report errors in order to
help an organization understand the source and results of system and process failures.
The EP does not conflict with holding individuals accountable for their blameworthy
errors.
A 7. The leaders define patient safety event and communicate this definition
throughout the organization.
Note: At a minimum, the organization’s definition includes those events subject to
review in the “Sentinel Events” (SE) chapter of this manual. The definition may
include any process variation that does not affect the outcome or result in an adverse
event, but for which a recurrence carries significant chance of a serious adverse
outcome or result in an adverse event, often referred to as a close call or near miss.
A 8. The hospital conducts thorough and credible comprehensive systematic analyses
(for example, root cause analyses) in response to sentinel events as described in
the “Sentinel Events” (SE) chapter of this manual.
A 9. The leaders make support systems available for staff who have been involved in an
adverse or sentinel event.
Note: Support systems recognize that conscientious health care workers who are
involved in sentinel events are themselves victims of the event and require support.
Support systems provide staff with additional help and support as well as additional
resources through the human resources function or an employee assistance program.
Support systems also focus on the process rather than blaming the involved individuals.
A 10. At least every 18 months, the hospital selects one high-risk process and conducts
a proactive risk assessment. (See also LD.04.04.03, EP 3)
Note: For suggested components, refer to the Proactive Risk Assessment section at the
beginning of this chapter.
A 11. To improve safety and to reduce the risk of medical errors, the hospital analyzes
and uses information about system or process failures and the results of proactive
risk assessments. (See also LD.04.04.03, EP 3)
A 12. The leaders disseminate lessons learned from comprehensive systematic analyses
(for example, root cause analyses), system or process failures, and the results of
proactive risk assessments to all staff who provide services for the specific
situation. (See also LD.03.04.01, EP 5)
A 13. At least once a year, the leaders provide governance with written reports on
the following:
n All system or process failures
n The number and type of sentinel events
n Whether the patients and the families were informed of the event
n All actions taken to improve safety, both proactively and in response to actual
occurrences
n For hospitals that use Joint Commission accreditation for deemed status
purposes: The determined number of distinct improvement projects to be

conducted annually
n All results of the analyses related to the adequacy of staffing (See also
PI.02.01.01, EP 14)
A 14. The leaders encourage external reporting of significant adverse events, including
voluntary reporting programs in addition to mandatory programs.
Note: Examples of voluntary programs include The Joint Commission Sentinel Event
Database and the US Food and Drug Administration (FDA) MedWatch. Mandatory
programs are often state initiated.
Medication Management (MM)
Standard MM.07.01.03
The hospital responds to actual or potential adverse drug events, significant adverse drug
reactions, and medication errors.
Elements of Performance for MM.07.01.03

C 3. The hospital complies with internal and external reporting requirements for
actual or potential adverse drug events, significant adverse drug reactions, and
medication errors.
Note: This element of performance is also applicable to sample medications.
Standard MM.08.01.01
The hospital evaluates the effectiveness of its medication management system.
Note: This evaluation includes reconciling medication information. (Refer to
NPSG.03.06.01 for more information)
Elements of Performance for MM.08.01.01

A 1. The hospital collects data on the performance of its medication management
system. (See also PI.01.01.01, EPs 14 and 15)
A 2. The hospital analyzes data on its medication management system.

A 3. The hospital compares data over time to identify risk points, levels of
performance, patterns, trends, and variations of its medication management
system.
A 4. The hospital reviews the literature and other external sources for new tech-
nologies and best practices.
A 5. Based on analysis of its data, as well as review of the literature for new
technologies and best practices, the hospital identifies opportunities for improve-
ment in its medication management system.
A 6. The hospital takes action on improvement opportunities identified as priorities
for its medication management system. (Refer to PI.03.01.01, EP 2)
A 7. The hospital evaluates its actions to confirm that they resulted in improvements
for its medication management system.
A 8. The hospital takes additional action when planned improvements for its
medication management processes are either not achieved or not sustained.
Medical Staff (MS)

Standard MS.08.01.01
The organized medical staff defines the circumstances requiring monitoring and
evaluation of a practitioner’s professional performance.
Elements of Performance for MS.08.01.01

A 1. A period of focused professional practice evaluation is implemented for all
initially requested privileges.
A 2. The organized medical staff develops criteria to be used for evaluating the
performance of practitioners when issues affecting the provision of safe, high
quality patient care are identified.
A 3. The performance monitoring process is clearly defined and includes each of
the following elements:
n Criteria for conducting performance monitoring
n Method for establishing a monitoring plan specific to the requested privilege
n Method for determining the duration of performance monitoring
n Circumstances under which monitoring by an external source is required
A 4. Focused professional practice evaluation is consistently implemented in accord-

ance with the criteria and requirements defined by the organized medical staff.
A 5. The triggers that indicate the need for performance monitoring are clearly
defined.
Note: Triggers can be single incidents or evidence of a clinical practice trend.
A 6. The decision to assign a period of performance monitoring to further assess
current competence is based on the evaluation of a practitioner’s current clinical
competence, practice behavior, and ability to perform the requested privilege.
Note: Other existing privileges in good standing should not be affected by this
decision.
A 7. Criteria are developed that determine the type of monitoring to be conducted.
A 8. The measures employed to resolve performance issues are clearly defined.
A 9. The measures employed to resolve performance issues are consistently im-
plemented.
Standard MS.09.01.01
The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on
reported concerns regarding a privileged practitioner’s clinical practice and/or com-
petence.
Elements of Performance for MS.09.01.01

A 1. The hospital, based on recommendations by the organized medical staff and
approval by the governing body, has a clearly defined process for collecting,
investigating, and addressing clinical practice concerns. (See also RI.01.07.01, EPs
1, 2, 4, 6, 7, and 10)
A 2. Reported concerns regarding a privileged practitioner’s professional practice are
uniformly investigated and addressed, as defined by the hospital and applicable
law.
Nursing (NR)
Standard NR.01.01.01
The nurse executive directs the delivery of nursing care, treatment, and services.
Elements of Performance for NR.01.01.01

A 2. The nurse executive has the authority to speak on behalf of nursing to the same
extent that other hospital leaders speak for their respective disciplines, depart-
ments, or service lines. (See also LD.01.02.01, EP 1 and LD.02.01.01, EP 1)
The nurse executive directs the hospital’s nursing services.

A 3. The nurse executive coordinates: The development of an effective, ongoing
program to measure, analyze, and improve the quality of nursing care, treatment,
and services. (See also LD.03.02.01, EP 5)
A 5. The nurse executive directs: The implementation of hospitalwide programs,
policies, and procedures that address how nursing care needs of the patient
population are assessed, met, and evaluated. (See also LD.04.04.07, EP 1)
Note: Examples of patient populations include pediatric, diabetic, and geriatric
patients.
A 6. The nurse executive directs: The implementation of an effective, ongoing
program to measure, analyze, and improve the quality of nursing care, treatment,
and services. (See also LD.03.02.01, EP 5)
The nurse executive establishes guidelines for the delivery of nursing care, treatment,
and services.

A 5. The nurse executive, registered nurses, and other designated nursing staff
write: Standards to measure, assess, and improve patient outcomes.
Provision of Care, Treatment, and Services (PC)

Standard PC.03.05.19
For hospitals that use Joint Commission accreditation for deemed status purposes: The
hospital reports deaths associated with the use of restraint and seclusion.
Elements of Performance for PC.03.05.19
purposes: The hospital reports the following information to the Centers for
Medicare & Medicaid Services (CMS) regarding deaths related to restraint or
seclusion (this requirement does not apply to deaths related to the use of soft
wrist restraints; for more information, refer to EP 3 in this standard):
n Each death that occurs while a patient is in restraint or seclusion
n Each death that occurs within 24 hours after the patient has been removed
from restraint or seclusion

n Each death known to the hospital that occurs within one week after restraint
or seclusion was used when it is reasonable to assume that the use of the
restraint or seclusion contributed directly or indirectly to the patient’s death.
The types of restraints included in this reporting requirement are all restraints
except soft wrist restraints.
Note: In this element of performance “reasonable to assume” includes, but is not
limited to, deaths related to restrictions of movement for prolonged periods of time or
deaths related to chest compression, restriction of breathing, or asphyxiation.
purposes: The deaths addressed in PC.03.05.19, EP 1, are reported to the
Centers for Medicare & Medicaid Services (CMS) by telephone, by facsimile, or
electronically no later than the close of the next business day following
knowledge of the patient’s death. The date and time that the patient’s death was
reported is documented in the patient’s medical record.
purposes: When no seclusion has been used and when the only restraints used on
the patient are wrist restraints composed solely of soft, non-rigid, cloth-like
material, the hospital does the following:
n Records in a log or other system any death that occurs while a patient is in
restraint. The information is recorded within seven days of the date of death
of the patient.
n Records in a log or other system any death that occurs within 24 hours after a
patient has been removed from such restraints. The information is recorded
within seven days of the date of death of the patient.
n Documents in the patient record the date and time that the death was
recorded in the log or other system
n Documents in the log or other system the patient’s name, date of birth, date
of death, name of attending physician or other licensed independent
practitioner responsible for the care of the patient, medical record number,
and primary diagnosis(es)||
n Makes the information in the log or other system available to CMS, either
electronically or in writing, immediately upon request
Performance Improvement (PI)

Standard PI.01.01.01
The hospital collects data to monitor its performance.
Elements of Performance for PI.01.01.01

A 1. The leaders set priorities for data collection. (See also LD.04.04.01, EP 1)
A 2. The leaders identify the frequency for data collection.
Note: For hospitals that use Joint Commission accreditation for deemed status
purposes: The leaders that specify the frequency and detail of data collection is the
governing body.
The hospital collects data on the following:
A 3. Performance improvement priorities identified by leaders. (See also
LD.04.04.01, EP 1)
A 4. Operative or other procedures that place patients at risk of disability or
death. (See also LD.04.04.01, EP 2; MS.05.01.01, EP 6)
A 5. All significant discrepancies between preoperative and postoperative
diagnoses, including pathologic diagnoses.
A 6. Adverse events related to using moderate or deep sedation or anesthesia.
(See also LD.04.04.01, EP 2)
A 7. The use of blood and blood components. (See also LD.04.04.01, EP 2)
||
For law and regulation guidance pertaining to those responsible for the care of the patient, refer to 42
CFR 482.12(c).
A 8. All reported and confirmed transfusion reactions. (See also LD.04.04.01,
EP 2; LD.04.04.05, EP 6)
A 11. The results of resuscitation. (See also LD.04.04.01, EP 2)
A 12. Behavior management and treatment. (See also LD.04.04.01, EP 2)
A 14. Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01,

EP 1)
A 15. Significant adverse drug reactions. (See also LD.04.04.01, EP 2;
MM.08.01.01, EP 1)
A 16. Patient perception of the safety and quality of care, treatment, or services.
A 30. The hospital considers collecting data on the following:

n Staff opinions and needs
n Staff perceptions of risk to individuals
n Staff suggestions for improving patient safety
n Staff willingness to report adverse events
A 38. The hospital evaluates the effectiveness of all fall reduction activities including
assessment, interventions, and education.
Note: Examples of outcome indicators to use in the evaluation include number of falls
and number and severity of fall-related injuries.
A 39. The hospital collects data on the effectiveness of its response to change or
deterioration in a patient’s condition.
Note: Measures may include length of stay, response time for responding to changes in
vital signs, cardiopulmonary arrest, respiratory arrest, and mortality rates before and
after implementation of an early intervention plan.
For hospitals that elect The Joint Commission Primary Care Medical Home option: The
primary care medical home collects data on the following:
A 40. Disease management outcomes.
A 41. Patient access to care within time frames established by the hospital.
option: The primary care medical home collects data on the following:
n Patient experience and satisfaction related to access to care, treatment, or
services, and communication

n Patient perception of the comprehensiveness of care, treatment, or services
n Patient perception of the coordination of care, treatment, or services
n Patient perception of the continuity of care, treatment, or services
(Refer to PI.01.01.01, EP 16)
A 46. The hospital collects data on patient thermal injuries that occur during magnetic
resonance imaging exams.
A 47. The hospital collects data on the following:
n Incidents where ferromagnetic objects unintentionally entered the magnetic
resonance imaging (MRI) scanner room
n Injuries resulting from the presence of ferromagnetic objects in the MRI
scanner room
The hospital compiles and analyzes data.

C 1. The hospital compiles data in usable formats.
A 2. The hospital identifies the frequency for data analysis.
C 3. The hospital uses statistical tools and techniques to analyze and display data.
A 4. The hospital analyzes and compares internal data over time to identify levels of
performance, patterns, trends, and variations.
A 5. The hospital compares data with external sources, when available.
A 6. The hospital reviews and analyzes incidents where the radiation dose index
(computed tomography dose index [CTDIvol], dose length product [DLP], or
size-specific dose estimate [SSDE]) from diagnostic CT examinations exceeded
expected dose index ranges identified in imaging protocols. These incidents are
then compared to external benchmarks.
Note 1: While the CTDIvol, DLP, and SSDE are useful indicators for monitoring
radiation dose indices from the CT machine, they do not represent the patient’s
radiation dose.
Note 2: This element of performance does not apply to dental cone beam CT
radiographic imaging studies performed for diagnosis of conditions affecting the
maxillofacial region or to obtain guidance for the treatment of such conditions.
A 7. The hospital analyzes its organ procurement conversion rate data as provided by
the organ procurement organization (OPO). (See also TS.01.01.01, EP 1)
Note: Conversion rate is defined as the number of actual organ donors over the
number of eligible donors defined by the OPO, expressed as a percentage.
A 8. The hospital uses the results of data analysis to identify improvement
opportunities. (See also LD.03.02.01, EP 5; PI.03.01.01, EP 1)
A 12. When the hospital identifies undesirable patterns, trends, or variations in its
performance related to the safety or quality of care (for example, as identified in
the analysis of data or a single undesirable event), it includes the adequacy of
staffing, including nurse staffing, in its analysis of possible causes.
Note 1: Adequacy of staffing includes the number, skill mix, and competency of all
staff. In their analysis, hospitals may also wish to examine issues such as processes
related to work flow; competency assessment; credentialing; supervision of staff; and
orientation, training, and education.
Note 2: Hospitals may find value in using the staffing effectiveness indicators (which
include National Quality Forum Nursing Sensitive Measures) to help identify
potential staffing issues. (Refer to the “Staffing Effectiveness Indicators” (SEI) chapter)
A 13. When analysis reveals a problem with the adequacy of staffing, the leaders
responsible for the hospitalwide patient safety program (as addressed at
LD.04.04.05, EP 1) are informed, in a manner determined by the safety
program, of the results of this analysis and actions taken to resolve the identified
problem(s). (See also LD.03.05.01, EP 7)
A 14. At least once a year, the leaders responsible for the hospitalwide patient safety
program review a written report on the results of any analyses related to the
adequacy of staffing and any actions taken to resolve identified problems. (See
also LD.04.04.05, EP 13)
The hospital improves performance on an ongoing basis.

A 1. Leaders prioritize the identified improvement opportunities. (See also
PI.02.01.01, EP 8; MS.05.01.01, EPs 1-11)
A 2. The hospital takes action on improvement priorities. (See also MS.05.01.01, EPs
1-11)
A 3. The hospital evaluates actions to confirm that they resulted in improvements.
(See also MS.05.01.01, EPs 1-11)
A 4. The hospital takes action when it does not achieve or sustain planned
improvements. (See also MS.05.01.01, EPs 1-11)
option: The primary care medical home uses the data it collects on the patient’s
perception of the safety and quality of care, treatment, or services to improve its
performance. This data includes the following:
n Patient experience and satisfaction related to access to care, treatment, or
services and communication

n Patient perception of the comprehensiveness of care, treatment, or services
n Patient perception of the coordination of care, treatment, or services
n Patient perception of the continuity of care, treatment, or services
Rights and Responsibilities of the Individual

(RI)
Standard RI.01.01.01
The hospital respects, protects, and promotes patient rights.
Elements of Performance for RI.01.01.01

A 1. The hospital has written policies on patient rights.
Note: For hospitals that use Joint Commission accreditation for deemed status
purposes: The hospital’s written policies address procedures regarding patient
visitation rights, including any clinically necessary or reasonable restrictions or
limitations.
A 2. The hospital informs the patient of his or her rights. (See also RI.01.01.03, EPs 1-
3)
Note 1: For hospitals that use Joint Commission accreditation for deemed status
purposes: The hospital informs the patient (or support person, where appropriate) of
his or her visitation rights. Visitation rights include the right to receive the visitors
designated by the patient, including, but not limited to, a spouse, a domestic partner
(including a same-sex domestic partner), another family member, or a friend. Also
included is the right to withdraw or deny such consent at any time.
purposes: The hospital makes sure that each patient, or his or her family, is informed
of the patient’s rights in advance of furnishing or discontinuing patient care whenever
possible.
C 4. The hospital treats the patient in a dignified and respectful manner that supports
his or her dignity.
C 5. The hospital respects the patient’s right to and need for effective communication.
(See also RI.01.01.03, EP 1)
C 6. The hospital respects the patient’s cultural and personal values, beliefs, and
preferences.
C 7. The hospital respects the patient’s right to privacy. (See also IM.02.01.01, EPs 1–
5)
Note 1: This element of performance (EP) addresses a patient’s personal privacy. For
EPs addressing the privacy of a patient’s health information, please refer to Standard
IM.02.01.01.
purposes and have swing beds: The resident’s right to privacy includes privacy and
confidentiality of his or her personal records and written communications, including
the right to send and receive mail promptly.
A 8. The hospital respects the patient’s right to pain management. (See also
HR.01.04.01, EP 4; PC.01.02.07, EP 1; MS.03.01.03, EP 2)
C 9. The hospital accommodates the patient’s right to religious and other spiritual
services.
A 10. The hospital allows the patient to access, request amendment to, and obtain
information on disclosures of his or her health information, in accordance with
law and regulation.
A 28. The hospital allows a family member, friend, or other individual to be present
with the patient for emotional support during the course of stay.
Note: The hospital allows for the presence of a support individual of the patient’s
choice, unless the individual’s presence infringes on others’ rights, safety, or is
medically or therapeutically contraindicated. The individual may or may not be the
patient’s surrogate decision-maker or legally authorized representative. (For more
information on surrogate or family involvement in patient care, treatment, and
services, refer to RI.01.02.01, EPs 6-8.)
A 29. The hospital prohibits discrimination based on age, race, ethnicity, religion,
culture, language, physical or mental disability, socioeconomic status, sex, sexual
orientation, and gender identity or expression.
The hospital respects the patient’s right to receive information in a manner he or she
understands.

C 1. The hospital provides information in a manner tailored to the patient’s age,
language, and ability to understand. (See also PC.02.01.21, EP 2; PC.04.01.05,
EP 8; RI.01.01.01, EPs 2 and 5)
C 2. The hospital provides language interpreting and translation services. (See also
HR.01.02.01, EP 1; PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)
Note: Language interpreting options may include hospital-employed language
interpreters, contract interpreting services, or trained bilingual staff. These options
may be provided in person or via telephone or video. The hospital determines which
translated documents and languages are needed based on its patient population.
C 3. The hospital provides information to the patient who has vision, speech, hearing,
or cognitive impairments in a manner that meets the patient’s needs. (See also
PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)
The hospital respects the patient’s right to participate in decisions about his or her care,
Note: For hospitals that use Joint Commission accreditation for deemed status purposes:
This right is not to be construed as a mechanism to demand the provision of treatment or
services deemed medically unnecessary or inappropriate.

A 1. The hospital involves the patient in making decisions about his or her care,
treatment, and services, including the right to have his or her family and
physician promptly notified of his or her admission to the hospital.
A 2. The hospital provides the patient with written information about the right to
refuse care, treatment, and services.
A 3. The hospital respects the patient’s right to refuse care, treatment, and services, in
accordance with law and regulation.
A 6. When a patient is unable to make decisions about his or her care, treatment, and
services, the hospital involves a surrogate decision-maker in making these
decisions. (See also RI.01.03.01, EP 6)
A 7. When a surrogate decision-maker is responsible for making care, treatment, and
services decisions, the hospital respects the surrogate decision-maker’s right to
refuse care, treatment, and services on the patient’s behalf, in accordance with law
and regulation.
A 8. The hospital involves the patient’s family in care, treatment, and services
decisions to the extent permitted by the patient or surrogate decision-maker, in
A 20. The hospital provides the patient or surrogate decision-maker with the
information about the outcomes of care, treatment, and services that the patient
needs in order to participate in current and future health care decisions.
A 21. The hospital informs the patient or surrogate decision-maker about unanticipated
outcomes of care, treatment, and services that relate to sentinel events as defined
by The Joint Commission. (Refer to the Glossary for a definition of sentinel
event.)
A 22. The licensed independent practitioner responsible for managing the patient’s
care, treatment, and services, or his or her designee, informs the patient about
unanticipated outcomes of care, treatment, and services related to sentinel events
when the patient is not already aware of the occurrence or when further
discussion is needed.
Note: In settings where there is no licensed independent practitioner, the staff member
responsible for managing the care of the patient is responsible for sharing information
about such outcomes.
option: The primary care medical home respects the patient’s right to make
decisions about the management of his or her care.
option: The primary care medical home respects the patient’s right and provides
the patient the opportunity to do the following:
n Obtain care from other clinicians of the patient’s choosing within the primary
care medical home

n Seek a second opinion from a clinician of the patient’s choosing
n Seek specialty care
Note: This element of performance does not imply financial responsibility for any
activities associated with these rights. (Refer to LD.04.02.03, EP 7)
The hospital honors the patient’s right to give or withhold informed consent.

A 1. The hospital has a written policy on informed consent.
A 2. The hospital’s written policy identifies the specific care, treatment, and services
that require informed consent, in accordance with law and regulation.
A 3. The hospital’s written policy describes circumstances that would allow for
exceptions to obtaining informed consent.
A 4. The hospital’s written policy describes the process used to obtain informed
consent.
A 5. The hospital’s written policy describes how informed consent is documented in
the patient record.
Note: Documentation may be recorded in a form, in progress notes, or elsewhere in
the record.
A 6. The hospital’s written policy describes when a surrogate decision-maker may give
informed consent. (See also RI.01.02.01, EP 6)
A 7. The informed consent process includes a discussion about the patient’s proposed
care, treatment, and services.
A 9. The informed consent process includes a discussion about potential benefits,
risks, and side effects of the patient’s proposed care, treatment, and services; the
likelihood of the patient achieving his or her goals; and any potential problems
that might occur during recuperation.
A 11. The informed consent process includes a discussion about reasonable alternatives
to the patient’s proposed care, treatment, and services. The discussion en-
compasses risks, benefits, and side effects related to the alternatives and the risks
related to not receiving the proposed care, treatment, and services.
A 12. The informed consent process includes a discussion about any circumstances
under which information about the patient must be disclosed or reported.
Note: Such circumstances may include requirements for disclosure of information
regarding cases of HIV, tuberculosis, viral meningitis, and other diseases that are
reported to organizations such as health departments or the Centers for Disease
Control and Prevention.
C 13. Informed consent is obtained in accordance with the hospital’s policy and
processes and, except in emergencies, prior to surgery. (See also RC.02.01.01,
EP 4)
The hospital addresses patient decisions about care, treatment, and services received at
the end of life.

A 1. The hospital has written policies on advance directives, forgoing or
withdrawing life-sustaining treatment, and withholding resuscitative services, in
A 4. For outpatient hospital settings: The hospital’s written advance directive policies
specify whether the hospital will honor advance directives.
Note: It is up to the hospital to determine in which of its outpatient settings, if any, it
will honor advance directives.
C 5. The hospital implements its advance directive policies.
C 6. The hospital provides patients with written information about advance

directives, forgoing or withdrawing life-sustaining treatment, and withholding
resuscitative services.
C 8. Upon admission, the hospital provides the patient with information on the extent
to which the hospital is able, unable, or unwilling to honor advance directives.
C 9. The hospital documents whether or not the patient has an advance
directive.
C 10. Upon request, the hospital refers the patient to resources for assistance in
formulating advance directives.
C 11. Staff and licensed independent practitioners who are involved in the patient’s
care, treatment, and services are aware of whether or not the patient has an
advance directive. (See also RC.02.01.01, EP 4)
A 12. The hospital honors the patient’s right to formulate or review and revise his or
her advance directives.
A 13. The hospital honors advance directives, in accordance with law and regulation
and the hospital’s capabilities.
C 15. The hospital documents the patient’s wishes concerning organ donation when
he or she makes such wishes known to the hospital or when required by the
hospital’s policy, in accordance with law and regulation.
C 16. The hospital honors the patient’s wishes concerning organ donation within the
limits of the hospital’s capability and in accordance with law and regulation.
A 17. The existence or lack of an advance directive does not determine the patient’s
right to access care, treatment, and services.
C 19. For outpatient hospital settings: The hospital communicates its policy on
advance directives upon request or when warranted by the care, treatment, and
services provided.
C 20. For outpatient hospital settings: Upon request, the hospital refers patients to
resources for assistance with formulating advance directives.
purposes: The hospital defines how it obtains and documents permission to
perform an autopsy.
The hospital informs the patient about his or her responsibilities related to his or her
care, treatment, and services.

A 1. The hospital has a written policy that defines patient responsibilities,
including but not limited to the following:
n Providing information that facilitates their care, treatment, and services
n Asking questions or acknowledging when he or she does not understand the
treatment course or care decision

n Following instructions, policies, rules, and regulations in place to support
quality care for patients and a safe environment for all individuals in the
hospital
n Supporting mutual consideration and respect by maintaining civil language
and conduct in interactions with staff and licensed independent practitioners

n Meeting financial commitments
C 2. The hospital informs the patient about his or her responsibilities in accordance
with its policy.
Note: Information about patient responsibilities can be shared verbally, in writing, or
both.

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Patient Safety Systems (PS)

What Does This Chapter Contain?

Sidebar 1. Key Terms to Understand

Note: It is impossible to determine if there are practical prevention or mitigation

Becoming a Learning Organization

Figure 1. The Trust-Report-Improve Cycle

In the trust-report-improve cycle, trust promotes reporting, which leads to improve-

A Fair and Just Safety Culture

Sidebar 2. Assessing Staff Accountability

Data Use and Reporting Systems

Effective Use of Data

Table 1. Defining and Comparing Analytical Tools

Tool When to Use Example

In the example above, the curve at the top of

A Proactive Approach to Preventing Harm

Sidebar 3. Strategies for an Effective Risk

Tools for Conducting a Proactive Risk Assessment

Encouraging Patient Activation

Beyond Accreditation: The Joint

Accreditation Participation Requirements

Elements of Performance for APR.09.01.01

Elements of Performance for APR.09.02.01

Environment of Care (EC)

Elements of Performance for EC.04.01.01

C 5. Incidents of damage to its property or the property of others. (See also

Human Resources (HR)

Infection Prevention and Control (IC)

Elements of Performance for IC.01.03.01

Elements of Performance for LD.02.01.01

Elements of Performance for LD.02.03.01

(See also NR.01.01.01, EP 3)

Elements of Performance for LD.02.04.01

Elements of Performance for LD.03.01.01

A 7. Leaders establish a team approach among all staff at all levels.

Elements of Performance for LD.03.02.01

Elements of Performance for LD.03.03.01

A 6. Planning activities adapt to changes in the environment.

A 7. Leaders evaluate the effectiveness of planning activities.

Elements of Performance for LD.03.04.01

A 3. Communication is designed to meet the needs of internal and external users.

Elements of Performance for LD.03.05.01

Elements of Performance for LD.03.06.01

Elements of Performance for LD.04.01.01

supervision of a doctor of medicine or osteopathy, psychiatric services for the

specified in 42 CFR 482.1 through 482.23, and 42 CFR 482.25 through

determine the degree and intensity of treatments, as specified in 42 CFR

Elements of Performance for LD.04.01.05

Elements of Performance for LD.04.04.01

to actual emergencies (See also EM.03.01.03, EP 15)

prioritized for implementation, recognizing that some emergency manage-

Elements of Performance for LD.04.04.05

A 2. One or more qualified individuals or an interdisciplinary group manages the

purposes: The determined number of distinct improvement projects to be

Elements of Performance for MM.07.01.03

Elements of Performance for MM.08.01.01

Note: This element of performance is also applicable to sample medications.

Medical Staff (MS)

Elements of Performance for MS.08.01.01

A 4. Focused professional practice evaluation is consistently implemented in accord-