Joint Commission: Patient Safety Standards

The Role of Hospital Leaders in Patient Safety

Hospital leaders provide the foundation for an effective patient safety system by doing the following:

  • Promoting learning
  • Motivating staff to uphold a fair and just safety culture
  • Providing a transparent environment in which quality measures and patient harms are freely shared with staff
  • Modeling professional behavior
  • Removing intimidating behavior that might prevent safe behaviors
  • Providing the resources and training necessary to take on improvement initiatives

Safety Culture

Staff and leaders that value transparency, accountability, and mutual respect.4

  • Safety as everyone’s first priority.4
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • By reporting and learning from patient safety events, staff create a learning organization.

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. 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 , 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.CAMH,, January 2017 PS – 9 Patient Safety Systems

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.Refer to Standard , which requires that staff are held accountable for their responsibilities.

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:

  • Collect information to monitor conditions in the environment
  • Identify risks for acquiring and transmitting infections
  • Use data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality
  • Have an organization wide, integrated patient safety program within their performance improvement activities
  • Evaluate the effectiveness of their medication management system
  • Report (if using Joint Commission accreditation for deemed status purposes) deaths associated with the use of restraint and seclusion
  • Collect data to monitor their performance
  • Improve performance on an ongoing basis

A Proactive Approach to Preventing Harm

  • Identification of actionable common causes
  • Avoidance of unintended consequences
  • Identification of commonalities across departments/services/units
  • Identification of system solutions

Encouraging Patient Activation

  • Patient safety guides all decision making.
  • Patients and families are partners at every level of care. n Patient- and family-centered care is verifiable, rewarded, and celebrated.
  • 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.
  • 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.
  • Staffing levels are sufficient, and staff has the necessary tools and skills. n The hospital has a focus on measurement, learning, and improvement.
  • 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.



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