Running head: JOINT COMMISSION 1

Patient Safety/Health Outcomes Organization Paper

Elaine Dean

Jacksonville University

NUR 533

February 3, 2017
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Patient Safety/Health Outcomes Organization Paper

Introduction

The Joint Commission is an independent U. S. based organization that accredits, evaluate,

measure, and share best practice in quality and safety with all categories of the nation health care

system. Located in Oakbrook Terrace Illinois it is the largest and most prestigious organization

providing innovative solutions, leadership and standard-setting services (Joint Commission,

2017).

Overview of the Organization

The Joint Commission has become a staple in the health care industry. Affectionately

known as “Jayco” the Joint Commission is the oldest and largest patient safety organization. Its

history is founded on providing the highest quality of patient care. In 1910 Dr. Ernest Codman

proposed the “end result” system of hospital standardization, under this program a hospital

would track each patient to determine the effectiveness of the treatment that was provided if it

was not effective then it would be evaluated and changed to provide the highest positive patient

outcome. During this period the conditions in health care were appalling so at the urging of a

colleague Dr. Codman founded the America College of Surgeons (ACS). The “end result”

system then became an important part of the ACS. The ACS proceeded to develop the Minimum

Standards for Hospitals and began on-site inspections of hospitals in the 1918s. The ACS

continued its tenure until 1951 when the American College of Physicians, the American Medical

Association, and the Canadian Medical Association joined with the ACS as corporate members

to create the Joint Commission on Accreditation of Hospitals (JCAH). In 1965 congress passed

the Social Security Amendment with a provision that hospitals accredited by JCHA are in

compliance with Medicare conditions of participation and are thereby able to participate in
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Medicare and Medicaid programs (Joint Commission, 2010). The organization had several

modifications of its name over the past six decades but in 2007 it simplified its name to The Joint

Commission. The Joint Commission bases its mission and vision statement on patient safety. Its

mission is to “continuously improve health care for the public, in collaboration with

stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing

safe and effective care of the highest quality and value”. The vision is that “all people always

experience the safest, quality, best-value health care across all settings” (Joint Commission,

2017). The Joint Commission governing body is its Board of Commissioners, this panel consist

of thirty-two members which include doctors, nurses, employees, quality experts, a consumer

advocate, and educators. This diverse leadership also participates in other subcommittees and

liaison groups including the Nursing Advisory Council.

Review of the Current Literature on The Joint Commission

An in-depth review of the literature showed a significant concentration on the Joint

Commission National Patient Safety Goals (NPSGs) program. This was established in 2002 with

the first set effective January 1, 2003. The NPSGs were established to help accredited

organization address specific areas of concern in regards to patient safety. The development of

the NPSGs is by a panel of experts who actively advises the Joint Commission. This panel is

known as the Patient safety Advisory Board, and in conjunction with the Sentinel Advisory

Group and Joint Commission staffers work closely together to establish these standards. The

experts on this panel have hands-on experience in addressing patient safety issues in a wide

variety of health care fields and settings. The expectation of the NPSGs is to create a safe

environment, and compliance with these goals is mandatory for facilities whose plan is to

become accredited. In the late 1990s, the Joint Commission began reviewing unexpected
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outcome that resulted in physical or psychological injury, loss of limb or function and or death.

A few years later the Institute of Medicine (IOM) increase its national focus on patient safety

with its publications: To Err is Human, Building a Safer Healthcare system, Crossing the Quality

Chasm: A New Health System for the 21st Century and Patient Safety: Achieving a New

Standard. These writings took a bold stand in calling for a national infrastructure designed to

share patient safety information and foster the safe delivery of care. The Joint Commission has

shown leadership in providing continued guidance with the NPSGs not only outlining these goals

but adds implementation expectation and rationale for each goal. Each year the joint Commission

issues the new NPSGs, it does not disrupt the sequential numbering methodology of each goal,

this means that if a goal is retired or eliminated then that number will never be used again. The

goals are derived in part from risk data collected through the Sentinel Event Alert Program and

are specific to each organizational category. The current 216 National Patient Safety Goals are:

identify patient correctly, improve staff communication, prevent infection, identify patient safety

risk, prevent mistakes in surgery, and use alarms safely.

Impact of the Joint Commission on Patient Safety/Health Outcome

The Joint Commission signature initiative, the NPSGs have greatly improved the quality

and safety of patient care. Implementing the goals have proved challenging for many

organization but the long-term benefit to patient quality and safety cannot be denied. Nurses

have woven the NPSGs in their daily practice on all units all over the country and the world.

These goals have help nurses change and improve how to identify patients, prepare them for

surgery, monitor their care and protect then from preventable adverse events, such as falls and

infections. The Joint Commission promotes a systematic strategy for the assessment of data

regarding sentinel events if and when they do happen. This process is known as root cause
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analysis. It is an effective way of organizing information and identifying causal factors. This

process is uniquely designed to find causes over which management has control. There are

several root causes of sentinel events and the three most frequent causes of errors are

communication, patient assessment, and procedural compliance. Other significant impacts the

Joint Commission has had on health care are certification services, accreditation services, setting

quality standards, evaluating organizational performance, transforming healthcare, advancing

safety and quality, providing information to consumers, providing supportive services, and

having a global impact. The international arm of TJC known as the JCI is also actively providing

worldwide accreditation, consultation, and educational programs. It assists the international

communities to improve the quality of patient care by engaging healthcare organizations, public

health agencies, and ministries of health to evaluate, improve, and implement quality of care and

safety measures. The ultimate goal of TJC and the JCI is to intentionally improve patient

outcome as it seeks to inspire and improve the safe effective care of the highest quality.

Future Considerations

The future of The Joint Commission is embedded in its mission statement. The functional

goal is to promote continuous improvement in health care quality and patient safety. The Joint

Commission conscious awareness of its patient safety goals emerged in the 1990s, it expanded

its advocacy potential for patient safety legislation which was enacted by congress creating the

Patient Safety Organization. The Joint Commission International collaborated with the World

Health Organization to initiate a broader world alliance for patient safety. Quality and safety is

the Joint Commission greatest asset, widely applauded and commands attention. The statistics

also show that Joint Commission standards relate directly to improved patient safety and quality

of care.
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Conclusion

Through the years the Joint Commission has become a recognized leader with a

distinguish mission-related portfolio including accreditation, performance measurements, patient

safety, information dissemination, and public policy initiative. Its’ platform have undergone

continuous changes over the last six decades. This is because the healthcare environment is

continuously changing. The coming years will no doubt see even more evolution in the

healthcare environment and this means that the Joint Commission will also be a changing

organization. However, the current high expectation of quality placed on healthcare is now the

new reality.
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References

Baker, D. W., & Berman, S. (2017). Continuity of change at the joint commission journal on

quality and patient safety. Joint Commission Journal on Quality and Patient Safety.

Bulloch, M. N., Tapley, N. G., Boopathy, S., & Paryon, J. M. (2016). Impact of joint

commission core measurement on antibiotic use and selection for community-acquired

pneumonia in the emergency room. Hospital Pharmacy, 51, 134-140.

http://dx.doi.org/10.1310/hpj5102-134

Chinn, S. (2014). Avoiding medical errors: Joint Commission’s national patient safety goals.

Podiatry Management.

Halassa, Y. A., Zeng, W., Chappy, E., & Shepard, D. S. (2015). Value and impact by

international accreditation: A case study from Jordon. Eastern Mediterranean Health

journal, 21(2), 90-99.

Institute of Medicine (2004). Keeping patients safe: Transforming the work environment of

nurses. Washington, DC: The National Academies Press.

Pugh, D., Mema, B., Brindle, M. E., Cook, L., & Stomer, J. (2015). Use of an error focused

checklist to identify incompetencies in lumbar puncture. Medical Education, 49, 1005-

1006.

Sullivan, J. L., Rivard, P. E., Shin, M. H., & Rosen, A. K. (2016). Applying high reliability

health care maturity model to assist hospital performance: A VA case study. The Joint

Commission Journal on Quality and Patient Safety, 42(9).

The Joint Commission. (2017). Retrieved from http://www.jointcommission.org

Grading Sheet: Please attach to the Patient Safety/Health Outcomes Organization Paper
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CRITERIA FOR EVALUATION OF THE PATIENT SAFETY/HEALTH OUTCOMES ORGANIZATION PAPER

Point Points
Value Earned
Overview of the Organization – historical overview; how, when, and why it became a 10
patient safety/health outcomes organization; include information on its leaders, mission,
and philosophy
Review of the Current Literature on the Organization – at least five references of which 25
three should be from the nursing and healthcare literature (not older than five years)
Impact of the Organization on Patient Safety/Health Outcomes – an analysis on the 25
potential and actual impact of the organization’s national patient safety resources,
initiatives, and regulations regarding patient safety/health outcomes.
Future Considerations – what are the future goals and initiatives planned for this 10
organization?
APA format for references, grammar, and writing guidelines 5
Total Points 75