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New hospital accreditation chapter puts heightened focus on safety

The Joint Commission announces publication of the new “Patient Safety Systems” chapter in the 2015 Comprehensive Accreditation Manual for Hospitals. The purpose of the chapter is to inform and educate hospital leaders about the importance and structure of an integrated patient-centered system that aims to improve quality of care and patient safety.

There are no new requirements in the Patient Safety Systems chapter. Instead, the standards are culled from existing chapters including Leadership, Rights and Responsibilities of the Patient, Performance Improvement, Medication Management and Environment of Care. The standards will continue to be published in their respective chapters as well as in the Patient Safety Systems chapter. During on-site surveys, the standards will be scored in their originating chapter.

To underscore the importance of a patient-centered safety system, The Joint Commission will make this new chapter available online indefinitely for customers and non-customers alike.

“For the first time, The Joint Commission is providing a standards chapter on our website because this information is so important that we want everyone to have access to it. A solid foundation for patient safety is a safety culture. For leaders, our hope is they will study this chapter and use it as a tool to build or improve their safety culture program,” says Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “Developing a culture of safety starts at the top of the chain of command and then works its way through the layers of management and employees to build trust, which is an essential ingredient for improvement. In order for improvement to take root and spread, leaders need to be engaged and know the current state of the culture in their organization.”

The chapter is oriented to leadership because leader engagement is imperative to the trust-report-improve cycle of establishing a safety culture. The standards are intended to assist leaders in creating a culture of safety that equates to an environment where staff and leaders work together to eliminate complacency, promote collective mindfulness, treat one another with respect and learn from patient safety events.

The chapter has three guiding principles:

  • 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.
  • Assisting health care organizations with advancing knowledge, skills and competence of staff and patients by recommending methods that will improve quality and safety processes.
  • Encouraging and recommending proactive methods and models of quality and patient safety that will increase accountability, trust and knowledge while reducing the impact of fear and blame.

The chapter is included only in the hospital accreditation manual; however, other health care settings may benefit from applying the patient safety strategies discussed in the chapter. Read the new chapter