JOINT COMMISSION AND AAAHC STANDARDS AND GOALS

The Joint Commission

The Joint Commission (TJC) is an independent, not-for-profit agency whose mission is to continuously improve the safety and quality of care provided to the public. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States, including hospitals and healthcare organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory, and nursing care center services.

Accreditation by the Joint Commission is not mandatory. Healthcare organizations, programs, and services voluntarily pursue accreditation and certification. Joint Commission surveyors visit accredited healthcare organizations a minimum of once every 36 months (two years for laboratories) to evaluate standards compliance. This visit is referred to as a survey. All regular Joint Commission surveys are unannounced.

During a survey, the surveyors randomly select patients, and using their medical records, the surveyors evaluate standards compliance. As they review each patient’s experience, they talk to doctors, nurses, and other staff who interacted with the patients. They also observe doctors, nurses, and other caregivers providing care and often speak to the patients themselves.

The Joint Commission Quality Reports give the public information on the safety and quality of care for all Joint Commission accredited/certified healthcare organizations. Reports include:

  • Accreditation decision and date
  • Programs and services accredited by the Joint Commission and other bodies
  • National Patient Safety Goal performance
  • Hospital National Quality Improvement Goal performance
  • Special quality awards
    (TJC, 2021d)

SENTINEL EVENT POLICY

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. The policy explains how the Joint Commission partners with healthcare organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

Each accredited organization is strongly encouraged, but not required, to report sentinel events to TJC. Benefits of reporting include:

  • TJC can provide support and expertise during the review of a sentinel event.
  • The opportunity to collaborate with a patient safety expert in TJC’s Sentinel Event Unit of the Office of Quality and Patient Safety.
  • Reporting raises the level of transparency in the organization and promotes a culture of safety.
  • Reporting conveys the healthcare organization’s message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future.
    (TJC, 2021a)

NATIONAL SAFETY GOALS

Every year TJC gathers information about patient safety issues from widely recognized experts and stakeholders. This information is the basis for their National Patient Safety Goals, which are tailored for each specific healthcare setting. The information also informs their sentinel event alerts, standards and survey processes, performance measures, educational materials, and Joint Commission Center for Transforming Healthcare projects.

The National Safety Goals address multiple healthcare sites:

  • Ambulatory healthcare
  • Behavioral healthcare and human services
  • Critical access hospital
  • Home care
  • Hospital
  • Laboratory
  • Nursing care center
  • Office-based surgery

Specific goals for each may include any of the following that have been identified as pertinent for the setting:

  • Identify patients correctly
  • Improve staff communication
  • Use medicines safely
  • Use alarms safely
  • Prevent infection
  • Identify patient safety risks
  • Prevent mistakes in surgery
  • Prevent patients from falling
  • Prevent bed sores (pressure injuries)
    (TJC, 2021e)

“DO NOT USE” ABBREVIATION LIST

Misreading medical abbreviations can be a cause of serious medication errors, and TJC has created a “do not use” list of abbreviations that endanger patients’ safety and that it requires its members to follow (see table).

JOINT COMMISSION “DO NOT USE” LIST
Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.
Do Not Use Potential Problem Instead Use
(TJC, 2020)
U, u Mistaken for “0” (zero), the number “4” (four), or “cc” Unit
IU Mistaken for IV (intravenous) or the number 10 (ten) International unit
Q.D., QD, q.d., qd Mistaken for each other Daily
Q.O.D., QOD, q.o.d, qod Period after the “Q” mistaken for “I” and the “O” mistaken for “I” Every other day
Lack of leading zero Decimal point is missed 0.X mg
MS Can mean morphine sulfate or magnesium sulfate Morphine sulfate or Magnesium sulfate
MSO4 and MgSO4 Confused for one another Magnesium sulfate
Trailing zero * Decimal point is missed X mg
* Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

The Institute for Safe Medication Practices has also compiled an extensive list of abbreviations, symbols, and dose designations that are frequently misinterpreted and involved in harmful medication errors, which can be accessed online (see “Resources” at the end of this course).

ROOT CAUSE ANALYSIS

Root cause analysis (RCA) has been adopted widely as a method for investigating serious adverse events. The Joint Commission has mandated use of RCA to analyze sentinel events since 1997. Many states and the District of Columbia have mandated reporting of serious adverse events, and many states also require that RCA be performed and reported after any serious event.

Root cause analysis identifies underlying problems that increase the likelihood of errors while avoiding focusing on mistakes made by individuals. The approach identifies both active errors and latent errors and is one of the most widely used retrospective methods for detecting safety hazards.

RCAs follow a prespecified protocol, beginning with data collection and reconstruction of the events through record review and participant interviews. A multidisciplinary team then analyzes the sequence of events leading to the error, with goals of identifying how the event occurred (by identifying active errors) and why the event occurred (by systematic identification and analysis of latent errors). The steps in this process include:

  • Prepare for root cause analysis
    • Organize a team
    • Define and study the problem
  • Determine direct and underlying causes
    • Determine what happened
    • Identify contributing process factors
    • Identify other contributing factors
    • Measure, collect, and assess data
    • Design and implement immediate changes
  • Identify root causes
    • Identify which systems are involved
    • Prune the list of root causes
    • Confirm root causes and consider their interrelationships
  • Design and implement a corrective action plan
    • Explore and identify risk reduction strategies
    • Formulate improvement actions
    • Design improvements
    • Ensure acceptability of the corrective action plan
    • Implement the improvement plan
    • Develop measures of effectiveness and ensure their success
    • Evaluate implementation of improvement efforts
    • Take additional action
    • Communicate the results

The ultimate goal of RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events.

Although RCA is widely used, its effectiveness is being debated. Studies have shown that RCAs often fail to result in the implementation of sustainable system-level solutions. The National Patient Safety Foundation has proposed that the process of root cause analysis be renamed to include action and as well as analysis (RCA2), emphasizing that a well-done RCA should yield strong corrective actions as well as risk reduction (AHRQ, 2020).

ROOT CAUSE ANALYSIS AND ACTION PLAN TEMPLATE

The Joint Commission has developed a template to be used while conducting a root cause analysis that recommends the following 24 questions be asked and answered and an action plan developed for any finding that can be considered a risk-reduction strategy.

  1. What was the planned flow of the procedure?
  2. What steps in the procedure did not occur as planned?
  3. What human factors were pertinent to the outcome?
  4. How did performance of equipment affect outcome?
  5. What controllable environmental factors directly affected the outcome?
  6. What external controllable factors affected the outcome?
  7. Were there any other factors that directly affected the outcome?
  8. In what other areas of the organization could this happen?
  9. Was the staff properly qualified and currently competent at the time of the event?
  10. How did real staffing compare with ideal levels?
  11. What is the plan for dealing with unforeseen staffing problems?
  12. Were such problems a factor in this event?
  13. Did staff perform to expectations during the event?
  14. Was all the necessary information available when needed? Was it accurate, complete, and explicit?
  15. Was communication among participants sufficient for this situation?
  16. Was this the appropriate physical environment for the situation?
  17. What systems are in place to recognize environmental risks?
  18. What planned and tested emergency and failure-mode responses are in place?
  19. How does the culture support risk reduction?
  20. What barriers exist to the communication of potential risk factors?
  21. What methods are utilized to communicate the high priority of prevention of adverse outcomes?
  22. What orientation and in-service training revisions are necessary to reduce risk of events in the future?
  23. Was available technology used as intended?
  24. What technology or redesign of technology might reduce risk in the future?
    (TJC, 2017)
CASE

St. Vincent Hospital  (continued from above under “Active and Latent Errors”)

Following identification of the cause of the accident in St. Vincent Hospital’s operating room, a root cause analysis was begun that day. The root cause was determined to be the use of an inappropriate gas mixture to expand the abdomen during laparoscopic surgery.

Contributing factors included:

  • All extra cylinders containing medical gases used in the OR are stored in metal tubes in a tank room, but only the top several inches of each cylinder and a portion of each tank’s label is visible above the top of the storage tubes. The tube height is to provide adequate support for the cylinders, so shortening the tubes to allow visualization of the entire label is not an appropriate option.
  • All tanks containing any percentage of CO2 are color-coded the same (grey). This is an industry standard over which individual facilities have no control.
  • When an OR logistics technician allowed a logistics technician from the catheterization lab to store an extra CO2/O2 tank in the OR tank room, no one in the OR, anesthesia, or logistics chain of command was informed. This is an example of well-intentioned interunit cooperation gone awry due to lack of appropriate communication.
  • The circulating nurse mistakenly replaced an empty CO2 tank with a blended CO2/O2 tank, not noticing the difference because they were both grey, with similar labeling, and because there was no history of anything but pure CO2 being stored in the OR tank room or used in the OR.
  • There was no pin indexing at the connection point between the cylinder and the gas delivery system that differentiates between pure CO2 and CO2/O2 blends. Any cylinder containing any percentage of CO2 fits to any yoke designed to accept CO2 in any concentration.

Corrective actions included policy changes and an intensive education initiative for all involved personnel:

  • Only medical gases intended for use in the OR are to be stored in the OR tank room.
  • Should a deviation from this policy be indicated for safety reasons and no other alternatives exist:
    • Tanks containing gases not used in the OR are to be stored in the OR tank room only until safe storage elsewhere is available.
    • If no alternative storage is available, storage in the OR tank room may be approved only by the senior professional and technical personnel in the OR and the anesthesia service. If the decision is made during “off” hours by a shift charge person, that person is responsible for notifying the appropriate senior personnel by the next shift or delegating and documenting that this notification is to be made by a specific, named person.
    • Any such tanks are to be indicated by orange fluorescent tags reading “Not for use in the OR” and placed in the most remote storage tubes in the tank room.
    • Information about the temporary storage is to be conveyed at each OR and anesthesia shift report and in the OR shift change log until the tank is removed.
  • Medical gases are elevated to the status of medications and the triple-check policy used for medications will be implemented for medical gases.
  • The OR manager will personally brief each shift for the next two days to minimize rumors.
  • All members of the involved surgical and logistics teams will be debriefed by their supervisors.
  • A description of the incident and follow-up will be published in the quality assurance journal for the healthcare system.
CASE

Céline is an 82-year-old patient who has suffered a stroke and been transferred to a local nursing home where inadequate staffing has been a recurrent problem. Céline has right-sided paralysis and requires total care. Her care plan includes repositioning every two hours. Today the nurse does the required biweekly skin assessment and finds a small open crater with visible subcutaneous tissue on the heel of her right foot (i.e., a stage 3 pressure injury).

The nurse documents and reports this long-term care sentinel event per facility policy, and a root cause analysis is begun by a multidisciplinary team that will identify how and why the event occurred. By asking questions as outlined in the facility’s root cause analysis template, the first step is to identify and define the problem:

  • Stage 3 pressure injury (damage to tissue leading to death of tissue) has developed on the heel of the patient’s right foot.
  • Tissue damage has negatively impacted the goal of patient safety.

The second step is to identify the cause:

  • Death of tissue caused by mechanical damage
  • Mechanical damage caused by pressure
  • Pressure injury due to patient remaining in same position
  • Patient remaining in same position due to failure to reposition every 2 hours
  • Failure to reposition every 2 hours due to inadequate level of staffing

The third step in the process is to select the best solution to reduce the risk of pressure injuries in the future.

  • Reposition patients at risk every 2 hours and document the action.
  • Utilize pressure-relieving devices such as beds, mattresses, or overlays.
  • Review and revise staffing formulas; improve staffing to meet the U.S. Department of Health and Human Services recommendations of 1 hour per resident per day for total licensed staff, 27 minutes per day for RNs, and 2 hours per day for nursing assistants.

Following completion of the root cause analysis, the facility determines to institute the action plan:

  • Alternating pressure pads are applied to the beds of all residents at high risk for pressure injuries.
  • The use of heel/elbow protectors becomes standard for all patients with immobility issues.
  • Documentation on the implementation and effectiveness of a turning schedule is instituted for each resident with immobility.
  • Staffing issues remained unresolved due to budget restraints, but ongoing exploration of means to improve the staffing level is being carried out.

Accreditation Association for Ambulatory Health Care

The Accreditation Association for Ambulatory Health Care (AAAHC) was founded in 1979 and is the leader in ambulatory healthcare accreditation, with more than 6,100 organizations accredited. AAAHC accredits a wide range of outpatient settings that include:

  • Ambulatory healthcare clinics
  • Ambulatory surgery centers
  • Birthing centers
  • College and university health centers
  • Community health centers
  • Dental group practices
  • Diagnostic imaging centers
  • Endoscopy centers
  • Federally qualified community health centers
  • Health plans
  • Independent physician associations
  • Indian Health Service centers
  • Lithotripsy centers
  • Medical home organizations
  • Military healthcare facilities
  • Multispecialty group practices
  • Occupational health centers
  • Office-based anesthesia organizations
  • Office-based surgery centers and practices
  • Oral and maxillofacial surgeons’ offices
  • Pain management centers
  • Podiatry practices
  • Radiation oncology centers
  • Single specialty group practices
  • Surgery recovery centers
  • Urgent or immediate care centers
  • Women’s health centers

AAAHC advocates for the provision of high-quality healthcare through the development and adoption of nationally recognized standards, providing a voluntary survey experience founded on a peer-based, educational approach to in-site review every three years.

The AAAHC Certificate of Accreditation demonstrates an organization’s commitment to provide safe, high-quality services to its patients. It is recognized by third-party payers, medical professional associations, liability insurance companies, state and federal agencies, and the public (AAAHC, 2021).