The Joint Commission’s Goals for Hospitals in 2010

The Joint Commission (“JC”) has issued its 2010 National Patient Safety Goals (“Goals”), which became effective on January 1, 2010. The streamlined 2010 Goals reflect the JC’s ongoing effort to focus on what it considers to be the highest priority topics related to patient safety and quality of care.

For the year 2010, the Goals applicable to hospitals include:

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
• Improve the safety of using medications
• Reduce the risk of health care-associated infections
• Accurately and completely check patient medicines across the continuum of care
• Identify patients at risk for suicide

To improve the accuracy of patient identification, the Goals require that hospitals correctly identify patients using at least two patient identifiers, such as the patient’s name and date of birth. Hospitals must also ensure, using a two-person verification process, that patients receiving blood transfusions are given the correct blood type. The Goals aim to improve the effectiveness of hospital staff communication by requiring that hospital staff promptly report critical test results.

Improving medication safety requires the labeling of all medications, including medications in syringes, cups and basins. Also required are specific standards designed to reduce the likelihood of patient harm associated with anticoagulant therapy.

In order to prevent health care–associated infections, the Goals call for the implementation and use of hand hygiene guidelines from the Centers for Disease Control and Prevention or World Health Organization, and the implementation of standards designed to prevent drug resistant infections, blood infections from central lines, and surgical site infections.

The fifth goal, accurately and completely checking patient medicines across the continuum of care, is perhaps the most comprehensive of the 2010 Goals. Currently, these requirements of this Goal are not in effect at this time. During the on-site survey, JC surveyors will evaluate the hospital’s medication reconciliation processes, discuss opportunities for improvement, and collect information on the progress hospitals are making in meeting this Goal. However, survey findings will not be factored into the JC’s accreditation decision and Requirements for Improvement (“RFIs”) will not be generated. This Goal requires that hospitals reconcile patients’ current medications with those medications ordered while under hospital care and accurately communicate a patient’s medications to directly to the patient and to the patient’s next provider upon discharge. Furthermore, hospitals are required to assess for potential allergic or adverse reactions between a patient’s current medications and a medication intended to be prescribed for minimal use or short-term.

The sixth and final Goal, identifying patients that are at risk for suicide, requires that psychiatric hospitals and general hospitals who treat patients for emotional or behavioral disorders implement performance standards to identify patients at risk for suicide.

Failure by a JC accredited hospital to address any of the requirements in effect at this time will result in a type I recommendation upon being surveyed. To view the new 2010 National Patient Safety Goals and related requirements, visit the JC website at www.jointcommission.org.