International Patient Safety Goals

JCI Board Approves International Patient Safety Goals, Tracer Methodology for 2007 Surveys 

The Joint Commission International (JCI) Board of Directors has refined the hospital accreditation survey process for 2007 with the approval of six International Patient Safety Goals (ISPGs) and the use of tracer methodology—an evaluation method “tracing” a single patient’s experiences within a health care organization—in the organization’s on-site surveys.

“The use of the International Patient Safety Goals and tracer methodology in the JCI accreditation process is a great victory for organizational performance improvement and patient safety,” says JCI’s Executive Director of International Accreditation Maureen Potter, R.N., MSN. “The IPSGs represent proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts. Incorporating these new tools into our requirements is a significant step, but organizations taking responsibility for using the goals and tracers to foster an atmosphere of continuous compliance and improvement is even more important.”

JCI introduced the IPSGs in 2006 and surveyors have been evaluating compliance with these goals during accreditation surveys in 2006, but these findings have not affected the accreditation decision. Beginning 1 January 2007, hospitals accredited by JCI will be required to display compliance with the following ISPGs (in addition to JCI’s 368 standards in 11 chapters):

Goal: Identify Patients Correctly
Requirement 1: Use at least two (2) ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. The patient's room number cannot be used to identify the patient.

Goal: Improve Effective Communication
Requirement 2: Implement a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification "read-back" of the complete order or test result by the person receiving the information.
NOTE: Not all countries permit verbal or telephone orders.

Goal: Improve the Safety of High-alert Medications
Requirement 3: Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.

Goal: Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery
Requirement 4: Use a checklist, including a "time-out" just before starting a surgical procedure, to ensure the correct patient, procedure and body part.
Requirement 5: Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins.
Requirement 6: Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this.

Goal: Reduce the Risk of Health Care–acquired Infections
Requirement 7: Comply with current published and generally accepted hand hygiene guidelines.
NOTE: This should recognize that not all countries have a CDC (Centers for Disease Control and Prevention) or may not recognize the US CDC.

Goal: Reduce the Risk of Patient Harm Resulting from Falls
Requirement 8: Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to decrease or eliminate any identified risks.

For further information on the IPSGs, see the Links at the bottom of this page.

JCI has been testing tracer methodology as an enhanced patient-focused survey process during accreditation surveys in 2006. During accreditation surveys, the JCI surveyors will follow the experience of individual patients through the health care system, visiting multiple care units, departments, and/or areas to “trace” the care, treatment, and services rendered to an individual. The JCI survey process will focus on validating compliance with the standards, evaluating that structures and processes are in place to sustain quality improvement and safety, and result in continuous quality improvement and better outcomes for the patients, organization and staff.

Organizations seeking further information on either the IPSGs or tracer methodology are encouraged to attend JCI’s 2006 Joint Commission International Executive Briefings, 31 October–1 November in Dublin, Ireland. Registration has been extended through 9 October 2006. For more information or to register, go to the Links at the bottom of this page.

JCI is also planning a variety of educational programs regarding accreditation, standards, and survey process over the coming months. For more information, see Links at the bottom of this page.