While Joint Commission compliance is a hospital-wide effort, the Director of Quality Management, Patient Safety Officer, and Compliance Officer typically lead these efforts
TJC standards focus on patient safety, quality of care, and operational effectiveness. Below is a list of the areas you need to be aware of.
- Patient Safety & Quality of Care
- National Patient Safety Goals (NPSGs):
- Sentinel Event Reporting:
- Root Cause Analysis (RCA)
- Infection Control & Prevention
- CDC & WHO guidelines
- Antibiotic stewardship programs
- Hand hygiene protocols
- Hospital-acquired infections
- Emergency Preparedness & Disaster Response
- Emergency Operations Plan (EOP)
- Emergency response drills
- Crisis communication and evacuation procedures.
- Medication Management & Safety
- Medication administration protocols
- Secure pharmacy environment
- Barcoding technology
- High-alert medication safeguards
- Leadership & Governance Compliance
- Leadership must actively participate in quality improvement initiatives.
- Clear chain of command and effective decision-making processes.
- Regular staff training.
- Whistleblower protections.
- Environment of Care & Facility Safety
- Risk assessments
- Fire safety compliance
- Secure handling of hazardous materials
- Workplace violence prevention programs
- Data Reporting & Performance Improvement
- Track, measure, and report quality outcomes
- Report clinical performance data
- Ongoing Performance Improvement (PI) projects
- Patient Rights & Ethics Compliance
- HIPAA compliance
- Informed consent
- Non-discrimination policies
- Grievance procedures.