Joint Commission Accreditation

How Performance Measurement Supports Quality Improvement and Patient Safety

"The mission of The Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations."

The fundamental goal of Joint Commission accreditation is performance improvement. Four major sets of activities support Joint Commission accreditation services: information dissemination, public policy initiatives and the two others given special focus in this report - performance improvement and patient safety.

The Joint Commission has been involved in performance measurement since 1986, viewing it as a critical way to extend the reach and sophistication of the accreditation process. The Joint Commission’s 1990 publication, The Primer on Clinical Indicator Development and Application — its all-time best-selling technical book — created a readily adaptable template for performance measure development that is still in wide use today and established The Joint Commission as a leader in this arena.

The Joint Commission continues this leadership through initiatives such as the creation of a performance measure data network. Today, this network of 48 measurement systems, all under contract to The Joint Commission, is the source of all quality-related data on The Joint Commission’s Quality Check Web site (www.qualitycheck.org) and provides 93 percent of the data displayed on the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare Web site.

In the early 2000s, The Joint Commission established National Patient Safety Goals (NPSGs) and related requirements. NPSGs were soon accompanied by additional standards encouraging organizations to establish internal patient safety programs, to undertake proactive risk analyses, and to be transparent in sharing information about adverse events with patients and their families. Today, more than 50 percent of The Joint Commission’s standards relate directly to patient safety.

The Joint Commission continues to issue "lessons learned" advisory Sentinel Event Alerts in response to serious adverse events and updates all adverse event and root cause data in its Sentinel Event database. The Sentinel Event Policy encouraging the reporting and requiring the root cause analysis of sentinel events began in response to a series of serious adverse events in hospitals that captured national public attention in 1995.

In 2005, the World Health Organization (WHO) designated The Joint Commission and Joint Commission International as a Collaborating Centre for Patient Safety Solutions as part of the broader World Alliance for Patient Safety.

To improve health care quality and safety, The Joint Commission continues to disseminate pertinent and necessary information and to serve as an advocate for improved public policies.