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The JCAHO Patient Safety Standards

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Cloudy Mayon

Cloudy Mayon and Patient safety

The Joint Commission on Accreditation of Healthcare Organization or JCAHO is one of the international accreditation bodies acknowledged as significant moving force behind  patient safety standards in hospitals. It accredits hospitals based on its prescribed standards.

A standard is an established norm or requirement. It is usually a formal document that establishes uniform technical criteria, methods, processes, and practices. It may be developed privately or unilaterally, for example by a corporation, regulatory body, accreditation body, others. The existence of a published standard does not imply that it is always useful or correct.

Those using the item or service should
have the responsibility to consider the available standards, specify the correct one, enforce compliance and use the item correctly. Validation of suitability is necessary.

Standards are reviewed, revised and updated regularly. The originator or standard writing body has the responsibility of publishing the current version of the standards.

Briefly, the patient safety standards deals on patient rights and organization ethics, education, continuum of care, improving organization performance, leadership, management of human resources and management of information.

The details are summarized as follows:

Patient Rights and Organization Ethics

  • ·Patients and their families are informed about  unanticipated outcome in their care.


  • Included in the patient and their family education  concerning their responsibilities in the health care delivery  process is their role  to facilitate the safe delivery  of care

Continuum of Care

  • Standard 1 : Safe and effective care is ensured throughout all phases of service to the patient.
  • Standard 2: There is a level of coordination among heath care professionals, services and setting that promotes safety in a patients care.

Improving organization performance

  • Standard 1 :New or redesigned process must take into consideration potential risks to patient
  • Standard 2 : Pilot testing or deep analysis of new and redesigned  systems should be done to  determine  whether or not the change in an improvement
  • Standard 3: Data must include information from patients, families and staff related to perceptions of  risks to patients and suggestions for improving patient safety.
  • Standard 4: A culture of openness must be fostered so that errors in the delivery of health care not hidden.
  • Standard 5 :Hazardous condition that may not yet have caused problems must be identified and modified proactively.
  • Standard 6 : An evaluation of systems in addition to individual processes must be a hallmark of performance improvement process


  • Standard 1: Leader must ensure the implementation of an integrated patient safety program throughout the organization
  • Standard 2: The program must be ongoing, interdisciplinary and proactive, clear in activities it will oversee, develop reporting system, define response mechanism and report to the governing body on errors and action taken.
  • Standard 3: Leaders must ensure that patient safety is given a high priority especially when new process or services are designed or redesigned.
  • Standard 4 : A “failure mode and effect analysis” must be performed at least annually on at least annually on at least one high-risk process for proactive risk assessment.
  • Standard 5 : The leaders planning process take into account unanticipated adverse occurrences affecting patients when assigning performance improvement priorities.
  • Standard 6 : Performance improvement activities include a commitment to improve patient safety
  • Standard 7 : Leaders foster communication and coordination among departments and staff as it relates to patient safety.
  • Standard 8 : Leaders ensure that processes within the organization are performed consistently across all departments and services.
  • Standard 9: Leaders ensure that at any given time, at least one high risk or error-prone process is being measured and analyzed to determine if it is being performed as designed.
  • Standard 10: Leaders provide adequate human  and other resources needed to improve patient safety.
  • Standard 11 : Adequacy of resources to improve are assessed by leaders routinely.
  • Standard 12 : Leaders measure themselves to determine the effectiveness of the contributions to improving patient safety

 Management of human resources

  • Standard 1: Orientation programs for all staff members should include specific job-related aspects of patient safety.
  • Standard 2:On-going in-service education for all staff should foster interdisciplinary and collaborative approaches to the delivery of patient care, often called “team training.”

Management of Information

  • Standard 1: Plan for and review verbal and  written communication among caregivers and others for accuracy, timeliness and completeness.
  • Standard 2 : Identify successful practices from other organizations or settings and have a mechanism to incorporate them into the patient safety program.
  • Standard 3 : Data used in the hospital for planning and improvement of process should include and support reduction in risks to patients.

Are our hospitals ready to be assessed based on the above standards?

Note: This article is derived from the lecture of former DOH Undersecretary, Ma. Margarita M. Galon, MD, MHA, in Sto. Domingo, Albay, Philippines. Dr. Galon is acknowledged to have already gained expertise on patient safety standards.

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