Operations Management

Acing the Joint Commission Regulatory Visit: Running an Effective and Compliant Safety Program

Published Online:Oct 10 2018https://doi.org/10.1148/rg.2018180134

Abstract

The authors describe necessary components of an effective safety program, highlight current challenges in patient and employee safety, and suggest how to manage safety data and prepare for a Joint Commission accreditation visit while working toward a proactive safety portfolio that identifies safety hazards before adverse events occur.

Ensuring the safety of patients and staff is a core effort of all health care organizations. Many regulatory agencies, from The Joint Commission to the Occupational Safety and Health Administration, provide policies and guidelines, with relevant metrics to be achieved. Data on safety can be obtained through a variety of mechanisms, including gemba walks, team discussion during safety huddles, audits, and individual employee entries in safety reporting systems. Data can be organized on a scorecard that provides an at-a-glance view of progress and early warning signs of practice drift. In this article, relevant policies are outlined, and instruction on how to achieve compliance with national patient safety goals and regulations that ensure staff safety and Joint Commission ever-readiness are described. Additional critical components of a safety program, such as department commitment, a just culture, and human factors engineering, are discussed.

^©RSNA, 2018

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Article History

Received: Apr 11 2018
Revision requested: May 18 2018
Revision received: June 15 2018
Accepted: July 12 2018
Published online: Oct 10 2018
Published in print: Oct 2018

Vol. 38, No. 6

Abbreviations

Abbreviations:
FMEA	failure mode and effect analysis
HFE	human factors engineering
NPSG	national patient safety goal
QA	quality assurance
RCA	root cause analysis

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