Accreditation

Patient care goal easy to meet, but don't dismiss

Briefings on The Joint Commission, October 1, 2006

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

After reading this article, you will be able to

1. -define the JCAHO's National Patient Safety Goal #13 and its requirement, #13a

2. -describe the expectation of goal #13

3. -recall an example of what JCAHO surveyors may ask for when assessing compliance with goal #13

4. -list some tips to meet goal #13

If there's one National Patient Safety Goal that isn't causing too much panic in the field, it's the new 2007 goal for patient-centered care. This is because

  • most hospitals already are doing things that encourage patients involvement in their care.
  • the goal's requirements are similar to those of the existing Accreditation Participation Requirement (APR) 8 (see below for an update to the APR and the April Briefings on JCAHO for more information).
  • the JCAHO already requires the goal for the home care, laboratory, assisted living, and disease-specific care accreditation programs. The JCAHO will expand the goal beginning January 1, 2007, to the hospital, critical-access hospital, ambulatory, office-based surgery, behavioral healthcare, and long-term care programs. For multiprogram facilities, meeting the goal may simply be a matter of expanding existing practices.

    The goal, #13, reads, "Encourage patients' active involvement in their own care as a patient safety strategy." Its single requirement, #13a, reads, "Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so."

    JCAHO surveyors will focus on this goal during upcoming surveys. Don't shrug it off because it has just one requirement that's scored at the C-level, because partial compliance (i.e., two observations of noncompliance or 80% performance) could result in a requirement for improvement.

    "The expectation of this goal is that you work to encourage the active involvement of patients and families to voice concerns about safety and make it easier for them to do so," says John Rosing, MHA, FACHE, practice director of accreditation and regulatory compliance services for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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