Deciphering the Joint Commission's National Patient Safety Goals for 2023
As a healthcare professional, you understand more than most the role that The Joint Commission (TJC) plays in ensuring the continued delivery of safe and high-quality patient care.
According to their own website, each year sees The Joint Commission’s standards “updated regularly to reflect the rapid advances in health care and medicine,” with “the hospital accreditation standards currently numbering more than 250, [addressing] everything from patient rights and education, infection control, medication management, and preventing medical errors.” 1
While annual updates to standards serve to ensure that the best and most up-to-date care is being delivered to patients nationwide, for many healthcare professionals, it can also mean that deciphering what exactly TJC is prioritizing each year can feel daunting.
In this blog post, we aim to shed light on what are the current ‘top’ TJC priorities, including exploring and outlining many of the “TJC Patient Safety Goals for 2023,” released earlier this year.
What The Joint Commission Says:
NPSG.01.01.01:
Use at least two patient identifiers when providing care, treatment, and services.
--Rationale for NPSG.01.01.01--
Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.
Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable features. In addition to well-known misidentification errors such as wrong patient/wrong procedure, misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system among all staff is necessary to prevent errors.
Element(s) of Performance for NPSG.01.01.01
1.Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient's room number or physical location is not used as an identifier. (See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)
2.Label containers used for blood and other specimens in the presence of the patient. (See also PC.02.01.01, EP 10)
3.Use distinct methods of identification for newborn patients.
Note: Examples of methods to prevent misidentification may include the following:
- Distinct naming systems could include using the mother’s first and last names and the newborn’s gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
- Standardized practices for identification banding (for example, using two body sites and/or bar coding for identification).
- Establish communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names). 2
This goal requires healthcare staff to use at least two patient identifiers when administering medications, drawing blood, or providing treatments, while also ensuring that room numbers or physical locations are not used for identification. Additionally, containers for blood and specimens should be labeled in the patient's presence. (For newborns, distinct identification methods are necessary, such as using the mother's name and the newborn's gender or employing standardized practices like barcoding). 2
What The Joint Commission Says:
NPSG.02.03.01:
Report critical results of tests and diagnostic procedure s on a timely basis.
--Rationale for NPSG.02.03.01--
Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.
To achieve this, healthcare facilities should establish written procedures that define critical results, specify who should report them, and set an acceptable timeframe for reporting, then put each of these procedures into practice. Healthcare organizations should also take time to assess and improve the timeliness of reporting critical results to better ensure swift patient care responses. 2
What The Joint Commission Says:
NPSG.07.01.01
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.
--Rationale for NPSG.07.01.01--
According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. Compliance with the World Health Organization (WHO) and/or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, monitors compliance, and provides feedback.
Element(s) of Performance for NPSG.07.01.01
Specifically, the goal addresses the crucial issue of HAIs in healthcare organizations, which affect millions of patients annually. HAIs are a significant safety concern, and one effective way to combat them is by improving the hand hygiene of healthcare staff. To achieve this, healthcare organizations should adhere to either the CDC or WHO hand hygiene guidelines. Compliance with these guidelines reduces the transmission of infectious agents from staff to patients, ultimately lowering the incidence of HAIs. To ensure compliance, organizations should also establish a comprehensive program that includes a hand hygiene policy, promotes a culture of hand hygiene, monitors compliance, and provides feedback. 2
-Goal #3: Improve the safety of using medications (NPSG.03.04.01)
-Goal #6: Reduce patient harm associated with clinical alarm systems (NPSG.06.01.01)
-Goal #15: The hospital identifies safety risks inherent in patient populations (NPSG.15.01.01)
-Goal #16: Improve health care equity (NPSG.16.01.01) 2
References:
According to their own website, each year sees The Joint Commission’s standards “updated regularly to reflect the rapid advances in health care and medicine,” with “the hospital accreditation standards currently numbering more than 250, [addressing] everything from patient rights and education, infection control, medication management, and preventing medical errors.” 1
While annual updates to standards serve to ensure that the best and most up-to-date care is being delivered to patients nationwide, for many healthcare professionals, it can also mean that deciphering what exactly TJC is prioritizing each year can feel daunting.
In this blog post, we aim to shed light on what are the current ‘top’ TJC priorities, including exploring and outlining many of the “TJC Patient Safety Goals for 2023,” released earlier this year.
TJC Audit Priorities: Your Roadmap for Success in 2023
2023 saw several specific new national patient safety goals (NSPG) introduced, all of which will play a pivotal role in determining exactly how healthcare professionals safeguard their patients’ well-being and enhance their overall quality of care moving forward. Below we’ve included a few of the TJC’s specific 2023 national patient safety goals, as well as brief breakdowns to help clarify and define exactly what is being asked for.NSPG 2023 Goal #1: Improve the accuracy of patient identification:
What The Joint Commission Says: 
NPSG.01.01.01:Use at least two patient identifiers when providing care, treatment, and services.
--Rationale for NPSG.01.01.01--
Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.
Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable features. In addition to well-known misidentification errors such as wrong patient/wrong procedure, misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system among all staff is necessary to prevent errors.
Element(s) of Performance for NPSG.01.01.01
1.Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient's room number or physical location is not used as an identifier. (See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)
2.Label containers used for blood and other specimens in the presence of the patient. (See also PC.02.01.01, EP 10)
3.Use distinct methods of identification for newborn patients.
Note: Examples of methods to prevent misidentification may include the following:
- Distinct naming systems could include using the mother’s first and last names and the newborn’s gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
- Standardized practices for identification banding (for example, using two body sites and/or bar coding for identification).
- Establish communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names). 2
What It Means:
Goal NPSG.01.01.01 - titled "Use at least two patient identifiers when providing care, treatment, and services” - aims to prevent wrong-patient errors in healthcare. This goal emphasizes two crucial objectives:- to reliably confirm the patient's identity for whom the care or treatment is intended; and
- to ensure that the care or treatment matches the correct individual.
- the patient’s name;
- an assigned ID number;
- the patient’s phone number;
- or other personal identifiers
This goal requires healthcare staff to use at least two patient identifiers when administering medications, drawing blood, or providing treatments, while also ensuring that room numbers or physical locations are not used for identification. Additionally, containers for blood and specimens should be labeled in the patient's presence. (For newborns, distinct identification methods are necessary, such as using the mother's name and the newborn's gender or employing standardized practices like barcoding). 2
NSPG 2023 Goal #2: Improve the effectiveness of communication among caregivers:
What The Joint Commission Says: 
NPSG.02.03.01:Report critical results of tests and diagnostic procedure
--Rationale for NPSG.02.03.01--
Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.
- Develop written procedures for managing the critical results of tests and diagnostic procedures that address the following:
- The definition of critical results of tests and diagnostic procedures
- By whom and to whom critical results of tests and diagnostic procedures are reported
- The acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures
- Implement the procedures for managing the critical results of tests and diagnostic procedures.
- Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures. 2
What It Means:
Goal NPSG.02.03.01 - titled "Report critical results of tests and diagnostic procedures on a timely basis" - focuses on ensuring swift communication of critical test results to healthcare providers. Since these results can signal life-threatening conditions, it’s crucial that test results be promptly shared with healthcare providers.To achieve this, healthcare facilities should establish written procedures that define critical results, specify who should report them, and set an acceptable timeframe for reporting, then put each of these procedures into practice. Healthcare organizations should also take time to assess and improve the timeliness of reporting critical results to better ensure swift patient care responses. 2
NSPG 2023 Goal #7: Reduce the risk of health-care associated infections:
What The Joint Commission Says: 
NPSG.07.01.01Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.
--Rationale for NPSG.07.01.01--
According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. Compliance with the World Health Organization (WHO) and/or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, monitors compliance, and provides feedback.
Element(s) of Performance for NPSG.07.01.01
- Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) and/or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 1)
- Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 1)
- Improve compliance with hand hygiene guidelines based on established goals. 2
What It Means:
Goal NPSG.07.01.01 - titled "Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines" - is dedicated to preventing healthcare-associated infections (HAIs) by enhancing the hand hygiene practices of healthcare staff.Specifically, the goal addresses the crucial issue of HAIs in healthcare organizations, which affect millions of patients annually. HAIs are a significant safety concern, and one effective way to combat them is by improving the hand hygiene of healthcare staff. To achieve this, healthcare organizations should adhere to either the CDC or WHO hand hygiene guidelines. Compliance with these guidelines reduces the transmission of infectious agents from staff to patients, ultimately lowering the incidence of HAIs. To ensure compliance, organizations should also establish a comprehensive program that includes a hand hygiene policy, promotes a culture of hand hygiene, monitors compliance, and provides feedback. 2
Other Goals:
The TJC 2023 Safety Goals features several other recommendations, including:-Goal #3: Improve the safety of using medications (NPSG.03.04.01)
-Goal #6: Reduce patient harm associated with clinical alarm systems (NPSG.06.01.01)
-Goal #15: The hospital identifies safety risks inherent in patient populations (NPSG.15.01.01)
-Goal #16: Improve health care equity (NPSG.16.01.01) 2
To see the full list of TJC recommendations for 2023, visit the TJC 2023 Safety Goals. 2
References:
- Joint Commission FAQs: https://www.jointcommission.org/who-we-are/facts-about-the-joint-commission/joint-commission-faqs/
- Joint Commission National Patient Safety Goals 2023: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jul2023.pdf
