Goal 1: The hospital ensures that the correct patient receives the correct care at the correct time.
Goal one establishes essential hospital patient care protocols: including accurate patient identification, timely communication of critical information, surgical site verification, effective patient flow management, and timely response to changes in patient condition and emergencies
- Salmasian H, Blanchfield BB, Joyce K, et al. Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors. JAMA Netw Open. 2020;3(11):e2019652. doi:10.1001/jamanetworkopen.2020.19652
- Longstreth MT, Whiteman K, Stephens K, Swanson-Biearman B, Cartwright-Stroupe LM. Implementing Best Practices for Decreasing Nurse Hesitancy to Call the Rapid Response Team: An Evidence-Based Quality Improvement Initiative. Journal of Continuing Education in Nursing. 2023;54(6):281-288. doi:10.3928/00220124-20230511-09
- Franco Vega MC, Ait Aiss M, George M, et al. Enhancing Implementation of the I-PASS Handoff Tool Using a Provider Handoff Task Force at a Comprehensive Cancer Center. Joint Commission Journal on Quality & Patient Safety. 2024;50(8):560-568. doi:10.1016/j.jcjq.2024.03.004
- McCarthy S, Motala A, Lawson E, et al. Use of structured handoff protocols for within-hospital unit transitions: a systematic review from Making Healthcare Safer IVBMJ Quality & Safety 2025;34:680-690.
Goal 2: The governing body and leadership team foster a culture of safety.
Goal two instructs the governing body and leadership team to foster a culture of safety by ensuring that the hospital's mission, vision, and goals guide its actions. This involves addressing conflicts of interest and ethics, designing work processes focused on safety and quality, and implementing a workplace violence prevention program
- Abusalem S, Polivka B, Coty M-B, Crawford TN, Furman CD, Alaradi M. The Relationship Between Culture of Safety and Rate of Adverse Events in Long-Term Care Facilities. Journal of patient safety. 2021;17(4):299-304. https://research.ebsco.com/linkprocessor/plink?id=f3d5a9d6-25f7-3587-bede-50c639c4be3a
- Workforce Safety and Well-Being Resource Center. Joint Commission. 2025. https://www.jointcommission.org/en-us/knowledge-library/workforce-safety-and-well-being-resource-center
- Labrague LJ, Cayaban AR. Association Between Patient Safety Culture and Missed Nursing Care in Healthcare Settings: A Systematic Review and Meta‐Analysis. Journal of Advanced Nursing (John Wiley & Sons, Inc). 2025;81(11):7992-8004. doi:10.1111/jan.16758
- Montminy SL. Leadership behaviors, attitudes and characteristics to support a culture of safety. Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management. 2022;42(2):31-38. doi:10.1002/jhrm.21521
Goal 3: The hospital has an emergency management program.
Goal three establishes a hospital's comprehensive emergency management program, detailing the responsibilities of hospital leadership to oversee and support emergency and disaster preparedness. The program is based on an "all-hazards" approach to address any potential emergency. Key components of the goal include creating detailed plans for communication, staffing, patient care, and safety and security during an emergency, as well as a disaster recovery strategy. The goal guidelines includes continuous training, regular exercises to test response procedures, and ongoing evaluation to ensure readiness.
Goal 4: The hospital prioritizes excellent health outcomes for all.
The hospital commits to prioritizing health outcomes for all patients by identifying disparities and social needs, implementing action plans with dedicated leadership, and transparently tracking progress and adjusting strategies as needed.
Goal 5: The hospital prioritizes infection prevention and control.
The hospital prioritizes infection prevention and control by implementing a program that includes ongoing surveillance, prevention, and control activities.
Goal 6: The hospital prioritizes pain management and safe prescribing practices.
Hospitals prioritize pain assessment and management through structured leadership, safety-focused prescribing, and rigorous data analysis.
Goal 7: The hospital respects the patient's right to safe, informed care.
Ensure patients are active, informed participants in their care through effective communication, ensuring dignity, and screening for abuse, neglect, and exploitation.
Goal 8: The hospital reduces the risk for suicide.
Hospitals prioritize the early identification and safe management of at-risk patients
Goal 9: The hospital develops and implements safe transplant practices.
Hospitals have rigorous tracking and safe handling procedures for tissues and organs to prevent medical errors and disease transmission.
Goal 10: The hospital performs waived testing in a safe and consistent manner.
Hospitals perform simple, low-risk laboratory tests in a safe and consistent manner.
Goal 11: The hospital maintains workplace and patient safety.
Hospitals create a secure and safe physical environment.
Goal 12: The hospital is staffed to meet the needs of the patients it serves, and staff are competent to provide safe, quality care.
Hospitals prioritize the identification and reduction of health disparities as a strategic organizational objective.
Goal 13: The hospital safely performs imaging services.
Hospitals prioritize the safe performance of imaging services for both patients and staff.
Goal 14: The hospital has a medication management program that focuses on safety.
The hospital safely manages pharmaceutical services through a multi-faceted approach that encompasses the entire medication management lifecycle.
