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
- 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.
- Dutta S, Dunham L, McEvoy DS, Cash RE, Meeker MA, White BA. Result Push Notifications Improve Time to Emergency Department Disposition: A Pragmatic Observational Study. Ann Emerg Med. 2025;85(1):53-62. doi:10.1016/j.annemergmed.2024.07.010
- Zouaidi K, Miner TW, Walji MF, et al. A Scoping Review of Patient Safety Checklists in Pediatrics. Acad Pediatr. 2025;25(8):102882. doi:10.1016/j.acap.2025.102882
- Pimentel CB, Snow AL, Carnes SL, et al. Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med. 2021;36(9):2772-2783. doi:10.1007/s11606-021-06632-9
- Hecht JD, Yoder LH, Danesh V, Heitkemper EM. A systematic review of the facilitators and barriers to rapid response team activation. Worldviews Evid Based Nurs. 2024;21(2):148-157. doi:10.1111/wvn.12700
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
- Muir KJ, Moon SKA, Agarwal AK. Emergency department workplace violence: Clinician-endorsed strategies informing prevention mandates. Nurs Outlook. 2025;73(5):102539. doi:10.1016/j.outlook.2025.102539
- 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
- McCamon T, Lowe V, George R, Gordon R, Watson H. Risky Business. Interventions to Prevent Aggression Against Health Workers From Patients at Risk: An Integrative Review. Journal of Clinical Nursing (John Wiley & Sons, Inc). 2025;34(4):1187-1200. doi:10.1111/jocn.17433
- Arnetz JE. The Joint Commission's New and Revised Workplace Violence Prevention Standards for Hospitals: A Major Step Forward Toward Improved Quality and Safety. Jt Comm J Qual Patient Saf. 2022;48(4):241-245. doi:10.1016/j.jcjq.2022.02.001
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.
- Federico M. Federici. Translating hazards: multilingual concerns in risk and emergency communication. The Translator. 2022;28:375-398. doi:10.1080/13556509.2023.2203998
- Tussing, T. E., Chesnick, H., & Jackson, A. (2022). Disaster Preparedness: Keeping Nursing Staff and Students at the Ready. Nursing Clinics of North America, 57(4), 599–611. https://doi.org/10.1016/j.cnur.2022.06.008
- Agency for Health Care Administration (AHCA) (2025) Emergency preparedness resources.
- Sadiq A-A, Dougherty RB, Entress R, et al. Mitigating and Preparing for Disasters at the Organizational Level: A Global Systematic Literature Review. International Journal of Disaster Risk Science. 2025;16(2):201-213. doi:10.1007/s13753-025-00630-9
- Hertelendy AJ, Dresser C, Gorgens S, Hertelendy AP, Biddinger PD, Ciottone G. Strengthening healthcare system resilience: a comprehensive framework for tropical cyclone preparedness and response. The Lancet Regional Health - Americas. 2025;48. doi:10.1016/j.lana.2025.101205
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.
- Rangachari, P., & Thapa, A. (2025). Impact of hospital and health system initiatives to address Social Determinants of Health (SDOH) in the United States: a scoping review of the peer-reviewed literature. BMC health services research, 25(1), 342. https://doi.org/10.1186/s12913-025-12494-2
- Wright J, Elder T, Gerges C, et al. A systematic review of telehealth for the delivery of emergent neurosurgical care. J Telemed Telecare. 2021;27(5):261-268. doi:10.1177/1357633X211015548
- Mundo W, Ward-Gaines J, Thiessen M, et al. Bridging the language gap: Simulation-based education improves communication, confidence, and knowledge for emergency medicine residents working with interpreters. AEM Educ Train. 2025;9(3):e70056. Published 2025 Jun 24. doi:10.1002/aet2.70056
- Muir KJ, Sliwinski KS, Ang L, et al. Improving Hospital Care for Patients Experiencing Communication Barriers Through Nurse-Endorsed Strategies. Inquiry. 2025;62:469580251370934. doi:10.1177/00469580251370934
- U.S. Department of Health and Human Services. Call to action: addressing health-related social needs in communities across the nation. Accessed April 2026.
- Telehealth Maternity Care Program. Sarasota Memorial Hospital Health Care System. 2026.
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.
- Infection Control & Hospital Epidemiology: Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals 2022 Updates
- Wilson KB, Satchell L, Smathers SA, Goff LFL, Sammons JS, Coffin SE. The power of feedback: Implementing a comprehensive hand hygiene observer program. Am J Infect Control. 2023;51(2):142-148. doi:10.1016/j.ajic.2022.06.003
- Hawes AM, Patel PK. Catheter-Associated Urinary Tract Infections Surveillance and Prevention. Infect Dis Clin North Am. Published online March 6, 2026. doi:10.1016/j.idc.2026.01.010
- Kamen A, Clark R, Bass MB, et al. Patient Hand Hygiene Before Meals: A Systematic Review. J Nurs Care Qual. 2025;40(3):217-224. doi:10.1097/NCQ.0000000000000858
- AHRQ's Healthcare-Associated Infections Program. Agency for Healthcare Research and Quality. Accessed April 2026.
- Campbell MM, Turi J, Collier S, et al. Implementation of Bundled Interventions to Reduce Surgical Site Infections in Pediatric Patients Undergoing Cardiothoracic Surgery: A Quality Improvement Project. AORN J. 2025;121(2):127-139. doi:10.1002/aorn.14286
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.
- Qaseem A, McLean RM, O'Gurek D, et al. Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. 2020;173(9):739-748. doi:10.7326/M19-3602
- Center for Disease Control. Guideline Recommendations and Guiding Principles,(Clinical Practice Guideline for Prescribing Opioids for Pain).
- U.S. Department of Justice. Manuals, Pharmacist’s and Practitioner’s Manuals.
- Hsu JR, Mir H, Wally MK, Seymour RB; Orthopaedic Trauma Association Musculoskeletal Pain Task Force. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. J Orthop Trauma. 2019;33(5):e158-e182. doi:10.1097/BOT.0000000000001430
- Anne S, Mims JW, Tunkel DE, et al. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg. 2021;164(2_suppl):S1-S42. doi:10.1177/0194599821996297
- Joshi GP, Mariano ER, Elkassabany NM, et al. 2026 American Society of Anesthesiologists Practice Guideline on Perioperative Pain Management Using Local and Regional Analgesia for Cardiothoracic Surgeries, Mastectomy, and Abdominal Surgeries. Anesthesiology. 2026;144(1):19-43. doi:10.1097/ALN.0000000000005790
- Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1
- Hayes L, Pabis JM, Millmann M, Milligan CN, Daffin M. Assessment and Non-pharmacological Management of Chronic Pain in Pediatric Cancer Survivors: Current Practices and Recommendations for Next Steps. Curr Pain Headache Rep. 2025;30(1):1. Published 2025 Dec 15. doi:10.1007/s11916-025-01446-4
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.
- American College of Radiology. ACR Manual on MR Safety (2024).(revised edition).
- Doda Khera R, Hirsch JA, Buch K, Saini S. ED MRI: Safety, Consent, and Regulatory Considerations. Magn Reson Imaging Clin N Am. 2022;30(3):553-563. doi:10.1016/j.mric.2022.04.011
- Committee Opinion No. 723: Guidelines for Diagnostic Imaging During Pregnancy and Lactation (Interim Update – Reaffirmed 2026). American College of Obstetricians & Gynecologists 2026; doi:10.1097/AOG.0000000000002355
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.
