Joint Commission Best Practices for Monitoring Safety Incidents


August 3, 2021

The Joint Commission recently released updates to their standards for workplace violence prevention. These best practices provide guidance for hospitals to ensure they are compliant with the Occupational Safety and Health Administration (OSHA), the U.S. Centers for Medicare & Medicaid Services (CMS), and other agencies and authorities critical to daily operations.

You can view the detailed standards from the Joint Commission here.

In this blog, we'll focus on one of the four elements of performance the Joint Commission has outlined—providing sustainable solutions to help ensure hospitals and health care facilities are achieving the safest environments possible.

Element of Performance: Environment of Care (EC.04.01.01)

From the Joint Commission:

“The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following: injuries to patients and others within the hospital’s facilities, occupational illnesses and staff injuries, incidents of damage to its property or the property of others, safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

Based on its process(es), the hospital reports and investigates the following: safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.”

Why is this important and how do you uphold this standard in your facility? Let’s break down EC.04.01.01 and review how training and resources from CPI help you achieve compliance.

Monitor, Report, and Investigate

CPI recommends that you document all incidents of violence as part of your regular post-incident process. Documenting incidents provides staff with the opportunity to not only evaluate what took place but to look for opportunities to adjust their intervention strategies at earlier levels of the crisis as well.

Why is debriefing and reporting such a critical feature in an effective workplace violence prevention program? According to training expert, Pam Roncone, “The problem with debriefing is that it doesn’t always take place . . . they might debrief for the individual involved, the student, the patient, the client, but they do not debrief for staff. It’s very difficult to have changes take place if staff are not being given the opportunity to talk about the incident and what took place.”

In Roncone’s podcast on the importance of using debriefing techniques to strengthen prevention efforts, she explains that most organizations fault “lack of time” as their reason for skipping over this critical step. Our solution at CPI is a proven model for assessing and gathering incident data that not only alleviates the amount of time required to debrief but also supplies a universal language to make implementation seamless.

CPI Nonviolent Crisis Intervention®, 2nd Edition Training provides this debriefing model.  This COPING ModelSM for debriefing outlines a process for reviewing and investigating the incident. It also prompts improvement and prevention strategies (or strategies to improve interventions and prevent crisis recurrences) which we call Postvention.

Taking a closer look at the COPING ModelSM, “C” is about control. Here, we’re helping staff get back in physical and mental control of the situation. “O” is all about orient. This is where we’re gathering facts about the incident and gaining the staff’s perspective of what took place. Next—through investigating, negotiating, and giving—we’re providing support and encouraging consistency in staff. This creates a more well-rounded team that is confident in providing a coordinated approach to safety when future incidents occur.

A Risk Assessment from CPI

Is your facility upholding these Joint Commission best practices? Schedule a free risk assessment with a CPI representative, to review the current policies you have in place, discuss the areas in which challenges are arising, and identify the appropriate steps to ensure you meet the Joint Commission’s requirements by January 1, 2022.

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