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One might hope that professionalism and concern for patients would be sufficient incentive to motivate safe behaviors on the part of providers, as well as institutional investments in system safety. Sadly, experience has taught us that this is not the case. There are simply too many competing pressures for attention and resources, and the nature of safety is that individuals and organizations can often get away with bad behavior for long periods of time. Moreover, it is unlikely that all providers and institutions will or can keep up with best practices, given a rapidly evolving research base and the never-ending need to keep at least one eye on the bottom line.

These realities create a need for more prescriptive solutions to safety: standards set by external organizations, such as accreditors, regulatory bodies, payer representatives, and government. This chapter will examine some of these solutions, beginning with regulations and accreditation.


Regulation is “an authoritative rule,” while accreditation is a process by which an authoritative body formally recognizes that an organization or a person is competent to carry out specific tasks. Much of what we tend to call regulation is actually accreditation, but takes place in an environment in which a lack of accreditation has nearly the impact of failing to adhere to a regulatory mandate. For example, the Accreditation Council for Graduate Medical Education (ACGME), the body that blesses U.S. residency and fellowship programs, is not a regulator but an accreditor. Nevertheless, when the ACGME mandated that residents work less than 80 hours per week in 2003 and proscribed traditional overnight call shifts for first-year residents in 2011 (Chapter 16), these directives had the force of regulation, because ACGME has the power to shut down training programs for noncompliance.1 It is worth noting that the ACGME relaxed the latter standards in 2017 based on the lack of evidence of safety benefit and increasing concerns about handoffs and threats to professionalism, an interesting case of a commonsense accreditation standard not achieving its desired effect.

The most important accreditor in the patient safety field (in the United States) is the Joint Commission. The Joint Commission, which began in 1951 as a joint program of the American College of Surgeons (which launched the first hospital inspections in 1918), the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association, has become an increasingly powerful force over the last 15 years by more aggressively exercising its mandate to improve the safety of American hospitals (and now, through its Joint Commission International subsidiary, hospitals around the world). A list of Joint Commission National Patient Safety Goals, one of the organization's key mechanisms for endorsing practices, highlighting safety problems, and generating action, is shown in Appendix IV.

Until the mid-2000s, Joint Commission visits to hospitals were announced ...

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