Joint Commission National Performance Goals Are Here: Be Prepared

Big changes are afoot for hospitals and critical access centers. Starting on Jan. 1, 2026, Joint Commission replaced its National Patient Safety Goals with a set of National Performance Goals. These 14 metrics are designed to bring “a sharper focus to pressing issues in healthcare.” 

What are the Joint Commission National Performance Goals? 

As part of an initiative to simplify to the accreditation process, called Accreditation 360, Joint Commission is moving away from compliance checklists and toward outcome-focused metrics. It is important to note that no new requirements have been added. Instead, existing requirements have been clarified and reorganized into the National Performance Goals’ 14 points. These points emphasize patient safety, equity, and care quality. 

Hospitals are required to demonstrate their compliance with Joint Commission National Performance Goals to surveyors to maintain accreditation. Surveyors will make sure hospitals are adhering to each of the 14 points and their associated criteria, summarized below. 

Right patient, right care 

Hospitals must: 

• Have processes in place to identify patients 

• Report critical results in a timely manner 

• Manage the flow of patients through the hospital 

• Maintain hand-off communications 

• Recognize and respond to changes in patients’ conditions 

• Ensure resources are available for resuscitation and post-resuscitation care 

• Conduct procedures correctly and with diligence 

Culture of safety 

Facilities must: 

• Regularly evaluate safety culture 

• Communicate the hospital’s vision to staff 

• Give staff a voice in governing bodies 

• Resolve conflicts of interest 

• Design a comprehensive safety program 

• Maintain codes of conduct for patients and staff that includes intimidation 

• Implement a workplace violence program 

Emergency readiness 

Hospitals must: 

• Maintain oversight and support of their emergency response programs 

• Have an all-hazards approach for emergency operations 

• Provide training for emergency management 

• Conduct vulnerability analyses and plan for identified issues 

• Test emergency readiness and associated plans (management, operations, response, etc.) 

• Maintain plans for emergencies and disasters that ensure communications, staffing, patient support and clinical care, safety and security, resource management, and disaster recovery 

High quality, safe care for all 

Organizations must: 

• Choose individuals to lead healthcare quality improvement initiatives 

• Identify socioeconomic disparities and inform patients of community resources related to their health-related social needs 

• Actively reduce disparities in care 

Preventing and controlling infection 

Hospitals are required to: 

• Implement functional and comprehensive infection prevention and control (IPC) programs 

• Prepare for particularly dangerous infectious diseases and pathogens 

• Train staff to be ready for those high-consequence diseases and pathogens 

• Comply with Centers for Disease Control or World Health Organization hand hygiene standards and maintain improvement plans for hand hygiene 

Pain management 

Organizations must: 

• Maintain pain assessment and management standards (including opioid prescription) as an organizational priority 

• Provide non-pharmacologic pain treatment 

• Measure and manage patient pain and minimize risk 

Safe, informed care 

Hospitals have to: 

• Give patients information in a way they can understand 

• Respect patients’ rights to give and retract informed consent and have a written policy outlining those rights 

• Evaluate patients for abuse and neglect on entry and report suspicions as needed 

Reducing the risk for suicide 

Hospitals must monitor and maintain plans to: 

• Assess and minimize features that can be used to attempt suicide in psychiatric units 

• Screen patients being treated for behavioral problems for suicidal ideation 

• Assess patients who screen positive for suicidal ideation with evidence-based standards 

• Document and plan to mitigate risks for suicide 

• Plan follow-up counseling and care as needed 

Tissue transplant safety 

As part of transplant efforts, hospitals must: 

• Standardize procedures for managing transplant tissues from acquisition to distributions and comply with Food and Drug Administration requirements 

• Trace tissues from donor/supplier to recipient 

• Investigate problems and complications related to tissue use or donor infections 

Waived testing 

Hospitals must ensure that: 

• Policies/procedures for waived testing are established and available 

• Staff members conducting waived tests are competent (and that their competence is documented) 

Creating a secure and safe physical environment 

Hospitals have to: 

• Manage security risks (access control, security incident planning, injury investigation, etc.) 

• Prepare for utility disruptions and maintain access to essential supplies/medications in the event of an outage 

• Coordinate decisions for incarcerated patients 

• Minimize/mitigate fall risks for patients based on need 

Health professional resource management 

Hospital leadership must ensure that: 

• Staffing needs are adequate for the patient population 

• Nurse executive(s) direct the use of nurse staffing plans 

• Psychiatric hospitals are in compliance with all local, state, and national regulations 

• Staff have completed all requirements for their respective positions 

• Provide education, training, and evaluation of staff for their respective competencies 

• Evaluate staff during performance improvement activities 

• Evaluate defined care delivery models 

Protecting patients and providers in imaging 

Hospitals must: 

• Define and verify educational requirements for imaging staff 

• Designate an imaging leader who maintains compliance with best safety practices 

• Manage imaging safety risks across all modalities 

• Collect data regarding imaging safety and investigate/respond to imaging safety incidents 

Effectively managing medications 

Hospitals are required to: 

• Ensure a qualified professional reviews medication orders in the absence of a 24/7 pharmacy (as well as have a pharmacist review those orders when the pharmacy reopens) 

• Implement policies specifying medications for automatic dispensing cabinet and review overrides 

• Select/procure medications while standardizing/limiting drug concentrations, procedurally alert staff to medication shortages and outages, and follow written drug substitution protocols during shortages 

• Label all medications, medicine containers, and other solutions both on and off the sterile field in perioperative and similar settings with all required information (name, strength, diluent data, etc.) 

• Reduce patient harm risk with anticoagulants 

• Maintain and transmit accurate patient medication data 

• Maintain an antibiotic stewardship program 

Demonstrating compliance with the National Performance Goals 

The new Accreditation 360 initiative carries the hope of streamlining and simplifying the accreditation process, as well as better communicating best practices. As part of that, Joint Commission has replaced its hospital and critical access hospital Survey Activity Guides with respective Survey Process Guides. Survey Activity Guides remain in place for its other accreditations, from home care to office-based surgery. Furthermore, the commission has collected its various guides into one library for ease of access and use. 

Each guide will be invaluable to prepare for surveyor arrival, ensure all requirements for compliance are met, and resolve any issues discovered during the survey. 

Meanwhile, to help your organization sync up with the National Performance Goals, Relias has produced a guide of how we can help you maintain accreditation, which you can check out below.