The Centers for Medicare and Medicaid Services Condition of Participation
(2004) states, “healthcare organizations must develop, implement and maintain an
effective, ongoing, hospital-wide, data-driven quality assessment and performance
improvement program” (p. 118). The Joint Commission (2009) standards LD.03.01.01
through LD.03.06.01 address “the management of important organization-wide systems
that support safety and quality” (p. 303). To enhance the management of an
organization-wide system to support, as well as improve, quality and safe patient care,
The Joint Commission established the National Patient Safety Goals. Goal Two of the
National Patient Safety Goals addresses how “ineffective communication is the most
frequently cited root cause for unexpected occurrences involving death or serious