An infrastructure built around a single department leads to success.
- In its journey to becoming a high-reliability organization, a healthcare system incorporated collective teamwork into disease-specific and advanced certifications, driving continuous process improvement.
- Centralized in one department, these certifications—including acute myocardial infarction, patient blood management, sepsis, and stroke—foster innovation, collaboration, and operational efficiency.
- Supported by executive leadership and multidisciplinary teamwork, this collective approach promotes care standardization and enhances patient outcomes.
The journey to becoming a high-reliability organization (HRO) requires establishing a cultural infrastructure in which leaders and staff continually evolve and refine practices through feedback, analysis, reflection on outcomes, and focus on improvements. The principles of an HRO—which include preoccupation with failure, reluctance to simplify observations, sensitivity to operations, commitment to resilience, and deference to expertise—are imperative to the healthcare industry, where process failures can prove catastrophic to patient outcomes. In addition to patient safety, providing high-quality, cost-effective healthcare for patients with chronic and acute conditions remains an increasing concern to insurers, care providers, policymakers, and the public.
In 2002, The Joint Commission (TJC) launched disease-specific and advanced certifications to evaluate clinical populations and disease-focused programs. The structured criteria and process-focused certification requirements support the establishment of a high-quality program aimed at improving patient outcomes. TJC’s biennial onsite surveys help identify patient care and service improvement opportunities, while certification evaluation assesses organizational leaders’ understanding and commitment to the program, the use of clinical outcomes for improvement, patient education, and discharge preparation.
Although structure creation, review, and continuous process improvement can prove rigorous, establishing the certification framework has been shown to decrease variability, reduce errors, and improve outcomes. For example, Chao and colleagues discovered that disease-specific care programs significantly improved performance indicators in kidney care.
A successful certification journey
John Peter Smith (JPS) Hospital, a 582-bed safety net hospital system in Fort Worth, Texas, recognizes the need for structure and accountability to achieve optimal patient outcomes. The hospital holds two inpatient TJC disease-specific certifications (acute myocardial infarction [AMI] and sepsis), a DNV comprehensive stroke center, and a TJC advanced certification of patient blood management. These programs have the advantage of collective teamwork within one department, nursing clinical services (NCS), with secondary accountability to the department that most impacts the specific program’s outcomes. (See Program history and outcomes.)
Program history and outcomes
Each of the JPS Hospital certified programs has a unique history.
Stroke program
The stroke program began in 2007 as a Joint Commission Primary Stroke Center certification. It expanded stroke care in 2016 with a Det Norske Veritas Comprehensive Stroke Center certification.
The program monitors over 500 patients annually and has been awarded the Get with the Guidelines Gold level award for the past 6 years. In 2024, Health Grades recognized JPS as one of America’s 100 Best Hospitals for Stroke Care.
Acute myocardial infarction program
Initially certified by The Joint Commission (TJC) in 2016, the acute myocardial infarction (AMI) program sees more than 280 patients annually.
In 2023, the program received the American College of Cardiology National Cardiology Data Registry Chest Pain-MI Registry Silver Performance Achievement Award, which recognizes sustained, high-level performance in quality of care. In June 2024, the AMI program certification survey achieved “no findings” from TJC.
Sepsis program
The sepsis program, initially certified by TJC in 2017, conducts more than 350 consults each month. The JPS SEP 1 measure, the early assessment and management bundle for patients suspected of severe sepsis or septic shock, ranks above both the state and national average for the Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock: Management Bundle measure.
In 2024, the sepsis program received a Health Grades Five-Star ranking for sepsis care. Also in 2024, the program’s TJC review resulted in no findings.
Patient blood management program
The patient blood management program, initially awarded a Level 1 certification by TJC in 2022, was the first to be certified in Texas and the 11th in the country. This program oversees an average of 1,000 transfusions per month, with 42 metrics assessing transfusion criteria and necessity, which has achieved a 24% reduction in blood transfusions per 1,000 billing days.
The 2024 TJC survey concluded with no findings. In addition, the specific care offered to individuals who choose to decline blood has brought patients to JPS for surgery because they know their wishes will be respected and they’ll receive optimal care.
For example, the AMI program coordinator’s office sits in the NCS department, but the coordinator collaborates closely with the executive director and manager of the cardiovascular service, the manager of emergency services, and the quality department to ensure the best outcomes for patients experiencing an acute MI. The close collaboration among these departments ensures that the outcomes, improvement structures, and processes exist to deliver consistent and reliable quality care. This structure supports innovation, operational and survey efficiency, and sustained motivation for a continuous improvement process. (See Care collaboration.)
Care collaboration
The following example describes the collaboration among the acute myocardial infarction (AMI) program and nursing clinical services, cardiovascular services, emergency services, and the quality department.
Nursing clinical services
- Facilitates work of all inpatient disease- and population-specific programs
- Ensures all inpatient disease- and population-specific programs meet certification standards
- Supports effective and productive working relationships with physicians, peers, staff, and other healthcare disciplines
- Facilitates staff coaching and development to provide direct or indirect supervision
- Collaborates with staff to submit abstracts for conferences, symposia, and research fairs to showcase each program’s work
AMI program
- Develops program goals
- Collaborates with physicians to assist in correct documentation
- Collaborates with the health information management department to ensure proper coding of AMI patients for correct billing
- Monitors quality metrics
- Identifies process improvement opportunities
- Coordinates best practices to ensure excellent outcomes
- Provides community outreach
- Provides education to staff, patients, and physicians
- Serves as a liaison among all departments
- Partners with local emergency medical services to ensure patient care excellence
- Guides staff in The Joint Commission (TJC) survey readiness
Cardiovascular services
- Responds to all STEMI activations as a primary percutaneous coronary intervention center
- Provides care of patients with ST-elevation myocardial infarction (STEMI), including emergent coronary angiography
- Provides patient care and stabilization while patients undergo procedures
- Provides handoff and safe transport to the ICU
- Coordinates care with emergency department (ED)
- Collaborates on and helps with metric recommendations based on guidelines and current trends
- Collaborates on process improvement opportunities
Emergency services
- Provides initial patient contact and diagnosis of STEMI via ECG
- Activates the STEMI team
- Provides patient stabilization and treatment until the interventional cardiology team arrives
- Provides handoff and safe patient transport to the cardiac catheterization laboratory
- Assists with metric recommendations based on guidelines and current trends
- Collaborates on process improvement opportunities through the ED sub-committee
- Provides staff education
- Assists in monitoring program metrics and reporting opportunities for improvement to staff
Quality department
- Supports program with American Heart Association’s Get With the Guidelines (GWTG)–CAD Registry data abstraction, validation, and reporting
- Supports program with GWTG registry scorecard data
- Supports program with quality education
- Provides inter-rater reliability (IRR) with AMI program coordinator on all STEMI cases
- Reports opportunities for improvement to physicians
- Attends data sessions for TJC survey to answer questions and explain data collection, validation, and IRR
The NCS role
NCS functions similarly to inpatient hospital nursing units. However, rather than focusing on direct patient care, NCS prioritizes excellence through the development of certified programs that support the organization’s journey toward providing optimal bedside care. The NCS programs report to one manager, and all NCS team members participate in Lean Six Sigma training to build skills in project management, process efficiency, improvement, and change management.
Collaborative, informal meetings occur daily among team members, with a weekly formal department meeting in which each team member shares challenges and the group brainstorms solutions. The NCS team works to standardize their programs by using specific templates for their interprofessional meetings, charters, opportunities for improvement feedback, and scorecards.
TJC surveys
To help facilitate smooth TJC surveys, advanced planning and preparation—using a detailed tracker to outline monthly roles, dates, and preparation tasks—begins 12 months before the scheduled survey date. This collective team approach ensures that each NCS team member takes responsibility for preparation tasks, including communication, environment of care checks, credentialing verification, human resources employee file verification, certification team notifications, and scribing.
The team created a standardized certification survey presentation with the assistance of the JPS learning and organizational development (OD) department. As survey dates approach, each program coordinator delivers their survey opening and data presentations to their NCS colleagues and the OD consultant for coaching, constructive critiques, and suggestions.
After each survey, the team holds a collective debrief to discuss what went well and the lessons learned. The NCS team writes thank-you notes to organizational team members who participated in the certification survey to express gratitude and build relationships.
Certification facts
According to TJC, certification encourages excellence by fostering high standards of clinical service and professional development, building clinical staff confidence, and increasing ownership in the process. The standardization of policies, procedures, algorithms, and care pathways promotes clinical service excellence and decreases variation and risk of errors. In the certification process, the collaboration of all services involved in disease- and population-specific patient care creates these tools.
Certification promotes professional development, nurtures clinical staff, and equips them for success. The certified program coordinators at JPS work closely with clinical nurses to ensure they have all the tools needed to support optimal patient outcomes. Education, resources, disease-specific committees, and 1:1 contact provide staff with the support and knowledge to turn them into experts.
JPS begins disease-specific instruction at general nurse orientation and resident physician education and continues to the point of care. For example, in addition to program-specific education requirements, the stroke and AMI coordinators attend stroke and ST-elevation myocardial infarction (STEMI) activations to assist clinical staff, build their confidence, and give just-in-time education. The sepsis program equips clinical staff with education via a QR code, which provides algorithms and patient education tips. All programs include an intranet site with clinical practice guidelines, dashboards, newsletters, and other resources. All of these touchpoints build clinical staff confidence and create a greater understanding of patient safety.
According to Chao and colleagues, certification encourages clinical staff to take ownership of the care process, fostering a sense of pride and a culture shift to safety. Partnerships with unit champions, clinical resource specialists, ED critical care coordinators, and house supervisors aid collaboration and accountability. (See Staff ownership.)
Staff ownership
JPS Hospital frontline staff take ownership of the certified programs in various ways, including the following:
- Clinical staff participated in the development of the emergency department (ED) acute myocardial infarction subcommittee. Initiatives from this committee include the following:
- Creation of ST-elevation myocardial infarction (STEMI) packs with all the supplies needed to care for patients with STEMI (I.V. start kits, I.V. catheters, blood collection tubes, ECG and defibrillator pads, and the STEMI folder and checklist);
- Development of the STEMI employee badge backer (an initial rollout for ED only, but other units soon requested the same badge backer);
- Establishment of an electronic health record (EHR) STEMI SMART phrase tool for ED physicians.
- The ED critical care coordinator and an ED technician developed two ECG classes to help improve STEMI awareness and decrease activation times.
- In preparation for The Joint Commission stroke survey, a unit-based clinical quality nurse suggested additional frequencies for the National Institute of Health Stroke Scale (NIHSS) assessment within the flowsheet of the EHR. This change resulted in more consistent NIHSS documentation.
Successful certification requirements
Several factors—including organizational leadership commitment, accountability, interprofessional expertise, action, tracking and reporting, and education—play a role in successful certification programs.
Organizational leadership commitment
To drive staff engagement and improved patient outcomes, organizational leadership must remain committed to disease-specific certifications. JPS executive leadership demonstrates its full support for the certified programs by assigning nursing and physician leaders to each program. The chief nursing officer (CNO) meets monthly with the director of clinical services to review metrics, improvement opportunities, and action plans. The CNO is engaged in the development of each program and the patient outcomes achieved.
In addition, each certified program has a minimum of two physician champions who attend monthly meetings as well as biennial TJC or annual DNV surveys. During the surveys, clinical staff witness executive leadership involvement, which includes the chief executive officer, CNO, chief quality officer, and chief medical officer.
Accountability
A dedicated leader who coordinates and oversees each program helps to establish accountability. The JPS certified programs, all built on accountability, provide a framework for positive patient outcomes. Department leaders remain fully engaged and work with the program coordinators to improve adherence to evidence-based clinical performance measures required by the certified programs.
When program compliance isn’t achieved, the coordinator promotes accountability by notifying involved staff of these opportunities for improvement. Department leaders review these opportunities and hold staff accountable by implementing education or improvement initiatives.
Interprofessional expertise
Each certified program has a robust interprofessional team, including nursing, pharmacy, radiology, quality, therapy services, and medical leaders from emergency services, intensive care, and the hospitalist team. For example, the sepsis interprofessional team includes physicians from the ED and ICU, antibiotic stewardship pharmacists, quality educators, quality abstractors, ED nurses, maternal and neonatal intensive care nurses, and others, as requested. Through this interprofessional approach, the programs promote teamwork while clinical staff serve as subject matter experts of specific diseases.
Action
Achieving certification requires the efforts of an interprofessional team, but the primary responsibility falls to the bedside clinical nurse. Disease- and population-specific protocols within the certified programs provide a framework for best practices and give bedside nurses the skills and structures (such as standardized workflows, checklists, and documentation tools) to achieve optimal outcomes.
Regular review of data and patient outcomes call attention to process outliers and trigger corrective action. For example, the stroke program initiated several process improvement projects to streamline the stroke alert process, decrease treatment times, and even determine a patient population more susceptible to hemorrhagic strokes. For any metrics that fall below a set goal, the team develops action plans for themselves and any relevant departments. The NCS team uses the Plan-Do-Study-Act process to aid improvement.
Tracking and reporting
The certified programs use tracking and reporting, with daily real-time patient monitoring, to help achieve optimal patient outcomes. For example, the stroke coordinator, stroke RN, and clinical resource specialists perform daily chart reviews for adherence to vital signs and neurologic assessments, timely medication administration, patient education, order set use, and overall protocol compliance. This real-time oversight enables prompt staff education, improved documentation, and timely care plan adjustments to drive patient outcomes.
The sepsis program follows a similar approach. A provider or nurse places a sepsis consult, which allows for a real-time review of the patient’s chart. The sepsis coordinator or sepsis RN can contact providers or nurses through direct monitoring and deliver just-in-time feedback. The team then monitors each real-time recovery for improvement.
Education
NCS supports collective and individual staff education, which occurs in various settings, including face-to-face interactions, targeted web-based instruction, new nurse orientation, nurse residencies, skills fairs, nursing grand rounds, unit-based professional development, physician education, and escape room scenarios. In addition, each program coordinator provides ongoing education and resources.
The program coordinators review disease-specific education on a regular basis to prevent silos and ensure that each program engages in all available hospital-wide opportunities. For example, the sepsis, stroke, and AMI programs plan and implement an annual conference for the Dallas-Fort Worth healthcare community. NCS coordinators and clinical staff RNs participate in these collaborative conferences through planning, setup, registration, and activity support.
In addition, each certified program provides community outreach, which the group disseminates collaboratively. These programs work in tandem to ensure participation in shared opportunities and to educate the community in recognizing the signs and symptoms of stroke, heart attack, and sepsis, as well as the importance of early intervention and timely care.
A commitment to care
JPS has demonstrated the transformative power of disease-specific and advanced certifications on its journey to becoming a high-reliability healthcare organization. By adopting HRO principles and making a commitment to excellence with structured criteria and rigorous processes, JPS promotes a culture of continuous process improvement and accountability. The organization’s pledge to support these certifications has helped to establish a culture of excellence, ensure high-quality care, and foster staff pride and confidence.
Elisabeth Rodgers is the executive director of clinical services at JPS Health Network in Fort Worth, Texas. Kathy Watts (retired) was the manager of nursing clinical services at JPS Health Network. Krissy Feinauer is a chest pain coordinator at JPS Health Network. Lauri Speirs is the stroke program CNS at JPS Health Network. Jessica Aguilar is a senior clinical consultant at Cytovale in San Francisco, California. Tess Watson is a patient blood management coordinator at JPS Health Network.
American Nurse Journal. 2025; 20(9). Doi: 10.51256/ANJ092548
References
Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-69. doi:10.1097/ccm.0000000000004363
Association for the Advancement of Blood & Biotherapies. Standards for a Patient Blood Management Program. 4th ed. Bethesda, MD: AABB; 2023.
Azmi H, Cocoziello L, Harvey R, et al. Development of a Joint Commission disease-specific care certification program for Parkinson’s disease in an acute care hospital. J Neurosci Nurs. 2019;51(6):313-9. doi:10.1097/jnn.0000000000000472
Barbash IJ, Davis BS, Yabes JG, Seymour CW, Angus DC, Kahn JM. Treatment patterns and clinical outcomes after the introduction of the medicare sepsis performance measure (SEP-1). Ann Intern Med. 2021; 174(7):927-35. doi:10.7326/m20-5043
Chao C, Chang CI, Wang PC, et al. Impact of a kidney‐specific disease‐specific care certification program on the institutional performance indicators of hospitals caring for patients with chronic kidney disease: A national data analysis. Nephrology. 2021;26(8):669-75. doi:10.1111/nep.13901
Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-1143. doi:10.1097/ccm.0000000000005337
Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage. Stroke. 2022;53(7):e282-361. doi:10.1161/str.0000000000000407
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22): e368-454. doi:10.1161/cir.0000000000001029
Hoh BL, Ko NU, Amin-Hanjani S, et. al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage. Stroke. 2023;54(7):e314-70. doi:10.1161/STR.0000000000000436
Jneid H, Addison D, Bhatt DL, et al. 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction. Circulation Cardiovasc Qual Outcomes. 2017;10(10): e3000032. doi:10.1161/hcq.0000000000000032
The Joint Commission. Benefits of Joint Commission certification fact sheet. jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-benefits-of-joint-commission-certification
The Joint Commission. Certification fact sheet. jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-certification/
The Joint Commission. Five Ways Joint Commission Certification Can Help Attract and Retain Frontline Staff. jointcommission.org/-/media/tjc/documents/what-we-offer/certification-and-frontline-staff-final.pdf
Kiser M. Improving sepsis compliance with human factors interventions in a community hospital emergency room. Patient Saf. 2023;
5(1):26-31. doi:10.33940/culture/2023.3.3
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(3) :e18-e114. doi:10.1161/cir.0000000000001038
Mohr NM, Zebrowski AM, Gaieski DF, Buckler DG, Carr BG. Inpatient hospital performance is associated with post-discharge sepsis mortality. Crit Care. 2020;24(1):626. doi:10.1186/s13054-020-03341-3
Oczkowski S, Alshamsi F, Belley-Cote E, et al. Surviving Sepsis Campaign Guidelines 2021: Highlights for the practicing clinician. Pol Arch Intern Med. 2022;132(7):16290. doi:10.20452/pamw.16290
O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-425. doi:10.1161/CIR.0b013e3182742cf6
Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/
NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771-862. doi:10.1161/cir.0000000000001309
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 Update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke. 2019;50(12):e344-418. doi:10.1161/str.0000000000000211
Sutcliffe KM. Building cultures of high reliability: Lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-17. doi:10.1016/j.anclin.2023.03.012
Weick KE, Sutcliffe KM. Managing the Unexpected: Sustained Performance in a Complex World. Hoboken, NJ: Wiley; 2015.
Key words: Disease-specific certifications, high-reliability organizations, process-improvement
