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On January 1, 2022, The Joint Commission’s updated requirements related to cardiopulmonary resuscitation will go into effect. One of these updates requires hospitals and critical care facilities to ensure that “an interdisciplinary committee reviews cases and data to identify and suggest practice and system improvements in resuscitation performance.” 

These groups, often referred to as resuscitation committees, Code Blue committees, or critical care committees, have already helped many hospitals across the country focus on improving their response to cardiac and respiratory arrest — one of the leading (and most neglected) causes of preventable harm and death in hospitals today.

Looking to not only comply with new resuscitation standards from The Joint Commission (TJC) but also to strive for demonstrably achievable improvements in Code Blue outcomes? Here are three key steps you’ll need to take to form an effective resuscitation committee.

1. Recruit the Right Roles for Your Resuscitation Committee

When it comes to collaborating on solutions to improve Code Blue care, the more brains — and the more diverse viewpoints — the better. You never know where a great idea will come from or how different members could inspire one another. That said, every hospital is different in terms of size and resources, so start with the following guidelines:

  • Ensure your resuscitation committee is multidisciplinary with varied areas of Code Blue response expertise represented (see examples below).
  • Open membership to volunteers who are active in the resuscitation work of the hospital, such as Code Blue response team members.
  • Recruit a mix of resuscitation team members to get representatives with strong clinical skills as well as some with deep knowledge of your institution’s systems — and how to effect change within them. 
  • Aim for a clinical-staff-heavy ratio. These committee members will ensure you get adequate feedback from actual Code Blue events, help the committee to learn more about barriers that arise during events, and provide more insight into each case that is reviewed.

Some departments should be specifically called upon to send a representative while others can be tapped as needed for relevant expertise and input. Active key members should include:

  • Code team leaders — typically Resident and/or Medical Doctors (MDs)
  • Registered Nurse (RN) responders — both critical care and medical-surgical
  • Representatives from anesthesia, surgery, and respiratory therapy
  • MD leadership and RN leaders, such as Nurse Specialists and Directors
  • Healthcare quality and patient relations/experience representatives
  • Quality and safety representatives to help with system navigation and improvements, and supporting changes at higher levels.1,2

2. Set Expectations for Resuscitation Committee Members

Next, make sure you’re setting your committee up for success by letting them know what they’re in for in terms of commitment, goals, and mindset. To ensure the success and effectiveness of your resuscitation committee, all members should:

  • Fully understand the importance of the committee. Improving Code Blue care and outcomes can save thousands of lives each year. You could even collaborate to create a mission or vision statement for the group to stay focused on this important goal. Plus, the committee is required to maintain compliance with standards from The Joint Commission.
  • Stay active and engaged in all committee activities. From collecting data and organizing discussions to participating in committee sessions and implementing quality improvement initiatives, members should be expected to maintain a high level of enthusiasm and dedication.
  • Go into resuscitation events with the right mindset — not looking for “what’s wrong” but rather “how can we improve care?” This will help committee members identify more areas for improvement, pinpoint knowledge gaps, and enhance resuscitation education efforts across the institution.
  • Attend at least 85% of meetings to ensure they keep up with trends and changes.
  • Help reinforce practice changes with staff across the organization. Often, the committee will be actively engaged in creating educational tools and developing quality improvement initiatives, so they are in an ideal position to lead others in adopting those changes.
  • Expect to take on the position of committee chair or co-chair at some point. Rotating committee leadership allows the group’s focus to shift over the years, which can help keep ideas fresh. Furthermore, maintain a mix of disciplines in these roles, such as pairing an MD and RN as co-chairs, to help the group gain more perspective, share ideas more freely, and advocate with confidence for effective changes that support all responders.

3. Outline Core Responsibilities of the Resuscitation Committee

Now that you’ve recruited the right roles and set their expectations appropriately, you must clearly outline what members will be expected to do as part of the resuscitation committee.

Ensure the proper data is collected and ready for review. 

As of January 1, 2022, The Joint Commission will require hospitals and critical care facilities to document:

  • The number and location of cardiac and respiratory arrest events
  • Outcomes of resuscitation
  • Transfer to a higher level of care

It also notes that the interdisciplinary committee could benefit from reviewing:

  • How often early warning signs of clinical deterioration were present prior to in-hospital cardiac arrest in patients in non-monitored or non-critical care units
  • Timeliness of staff’s response to a cardiac arrest
  • Quality of cardiopulmonary resuscitation (CPR)
  • Post-cardiac arrest care processes
  • Outcomes following cardiac arrest

Clinical staff will likely have a direct hand in either collecting this data or ensuring it is collected during Code Blue events, while discipline leader committee members will have a more indirect (but highly impactful) influence in requiring its collection. In any case, specific members should be tasked with gathering the information that will be reviewed at committee sessions.

Regularly review system-wide case data. 

All committee members will review cases and data in order to:

  • Help identify areas for improvement both in clinical practice and across hospital systems. This should include comparing real case data against industry best practices.
  • Make recommendations for practical solutions to improve those areas that need work based on real-world data. This process should be highly collaborative, open, and clearly documented.
  • Track progress in areas where improvements have been recommended and document the effectiveness of quality improvement (QI) initiatives by comparing against baseline data over time.

Support the implementation of quality improvement initiatives.

The only task more important than collecting QI data is implementing positive changes based on that data. Committee members can:

  • Personally adhere to the changes agreed upon by the committee in everyday practice.
  • Create tools and resources to help educate staff about quality improvement initiatives.
  • Verbally support and/or enforce changes as their seniority allows.

Report findings to an executive committee.

Gaining administrative and financial support is the key to driving even bigger positive changes. The resuscitation committee should report all findings and QI work annually to an executive committee at the institution. Findings should include results of any and all QI initiatives that were rolled out. Whether they show success or an area for continued improvement, these reports help demonstrate the impact the committee has on patient safety and care.

How Can We Help?

A resuscitation committee that uses meaningful data to make positive, sustainable change to improve patient care and outcomes is a success. With CoDirector® Software from Nuvara®, Code Blue responders and Resuscitation Committees can:

  • Digitally document all interventions in real time
  • Easily customize and update a real-time guidance system with your hospital’s resuscitation algorithms and medication dosing protocols
  • Use an interactive dashboard of automated timers to pace recurring actions and monitor CPR quality in the moment
  • Access out-of-the-box, automatic event reporting for key clinical quality indicators and exportable data for deeper data analysis
  • Access automatically created, insight-rich reports that provide a single, shared, comprehensive view of Code Blue operations — and how to improve them
  • Continually aggregate and analyze facility-wide event data to uncover trends and new opportunities to enhance care over time


See For Yourself

Ready to learn more about how Nuvara’s CoDirector Software can help your hospital comply with evolving TJC resuscitation standards?


  1. Becker, L. B., Aufderheide, T. P., & Graham, R. (2015). Strategies to improve survival from cardiac arrest. JAMA, 314(3), 223.
  2. Chan PS, Krein SL, Tang F, et al. Resuscitation practices associated with survival after in-hospital cardiac arrest: a nationwide survey. JAMA Cardiol. 2016;1(2):189-197.
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