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Pointing to widespread variability of in-hospital cardiac arrest (IHCA) care and outcomes nationally, The Joint Commission (TJC) released revised resuscitation standards that went into effect in early 2022. By now, hospitals are well aware of — and actively working to comply with — the new requirements, which cover everything from data collection to post-cardiac arrest care.

TJC-accredited hospitals know that compliance is a hospital-wide effort — one that requires commitment and participation from all staff involved in resuscitation. But for hospitals that already have a resuscitation committee in place (or are in the process of forming one), it makes sense to think strategically about the committee’s specific role. Why? At most hospitals, resuscitation committees, or “code committees,” already have a big-picture view of IHCA performance and outcomes — and are focused on identifying gaps and improving quality.

In this article, we’ll look at 3 key areas covered under TJC’s revised resuscitation standards — evidenced-based policies and procedures, data collection, and case review – and identify specific ways your resuscitation committee can help with compliance.

1. Analyze resuscitation policies, procedures, and protocols

The Joint Commission’s resuscitation standards

In the revised standards, TJC emphasizes having — and adhering to — research-backed policies, procedures, or protocols across multiple areas of resuscitation care. This includes:

  • Standard PC.02.01.11, EP 1: “Resuscitative services are provided to the patient according to the hospital’s policies, procedures, or protocols.”
  • Standard PC.01.20, EP 1: “The hospital develops and follows policies, procedures, or protocols based on current scientific literature for interdisciplinary post-cardiac arrest care.”
  • Standard PC.01.20, EP 2: “The hospital develops and follows policies, procedures, or protocols based on current scientific literature to determine the neurological prognosis for patients who remain comatose after cardiac arrest.”

How your resuscitation committee can help

1. Perform a needs assessment:  If your hospital is in the early stages of evaluating the revised resuscitation standards, have the resuscitation committee take stock of what protocols your hospital currently has and identify any gaps.

  • What policies/procedures do we already have in place?
  • What policies/procedures do we need to create, revise, or develop further?
  • Are our policies/procedures grounded in current scientific literature? Do any need to be updated?

After the committee’s initial analysis, next steps will depend on the gaps identified and the scope of work involved. If the changes are relatively minor, committee members may be able to tackle the revisions themselves and call on other departments and subject matter experts for consultation and review. For more involved changes, the committee may recommend creation of a smaller, focused task force (e.g., post-arrest care) instead.

2. Evaluate implementation: If your hospital already has TJC-compliant policies in place, the committee can then turn its attention to adherence.

  • How well are we adhering to the policies throughout the hospital?
  • How informed are staff members? Do they know what the policies are, where to find them, and how to implement them?
  • What can we do to better communicate policy changes?

2. Enforce data collection requirements

The Joint Commission’s resuscitation standards

Another common theme throughout the revised guidelines: the importance of accurate, comprehensive data collection. Per standard PI.01.01.01, EP 10, that means focusing on the following:

  • Number and location of cardiac arrests
  • Resuscitation outcomes
  • Transfer to a higher level of care

TJC also requires an interdisciplinary committee to review Code Blue cases (standard PI.03.01.01, EP 22). In the next section, we’ll offer tips for performing that review. But from a data collection perspective, this standard calls on hospitals to track the following:

  • How often early warning signs of clinical deterioration were present for patients in non-monitored or non-critical care units
  • Timeliness of staff response to cardiac arrest
  • Quality of cardiopulmonary resuscitation
  • Post-cardiac arrest care processes
  • Outcomes following cardiac arrest

How your resuscitation committee can help

Much of the actual data collection won’t happen at the committee level itself. But the committee is well-positioned to provide oversight and ensure the right data is being collected consistently across Code Blue teams. That’s because — accreditation aside — accurate, usable data is integral to code committees. They can’t gauge current performance or prioritize quality improvement initiatives without it. And since meeting organizers and/or committee members are compiling both individual and aggregate data prior to each meeting anyway, it’s a good opportunity to cross-check against the data requirements above.

3. Review Code Blue cases

The Joint Commission’s resuscitation standards

New to the standards as of 2022, Code Blue cases and data must be reviewed by an interdisciplinary committee to “identify and suggest practice and system improvements” (standard PI.03.01.01, EP 22).

How your resuscitation committee can help

It sounds straightforward enough: Case review is a logical addition to the resuscitation committee’s agenda (if it’s not being done already). But there are a few tips to keep in mind for compliance:

  • Review individual cases. Aggregate data is invaluable for committee analysis. But for compliance with this standard, it shouldn’t be the sole focus. Make sure your committee is regularly reviewing individual Code Blue cases.
  • Be thorough. At a minimum, the committee should analyze all the data we discussed in the last section from standard PI.03.01.01, EP 22: early warning signs, timeliness of the response, etc. You can always build on that list to meet your hospital’s particular needs, but don’t skip or skimp on the examples TJC suggests.
  • Document the analysis and takeaways. Be sure to designate a member who is responsible for documenting the committee’s findings. What data was analyzed during the case review? Equally important: What were the key takeaways? What changes or improvements were made as a result? The goal is not only to review cases, but to take action based on the findings.
  • Include all committee members in the discussion. TJC specifies that the committee reviewing the cases must be interdisciplinary. It’s a good idea to regularly review the composition of your committee to ensure all key groups and stakeholders are represented and heard during the discussion. Typically, this will include Code Blue responders and leadership (both nurses and physicians), plus representatives from patient care services, respiratory therapy, anesthesia, telecommunications, and more.


Ready to learn more?

Your hospital’s resuscitation committee already plays a key role in identifying and removing barriers to optimal Code Blue response. If you’re ready to maximize their effectiveness and impact, read our blog on strategies to optimize committee meetings next.


The Joint Commission. (2021). R3 Report: Resuscitation Standards for Hospitals. Available at: r3-report_resuscitation_hap_final_.pdf (
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