Joint Commission Recognizes MRH Patient Safety Program as Performance Strength

National recognition highlights innovative approach to learning from safety events

MONTROSE, Colo. (June 29, 2026) – The Joint Commission has selected a patient safety initiative developed at Montrose Regional Health (MRH) for inclusion in its national resource library, recognizing the organization’s Safety Event Review Team (SERT) program as a performance strength. The resource will be shared with healthcare organizations across the country as an example of effective safety event review, organizational learning, and continuous improvement.

Developed and coordinated by Kyle Kelley, RN, BSN, CPHRM, CPHQ, risk management coordinator at MRH, the SERT program was created to ensure findings and improvement opportunities from safety events are consistently shared across departments. The multidisciplinary team reviews safety events, conducts root cause analyses, and develops action plans designed to strengthen patient safety across the organization.

“Every safety event presents an opportunity to learn and improve,” Kelley said. “SERT was created to ensure lessons learned are shared across the organization so we can strengthen processes, improve patient safety, and foster a culture of accountability, transparency, and continuous learning.”

One example highlighted by The Joint Commission involved MRH’s Mass Transfusion Protocol (MTP), which is used during life-threatening bleeding emergencies. Following a SERT review, the hospital implemented standardized workflows, improved communication tools, enhanced staff training, clarified responsibilities, and updated policies related to the protocol. Since those improvements were implemented, MRH has reported no additional mass-transfusion-related safety events.

The Joint Commission also noted that the SERT program has helped strengthen staff engagement in safety reporting by providing visible feedback and demonstrating that reported concerns lead to meaningful action. The organization’s resource summary highlighted improvements in transparency, trust, and communication across departments.

“This recognition reflects the dedication of caregivers across Montrose Regional Health who work every day to provide safe, high-quality care,” Jeff Mengenhausen, MRH CEO, said. “Patient safety is a shared responsibility, and the success of SERT is the result of collaboration across departments throughout the organization.”

The Joint Commission will share MRH’s SERT program with healthcare organizations across the country as a resource for strengthening patient safety, communication, and organizational learning.