National Patient Safety Goals

1
National Patient Safety Goals

• Peter Angood MD FACS FCCM
• Vice President Chief Patient Safety Officer
• Joint Commission (JCAHO)

2
The Joint CommissionsSentinel Event Policy

• Established in January 1996 with the following
  goals
• To have a positive impact in improving care
• To focus attention on underlying causes and risk
  reduction
• To increase the general knowledge about sentinel
  events, their causes and prevention
• To maintain public confidence in the
  accreditation process

3
Joint Commission Public Policy Position on
Reporting Managing Medical Errors

• In order to measurably improve patient safety,
  the Joint Commission supports
• Creation of an effective national reporting
  system
• (mandatory or voluntary)
• Conditioned on the following
• Standardized definition of a reportable medical
  error or event
• Requirement for in-depth analysis of each
  error/event
• Federal protection from disclosure of the
  resulting information
• Requirement for action plan with follow-up
• Sharing of event-related information with
  oversight bodies

4
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)

• Event resulted in unanticipated patient death or
  major permanent loss of function (unrelated to
  the natural course of the patient's illness or
  underlying condition)
• OR

5
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)

• Or, the event involves one of the following
• Suicide in a round-the-clock staffed care setting
  or within 72 hours of discharge
• Abduction of a patient (any age)
• Infant discharge to wrong family
• Rape
• Hemolytic transfusion reaction
• Surgery on wrong patient or wrong body part

6
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)

• Or, the event involves one of the following
• Unintended retention of a foreign object after
  surgery
• Severe neonatal hyperbilirubinemia
• (gt30 milligrams/deciliter)
• Radiation overdose
• Fluoroscopy gt 1500 rad to a single field
• Radiotherapy to the wrong body region or gt25
  above the planned dose

7
Sentinel Event Experience to Date
Of 3548 sentinel events reviewed by the Joint
Commission, January 1995 through December 2005

• 464 inpatient suicides
• 455 events of surgery at the wrong site
• 444 operative/post op complications
• 358 events relating to medication errors
• 269 deaths related to delay in treatment
• 189 patient falls
• 138 deaths of patients in restraints
• 121 assault/rape/homicide
• 109 perinatal death/injury
• 94 transfusion-related events
• 67 infection-related events
• 66 deaths following elopement
• 65 fires
• 58 anesthesia-related events
• 651 other

3548 RCAs
8
Percent of Events That Were Self-Reported (by
State)
9
Root Causes of Sentinel Events
(All categories 1995-2004)
Percent of 2966 events
10
Root Causes of Sentinel Events
(All categories 2005)
Percent of 582 events
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(No Transcript)
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Sentinel Event Alert

• Potassium chloride
• Policy issues
• Policy issues
• Policy issues
• Policy issues
• Wrong site surgery
• Suicide
• Restraint deaths
• Infant abductions
• Transfusion errors
• High Alert Medications
• Op/post-op complications
• Impact of SE Alert
• Fatal falls
• Infusion pumps
• Proactive risk reduction
• Home fires (O2 therapy)
• Kernicterus

• Look-alike, sound-alike drugs
• Kreutzfeldt-Jakob disease
• Medical gas mix-ups
• Needles sharps injuries
• Dangerous abbreviations
• Wrong-site surgery 2
• Ventilator-related events
• Delays in treatment
• Bed rail deaths injuries
• Nosocomial infections
• Surgical fires
• Perinatal deaths
• Anesthesia awareness
• Kernicterus 2
• PCA by proxy
• Intrathecal vincristine
• Medication reconciliation
• Tubing misconnections
• Emergency power failures

13
National Patient Safety Goals

• Each year, a set of Goals will be identified from
  topics published in Sentinel Event Alert
• A small number of specific requirements for each
  of the Goals will be identified for survey the
  following year
• The Goals and their requirements will be
  published by mid-year
• Selection of the Goals and requirements will be
  guided by a panel of experts the Sentinel Event
  Advisory Group

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The Sentinel Event Advisory Group

• Nationally recognized experts in patient safety
• Systems engineers with practical knowledge of
  root cause analysis, failure mode effects
  analysis, human factors engineering, etc.
• Individuals with hands-on experience in health
  care organizations, representative of the types
  sizes of organizations and the various patient
  populations
• Experts in related fields such as
  pharmaceuticals, information technology, medical
  equipment, etc.
• Ad hoc appointments for special expertise

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The Sentinel Event Advisory Group

• Assess the evidence for and face validity of
  Sentinel Event Alert recommendations
• Assess the practicality and cost of implementing
  each of the identified evidence-based
  recommendations
• Reach consensus on candidates for National
  Patient Safety Goals
• Assess the comparability of alternatives to the
  NPSG requirements that are implemented by
  individual organizations
• Advise on future topics for Sentinel Event Alert

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The Joint Commission 2005National Patient Safety
Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery
• Infusion pumps
• Clinical alarm systems
• Health care-associated infections
• Reconciliation of medications
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• NPSG implementation by network components

17
The Joint Commission 2006National Patient Safety
Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery (Universal Protocol)
• Health care-associated infections
• Reconciliation of medications
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• Patient involvement
• Pressure ulcers

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NPSG Compliance Data for 20032006(General
Hospital Full Surveys Percent Non-compliance)
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Requesting Review of an Alternative Approach

• Requests for review of an alternative approach to
  one of the NPSG requirements must be submitted
  prior to survey
• Request form and procedure available on
  www.jcaho.org
• Review by Sentinel Event Advisory Group
• Decision by the Joint Commission on acceptability
  of the alternative approach
• Evaluation of implementation by surveyor

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Alternatives Approaches to the NPSGs
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The JCAHO 2006National Patient Safety Goals

• The 2006 Goals and associated requirements were
  approved by the Board of Commissioners on May 20,
  2005
• Keep the focusNo more than two new requirements
  per program
• High impact
• Evidence-based
• Cost-effective
• No increase in the total number of requirements

22
Moving from 2005 to 2006

• Retire, modify or transition some 2005 goals
• 1a, 1b, 2aContinue in 2006 no change
• 2bContinue with changes per Summit
• 2c, 2dModify (timely communication between
  providers delete directly)
• 3aRetire (covered in Med Use standards)
• 3bContinue implement Rule-of-6 transition plan
• 3cContinue in 2006 no change
• 4a, 4b, 5a, 6a, 6bRetire (covered in U.P. and EC
  standards)
• 7a, 7bContinue in 2006 no change
• 8a, 8bMove from planning to implementation
• 9aRetire (replace with 9b)
• 10a,b,c 11a, 12aContinue in 2006 no change

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New Goals Requirements for 2006

• Add to Goal 2 Hand-off communication
• (All programs)
• Add to Goal 3 Label meds on sterile field
• (Hospitals, Ambulatory, Office-based Surgery)
• New Goal 13 Patient involvement in safety
• (Home Care, Lab, Assisted Living, DSC)
• New Goal 14 Pressure ulcer prevention
• (Long Term Care)

24
The Joint Commission 2006National Patient Safety
Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery Universal Protocol
• Infusion pumps
• Clinical alarm systems
• Health care-associated infections
• Medication reconciliation
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• NPSG implementation by network components
• Patient involvement
• Pressure ulcers

25
The Joint Commission 2007National Patient Safety
Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery (Universal Protocol)
• Health care-associated infections
• Reconciliation of medications
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• Patient involvement
• Pressure ulcers
• Identify safety risks inherent in patient
  population

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Implementation Expectations and FAQs

• Implementation Expectations
• Rationale
• Performance expectations requirements
• FAQs
• Interpretation of terms, scope, applicability
• Suggestions and recommendations for how to
• Self-assessment and survey process insights

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National Patient Safety Goals

• Goal 1 Improve the accuracy of patient
  identification.
• Requirement 1.a.
• Use at least 2 patient identifiers (not the
  patients room number) whenever administering
  medications or blood products taking blood
  samples and other specimens for clinical testing
  or providing any other treatments or procedures.
• Requirement 1.b. (Universal Protocol)
• Prior to the start of any surgical or invasive
  procedure, conduct a verification time out to
  confirm the correct patient, procedure, and site.

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National Patient Safety Goals

• Goal 1 Improve the accuracy of patient
  identification.
• Requirement 1.a. For Laboratories only
• Use at least two patient identifiers (neither to
  be the patient's location) whenever collecting
  laboratory samples or administering medications
  or blood products, and use two identifiers to
  label sample collection containers in the
  presence of the patient. Processes are
  established to maintain samples' identity
  throughout the pre-analytical, analytical and
  post-analytical processes.

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National Patient Safety Goals

• Goal 1 Improve the accuracy of patient
  identification.
• Requirement 1.b. For Laboratories only
• Immediately prior to the start of any invasive
  procedure, conduct a final verification process
  to confirm the correct patient, procedure, site,
  and availability of appropriate documents. This
  verification process uses activenot
  passivecommunication techniques. The patient's
  identity is re-established if the practitioner
  leaves the patient's location prior to initiating
  the procedure. Marking the site is required
  unless the practitioner is in continuous
  attendance from the time of the decision to do
  the procedure and patient consent to the
  initiation of the procedure (for example, bone
  marrow collection, or fine needle aspiration).

30
National Patient Safety Goals

• Goal 2 Improve the effectiveness of
  communication among caregivers.
• Requirement 2.a.
• For verbal or telephone orders or for telephonic
  reporting of critical test results , verify the
  complete order or test result by having the
  person receiving the order or test result
  read-back the complete order or test results.
• Requirement 2.b.
• Standardize a list of abbreviations, acronyms,
  and symbols that are not to be used throughout
  the organization.

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Official Do Not Use list

• u
• IU
• qd
• qod
• Leading decimal point
• (always use a Leading zero)
• Trailing zero
• MS
• MSO4
• MgSO4

No additions for 2007
Plus an additional 3 items of the organizations
choosing
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Recommendations from the Summit

• Expected level of compliance
• 100 for pre-printed forms
• 90 for handwritten documentation in 2005
• Annual increase in expected level of compliance
  after 2005
• Up to maximum of 95
• Further study needed to establish rules for
  computer-generated forms and computer displays

Approved for 2005
No change for 2006-07
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Clarification of Orders Containing Do Not Use
Abbreviations

• 2005 Clarification of any order containing a do
  not use abbreviation is expected
• Problem Unintended consequence of burden on
  nurses and pharmacists prescribers not returning
  calls from pharmacy
• 2006 New approach
• Require clarification with the prescriber when
  the order is not clearno call required if order
  is clear
• Use of prohibited terms is scored whenever used
• Failure to clarify unclear orders, will be scored
  separately
• Medical staff is responsible for managing
  prescriber behaviors (not nurses pharmacists)

34
National Patient Safety Goals

• Goal 2 Improve the effectiveness of
  communication among caregivers.
• Requirement 2.c.
• Measure, assess and, if appropriate, take action
  to improve the timeliness of reporting, and the
  timeliness of receipt by the responsible licensed
  caregiver, of critical test results and values.

35
Improving the Timeliness of Reporting Critical
Test Results

• This is a performance improvement requirement
• Measure, assess, improve (if appropriate)
• It applies to all types of diagnostic testing
  (not just lab)
• Critical test
• Measure time from order to time of report
• Critical result / value
• Measure time from identification of critical
  result to time of report

36
Improving the Timeliness of Reporting Critical
Test Results

• The health care organization defines
• Its critical tests
• Its critical results/values
• Its target turn-around times
• Its measurement strategies

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National Patient Safety Goals

• Goal 2 Improve the effectiveness of
  communication among caregivers.
• Requirement 2.d. For Laboratories only
• All values defined as critical by the laboratory
  are reported directly to a responsible licensed
  caregiver within time frames established by the
  laboratory (defined in cooperation with nursing
  and medical staff). When the patients
  responsible licensed caregiver is not available
  within the time frames, there is a mechanism to
  report the critical information to an alternative
  responsible caregiver.

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National Patient Safety Goals

• Goal 2 Improve the effectiveness of
  communication among caregivers.
• Requirement 2.e. All programs
• Implement a standardized approach to hand off
  communications, including an opportunity to ask
  and respond to questions.

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Hand-off Communication

• A hand off communication is a contemporaneous,
  interactive process of passing patient-specific
  information from one caregiver to another or from
  one team of caregivers to another for the purpose
  of ensuring the continuity and safety of the
  patients care.
• Examples
• Nursing change-of-shift report
• Physician sign-out to a covering physician
• Anesthesia provider or circulating nurse
  reporting to the PACU staff
• ED staff communicating with staff at a receiving
  facility

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Developing a Standardized Approach to Hand-off
Communications

• A standardized approach should identify
• The hand off situations that it applies to
• Who is, or should be, involved in the
  communication
• What information should be communicated
• Diagnoses and current condition of the patient
• Recent changes in condition or treatment
• Anticipated changes in condition or treatment
• What to watch for in the next interval of care
• Opportunities to ask and respond to questions
• When to use certain techniques (repeat-back
  SBAR)
• What print or electronic information should be
  available

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National Patient Safety Goals

• Goal 3 Improve the safety of using
  medications.
• Requirement 3.a. Retiredsee MM.2.20, EP 9
• Remove concentrated electrolytes from patient
  care units (including KCl, K3PO4, NaCl gt 0.9)
• Requirement 3.b.
• Standardize and limit the number of drug
  concentrations available in the organization.

42
National Patient Safety Goals

• Goal 3 Improve the safety of using
  medications.
• Requirement 3.c.
• Identify and, at a minimum, annually review a
  list of look-alike/sound-alike drugs used in the
  organization, and take action to prevent errors
  involving the interchange of these drugs.

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Lists of Look-alike, Sound-alike Drugs

• Go to www.jcaho.org
• Click on NPSGs and FAQs
• Then click on Hospital
• Then click on FAQs about the 2005 NPSGs
• Select New Look-alike, sound-alike drug list
• An organizations list of look-alike/sound-alike
  drugs must contain a minimum of 10 drug
  combinations. At least 5 of these combinations
  must be selected from Table I or from Table II,
  as appropriate to the type of organization. An
  additional 5 combinations must be selected from
  any of the Tables I, II and/or III.

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National Patient Safety Goals

• Goal 3 Improve the safety of using
  medications.
• Requirement 3.d. Hospital, Amb., OBS
• Label all medications, medication containers
  (e.g., syringes, medicine cups, basins), or other
  solutions on and off the sterile field in
  perioperative and other procedural settings.

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Label all medications

• See standard MM.4.30 Medications are
  appropriately labeled
• Includes all medications and solutions
• Even if there is only one
• Even if it is obvious
• It also applies to anesthesia medications
• It applies to the O.R. and other procedural
  settings, not just invasive procedures

46
What Should Be on the Label?

• Required by standard MM.4.30 for all settings
• Drug name, strength, amount (if not apparent from
  the container)
• Expiration date, when not used within 24 hours
• Expiration time when expiration is within 24
  hours
• For IV admixtures and parenteral nutrition
  solutions, the date prepared and diluent.
• Additional requirements for labeling in
  perioperative/procedural settings
• The date (of transfer and use)
• Initials of the person preparing the label
• Verification of label by a second person unless
  the same person prepares and uses the med /
  solution

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National Patient Safety Goals

• Goal 4 Eliminate wrong-site, wrong-patient,
  wrong-procedure surgery.
• Retired Now Surveyed under the Universal
  Protocol

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Sentinel Event TrendsWrong-site Surgeries
Reported by Year
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Provisions of the Universal Protocol

• Preoperative verification process
• Relevant pre-op tasks completed and information
  is available and correct
• Surgical site marking
• Unambiguous mark, visible after prep drape
• Right/left, multiple structures or levels
• Time out immediately before starting
• Involves entire team active communication
• Fail-safe model No go unless all agree
• Applicable to invasive procedures in all settings

50
Marking the Operative Site(Special
considerations)

• Spinal surgery
• Mark general level prior to surgery (C/T/L)
• Mark precise level intraop using radiographic
  tech.
• Teeth need not be marked directly
• The dental radiograph or diagram must be marked
  and available at the time of the procedure
• Other exemptions
• Site not predetermined
• Continuous attendance
• Premature infants
• Procedure for patient refusal of site marking

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Time out Immediately Before Starting the
Procedure

• In the location where the procedure will be done
• Involve entire team using active communication
• Must be briefly documented
• Must include, at a minimum
• Correct patient
• Correct procedure
• Correct site
• Correct positioning
• Correct implant(s) and special equipment
• Process for reconciling differences

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The JCAHO 2006National Patient Safety Goals

• Goal 5 Improve the safety of using infusion
  pumps.
• Retiredsee EC.6.20, EP 2

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The JCAHO 2006National Patient Safety Goals

• Goal 6 Improve the effectiveness of clinical
  alarm systems. Retired Surveyed under the EC
  standards EC.6.20

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National Patient Safety Goals

• Goal 7 Reduce the risk of health
  care-associated infections.
• Requirement 7.a.
• Comply with current CDC hand hygiene guidelines.
  
• Requirement 7.b.
• Manage as sentinel events all identified cases
  of unanticipated death or major permanent loss of
  function associated with a health care-associated
  infection.

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CDC Hand Hygiene Guidelines

• Full report available at http//www.cdc.gov/handhy
  giene/
• Specific recommendations
• Indications for hand washing and hand antisepsis
• Visibly soileduse soap and water
• Not visibly soiledmay use alcohol-based hand rub
• List of specific clinical circumstances
• Towelettes are not a substitute
• Non-alcohol-based hand rubs not recommended

56
CDC Hand Hygiene Guidelines

• Specific recommendations (contd.)
• Hand hygiene technique
• Alcohol-based hand rubuntil dry
• Soap waterat least 15 seconds
• Surgical hand antisepsis
• Selection of hand hygiene agents
• Skin care
• Other aspects of hand hygiene

57
CDC Hand Hygiene Guidelines

• Each CDC hand hygiene recommendation cites the
  strength of evidence supporting the
  recommendation
• Category I (IA, IB, or IC)
• Category II
• Under Goal 7a, implementation of all CDC hand
  hygiene recommendations supported by Category I
  evidence will be required.
• Organizations will be asked to consider
  implementing all CDC hand hygiene recommendations
  supported by Category II evidence.

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CDC Hand Hygiene Guidelines

• Compliance expectation
• Satisfactory compliance
• at least 90 compliance with Level I CDC hand
  hygiene recommendations throughout the
  organization

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National Patient Safety Goals

• Goal 7 Reduce the risk of health care-acquired
  infections.
• Requirement 7.a.
• Comply with current CDC hand hygiene guidelines.
  
• Requirement 7.b.
• Manage as sentinel events all identified cases
  of unanticipated death or major permanent loss of
  function even if associated with a health
  care-acquired infection.

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Healthcare-Associated Infection and Sentinel
Events

• This is not a new requirement
• Any unanticipated death or major injury is a
  sentinel event whether there is an infection or
  not
• No change in surveillance methods is required
• This does not replace traditional rate-based
  analysis of health care-acquired infections
• RCA is not required for all health care-acquired
  infections only those that result in death or
  major injury
• The RCA looks comprehensively at the care of the
  patient, not just the infection
• See http//www.apic.org for Integrating sentinel
  event analysis into your infection control
  practice

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National Patient Safety Goals

• Goal 8 Accurately and completely reconcile
  medications across the continuum of care.
• Requirement 8.a.
• Implement a process for obtaining and
  documenting a complete list of the patient's
  current medications upon the patient's admission
  to the organization and with the involvement of
  the patient. This process includes a comparison
  of the medications the organization provides to
  those on the list.
• Requirement 8.b.
• A complete list of the patient's medications is
  communicated to the next provider of service when
  it refers or transfers a patient to another
  setting, service, practitioner or level of care
  within or outside the organization. The complete
  list is also provided to the patient on discharge.

New !
62
Why Is Medication Reconciliation Important?

• The most frequently occurring type of medical
  error
• Medication errors
• The most frequently cited category of root causes
  for serious adverse events
• Ineffective communication
• The most vulnerable parts of a process
• Links between the steps (the hand-offs)
• Medication reconciliation addresses all of these

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Which Medications Must Be Reconciled?

• Medication includes
• Prescription medications
• Sample medications
• Vitamins
• Nutriceuticals
• Over-the-counter drugs
• Vaccines
• Diagnostic and contrast agents
• Radioactive medications
• Respiratory therapy-related medications
• Parenteral nutrition
• Blood derivatives
• Intravenous solutions (plain or with additives)
• Any product designated by the FDA as a drug

64
What Should Be on the Home Med List?

• Medications on the home med list typically
  include
• Prescription medications
• Sample medications
• Vitamins
• Nutriceuticals
• Over-the-counter drugs
• Respiratory therapy-related medications
• For each medication, the list should include
• Name of the medication
• Dose
• Route
• Frequency
• Last dose (if patient is to be admitted)

Include all current medications. This is not a
medication history.
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Steps in the Reconciliation Process

• Develop a complete and accurate list of the
  patients medications (Not new see MM.1.10)
• Compare (reconcile) the listed medications with
  any new orders for medications
• Omission
• Duplication
• Interaction
• Name/dose/route confusion
• Update the list as orders change during the
  episode of care
• Communicate the updated list to the next
  provider(s) of care

66
When Should Reconciliation Occur?

• Whenever the organization
• refers or transfers a patient to another
  setting, service, practitioner, or level of care
  within or outside the organization.
• At a minimum
• Any time the organization requires that orders
  be rewritten
• Any time the patient changes service, setting,
  provider or level of care and new medication
  orders are written
• For transitions not involving new medications or
  rewriting of orders, the organization determines
  whether reconciliation must occur.

67
What About Minimal Medication Use Scenarios?

• Brief outpatient encounter (e.g., ED, Xray)
• No new meds prescribed for use after discharge
• No changes to the patient's current meds
• Minimal medication use during encounter
• Act locally with minimal systemic activity
• Examples
• Minimally absorbed topical agents
• Low volume local infiltration anesthetics
• Non-absorbable enteric contrast agents
• Should the Med Rec process be different?

68
How Many Lists Do We Need?

• An initial home medication list
• Keep this handydont change it.
• A list of medications that is updated throughout
  the episode of care
• This corresponds to what is on the M.A.R.
• Which list do we use for reconciliation? Both!
• Remember, some home medications may be held
  when a patient is admitted or goes to surgery.
  They may need to be resumed upon transfer to a
  different level of care, return from the OR, or
  at discharge.

69
Whats on the list and who gets it?

• Requirement 8.b.
• A complete list of the patient's medications is
  
• communicated to the next provider of service
• when the organization refers or transfers a
• patient to another setting, service,
  practitioner
• or level of care within or outside the
  organization.
• Whats on the list?
• All the medications the patient is to be taking
  after discharge, including dosage, frequency, and
  route.
• Who gets the list?
• The next provider of care
• The patient

70
Discharge Orders, Instructions, Lists

• Discharge orders
• Directed to other caregivers (treatments, Rx)
• Blanket orders (resume all ) are prohibited
• Discharge instructions
• Directed to the patient (self-care)
• Resume home meds is permitted
• Discharge list of medications
• Complete list of continuing medications
• This is not an order previous medications do not
  need to be reordered

71
Barriers to Implementation

• Physician buy-in
• Engage medical staff leaders early in the
  development process
• Demonstrate value, not just in terms of patient
  safety but in efficiency for the practitioners
• Provide feedback on good catches
• Just another add-on activity
• Integrate the Med Rec process into the existing
  work flow
• Its not my job
• Make it a team activity with clear
  responsibilities for each of the steps in the
  process

72
The JCAHO 2006National Patient Safety Goals

• Goal 9 Reduce the risk of patient harm
  resulting from falls.
• Requirement 9.a. Retired
• Assess and periodically reassess each patient's
  risk for falling, including the potential risk
  associated with the patient's medication regimen,
  and take action to address any identified risks.
• Requirement 9.b. Replaces 9.a.
• Implement a fall reduction program, including a
  transfer protocol, and evaluate the effectiveness
  of the program.

73
Fall Reduction Program

• Include, as appropriate to the setting and
  patient population
• Individual patient assessment and periodic
  reassessment
• Consideration of the patients medication regimen
• Assessment of the environment of care
• Modifications to the environment of care
• Transfer protocols
• Alarm systems
• Staff orientation training

74
National Patient Safety Goals

• Goal 10 Reduce the risk of influenza and
  pneumo-coccal disease in older adults. LTC
  AL, only
• Requirement 10.a.
• Develop and implement a protocol for
  administration and documentation of the flu
  vaccine.
• Requirement 10.b.
• Develop and implement a protocol for
  administration and documentation of the
  pneumococcus vaccine.
• Requirement 10.c.
• Develop and implement a protocol to identify new
  cases of influenza and to manage an outbreak.

75
National Patient Safety Goals

• Goal 11 Reduce the risk of surgical fires.
• Requirement 11.a.
• Educate staff, including operating licensed
  independent practitioners and anesthesia
  providers, on how to control heat sources and
  manage fuels, and establish guidelines to
  minimize oxygen concentration under drapes.
• AHC and OBS, only.

76
National Patient Safety Goals

• Goal 12 Implementation of applicable National
  Patient Safety Goals and associated requirements
  by components and practitioner sites.
  Networks PPOs, only
• Requirement 12.a.
• Inform and encourage components and practitioner
  sites to implement the applicable National
  Patient Safety Goals and associated requirements.

Also, see hospital standard LD.3.50 Services
provided by consultation, contractual
arrangements, or other agreements are provided
safely and effectively.
77
National Patient Safety Goals

• Goal 13 Encourage the active involvement of
  patients and their families in the patients care
  as a patient safety strategy. AL, DSC, HC, Lab
• Requirement 13.a.
• Define and communicate the means for patients to
  report concerns about safety and encourage them
  to do so.
• For 2007 Ambulatory, behavioral health care,
  critical access hospital, hospital, long term
  care office-based surgery

New !
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National Patient Safety Goals

• Goal 14 Prevent health care-associated
  pressure ulcers (decubitus ulcers). LTC
  only
• Requirement 14.a.
• Assess and periodically reassess each residents
  risk for developing a pressure ulcer and take
  action to address any identified risks.

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Moving to the 2007 JCAHONational Patient Safety
Goals

• Goal 15 The organization identifies safety
  risks inherent in its patient population
• Requirement 15.a.
• the organization identifies patients at risk for
  suicide BHC, HAP
• Requirement 15.b.
• the organization identifies risks associated with
  long-term oxygen therapy such as home fires Home
  care

New !
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Surveying and Scoring theNational Patient Safety
Goals

• Must implement all applicable Goals
  Requirements or implement an acceptable
  alternative approach(es)
• Evaluated in the PPR and during all full
  accreditation surveys and for-cause surveys
• Surveyors evaluate actual performance, not just
  intent
• Failure to comply with one or more requirements
  of a Goal will result in a Requirement for
  Improvement
• NPSG requirements that are also in the standards
  will only be scored once (no double jeopardy)

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Survey and Scoring Method for Requirements 2b and
7a

• All NPSG requirements are pass/failno partial
  compliance
• Three observation rule is used by surveyors for
  2b and 7a
• For Requirement 2b, one observation one or
  more slips per clinician per record
• For Requirement 7a, one observation any
  instance of non-compliance with a CDC category I
  recommendation
• Three observations a Requirement for Improvement

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Public Disclosure of Compliance with the National
Patient Safety Goals

• Aggregate data
• Data from 2003 - 2005 surveys posted on Joint
  Commission web site
• Individual health care organizations
• Compliance with specific requirements
• Revised Quality Reports
• on web site since mid-year 2004

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Additional Topics Being Considered for 2008
Implementation

• Comprehensive risk assessment
• Scope of this assessment to be program-specific
• Manage disruptive behavior
• Contract worker orientation training
• Anticoagulant management
• Intravascular catheter infections
• Expand scope of certain existing requirements
• Pressure ulcer prevention
• Patient involvement
• Surgical fires

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Patient Safety and Quality Improvement Act of 2005

• To encourage a culture of safety through legal
  protection of patient safety information
  voluntarily reported to PSOs.
• Patient safety organization (PSO)
• Duties
• Eligibility criteria and certification
• HIPAA considerations Business associate
• Patient safety work product (PSWP)
• PSWP is privileged and confidential
• National Network of patient safety databases
• Report to HHS IOM Effectiveness study by GAO

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For more information

• The Joint Commission Web Site
• www.jointcommission.org
• Joint Commission International Web Site
• www.jointcommissioninternational.org
• Joint Commission International Center for Patient
  Safety
• www.jcipatientsafety.org