Transcript JCAHO_08_NPSG_genera..

© Copyright, The Joint Commission
2008 National Patient Safety Goals
© Copyright, The Joint Commission
The purpose of the Joint Commission’s
National Patient Safety Goals (NPSGs)
is to promote specific improvements in
patient safety.
The Requirements highlight problematic
areas in health care and describe
evidence and expert-based solutions to
these problems.
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The Requirements focus on systemwide
solutions, wherever possible.
National Patient Safety Goals
 Each year, the Sentinel Event Advisory Group
works with The Joint Commission to undertake a
systematic review of the literature and available
databases to identify potential new Goals and
Requirements
 The Goals and their Requirements are published
mid-year
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 Goals and Requirements are guided by the
Sentinel Event Advisory Group
The Sentinel Event Advisory Group
 Nationally recognized experts in patient safety
 Individuals with hands-on experience in health care
organizations, representative of the types and sizes
of accredited organizations and the various patient
populations
 Experts in related fields such as pharmaceuticals,
information technology, medical equipment, etc.
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 Systems engineers with practical knowledge of root
cause analysis (RCA), failure mode and effects
analysis, human factors engineering, etc.
The Sentinel Event Advisory Group
 Annually recommends core and program-specific
NPSGs for adoption by the Board of Commissioners
 Reviews draft patient safety recommendations for
potential publication in Sentinel Event Alert
 Recommends topics for future consideration in
Sentinel Event Alert
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 Provides advice on the acceptability of alternative
practices implemented by accredited organizations in
lieu of the specific NPSG Requirements
The Joint Commission
2008 National Patient Safety Goals
Approved by the Joint Commission’s Board
of Commissioners in June 2007
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The Goals and Requirements are programspecific
Patient Identification
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Goal: Improve the accuracy of patient
identification.
Patient Identification
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: Use at least two patient
identifiers when providing care, treatment or
services.
Patient Identification
Applies to: Assisted Living, Home Care, Lab, Long
Term Care
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• Requirement: Prior to the start of any
invasive procedure, conduct a final
verification process, (such as a “time out,”) to
confirm the correct patient, procedure and
site, using active—not passive—
communication techniques.
Improve Communication
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Goal: Improve the effectiveness of
communication among caregivers.
Improve Communication
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: 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
information record and "read-back" the
complete order or test result.
Improve Communication
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: Standardize a list of
abbreviations, acronyms, symbols, and dose
designations that are not to be used
throughout the organization.
Improve Communication
Applies to: Ambulatory Care, Behavioral Health Care,
Critical Access Hospital, Disease-Specific Care, Home
Care, Hospital, Lab, Long Term Care, Office-Based
Surgery
New for Long Term Care in 2008
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• Requirement: 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 tests and critical results and values.
Improve Communication
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: Implement a standardized
approach to “hand off” communications,
including an opportunity to ask and respond
to questions.
Medication Safety
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Goal: Improve the safety of using medications.
Medication Safety
Applies to: Ambulatory Care, Behavioral Health Care,
Critical Access Hospital, Home Care, Hospital, Long
Term Care, Office-Based Surgery
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• Requirement: Identify and, at a minimum,
annually review a list of look-alike/soundalike drugs used by the organization, and
take action to prevent errors involving the
interchange of these drugs.
Medication Safety
Applies to: Ambulatory Care, Critical Access Hospital,
Hospital, Office-Based Surgery
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• Requirement: Label all medications,
medication containers (for example,
syringes, medicine cups, basins), or other
solutions on and off the sterile field.
Medication Safety
• Requirement: Reduce the likelihood of
patient harm associated with the use of
anticoagulation therapy.
New for 2008
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Applies to: Ambulatory Care, Critical Access Hospital,
Home Care, Hospital, Long Term Care, Office-Based
Surgery
Health Care-Associated Infections
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Goal: Reduce the risk of health careassociated infections.
Health Care-Associated Infections
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
Expanded for 2008
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• Requirement: Comply with current World
Health Organization (WHO) Hand Hygiene
Guidelines or Centers for Disease Control
and Prevention (CDC) hand hygiene
guidelines.
Health Care-Associated Infections
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: Manage as sentinel events all
identified cases of unanticipated death or
major permanent loss of function associated
with a health care-associated infection.
Reconcile Medications
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Goal: Accurately and completely reconcile
medications across the continuum of care.
Reconcile Medications
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Long
Term Care, Office-Based Surgery
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• Requirement: There is a process for
comparing the patient’s current medications
with those ordered for the patient while under
the care of the organization.
Reconcile Medications
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Long
Term Care, Office-Based Surgery
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• Requirement: A complete list of the patient’s
medications is communicated to the next
provider of service when a patient is referred
or transferred to another setting, service,
practitioner or level of care within or outside
the organization. The complete list of
medications is also provided to the patient on
discharge from the facility.
Reduce Falls
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Goal: Reduce the risk of patient harm
resulting from falls.
Reduce Falls
• Requirement: Implement a fall reduction
program including an evaluation of the
effectiveness of the program.
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Applies to: Assisted Living, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Long
Term Care
Influenza & Pneumococcal Disease
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Goal: Reduce the risk of influenza and
pneumococcal disease in institutionalized
older adults.
Influenza & Pneumococcal Disease
• Requirement: Develop and implement a
protocol for administration and
documentation of the flu vaccine.
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Applies to: Assisted Living, Disease-Specific Care,
Long Term Care
Influenza & Pneumococcal Disease
Applies to: Assisted Living, Disease-Specific Care,
Long Term Care
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• Requirement: Develop and implement a
protocol for administration and
documentation of the pneumococcus
vaccine.
Influenza & Pneumococcal Disease
• Requirement: Develop and implement a
protocol to identify new cases of influenza
and to manage an outbreak.
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Applies to: Assisted Living, Disease-Specific Care,
Long Term Care
Surgical Fires
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Goal: Reduce the risk of surgical fires.
Surgical Fires
Applies to: Ambulatory Care, Office-Based Surgery
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• Requirement: Educate staff, including
operating licensed independent practitioners
and anesthesia providers, on how to control
heat sources and manage fuels with enough
time for patient preparation, and establish
guidelines to minimize oxygen concentration
under drapes.
Implementation of NPSGs
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Goal: Implementation of applicable National
Patient Safety Goals and associated
requirements by components and
practitioner sites.
Implementation of NPSGs
• Requirement: Inform and encourage
components and practitioner sites to
implement the applicable National Patient
Safety Goals and associated requirements.
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Applies to: Networks
Patient Involvement
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Goal: Encourage patients’ active involvement
in their own care as a patient safety strategy.
Patient Involvement
Applies to: Ambulatory Care, Assisted Living,
Behavioral Health Care, Critical Access Hospital,
Disease-Specific Care, Home Care, Hospital, Lab,
Long Term Care, Office-Based Surgery
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• Requirement: Define and communicate the
means for patients and their families to
report concerns about safety and encourage
them to do so.
Pressure Ulcers
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Goal: Prevent health care-associated
pressure ulcers (decubitus ulcers).
Pressure Ulcers
• Requirement: Assess and periodically
reassess each resident’s risk for developing
a pressure ulcer (decubitus ulcer) and take
action to address any identified risks.
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Applies to: Long Term Care
Risk Assessment
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Goal: The organization identifies safety risks
inherent in its patient population.
Risk Assessment
Applies to: Behavioral Health Care, Hospital
(applicable to psychiatric hospitals and patients being
treated for emotional or behavioral disorders in
general hospitals)
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• Requirement: The organization identifies
patients at risk for suicide.
Risk Assessment
• Requirement: The organization identifies
risks associated with long-term oxygen
therapy such as home fires.
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Applies to: Home Care
Changes in Patient Condition
New for 2008
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Goal: Improve recognition and response
to changes in a patient’s condition.
Changes in Patient Condition
Applies to: Critical Access Hospital, Hospital
New for 2008
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• Requirement: The organization selects a
suitable method that enables health care
staff members to directly request
additional assistance from a specially
trained individual(s) when the patient’s
condition appears to be worsening.
Universal Protocol for Preventing Wrong-site,
Wrong-person, Wrong-procedure Surgery
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• Requirement: Use a pre-op verification
process, such as a checklist, to confirm
appropriate documents are available.
Universal Protocol for Preventing Wrong-site,
Wrong-person, Wrong-procedure Surgery
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• Requirement: Implement a process to mark
the surgical site and involve the patient in the
process.
Universal Protocol for Preventing Wrong-site,
Wrong-person, Wrong-procedure Surgery
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• Requirement: Prior to the start of any
surgical or invasive procedure, conduct a
final “time out” verification to confirm the
correct patient, procedure, and site.
Submitting Alternative Approaches
Submit a “Request for Review of an
Alternative Approach to a NPSG
Requirement ” form found on
www.jointcommission.org/PatientSafety/NationalPati
entSafetyGoals
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Alternatives much be at least as effective as
the published Requirements in achieving the
Goals and must be approved by The Joint
Commission based on the Sentinel Event
Advisory Group’s review.
Submitting Alternative Approaches
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If an alternative is not accepted, the
organization will need to either revise the
alternative until it is approved, or implement
the Requirement as issued by The Joint
Commission.
Surveying and Scoring the
National Patient Safety Goals
 All applicable Goals & Requirements, or
acceptable alternative approaches, must be
implemented
 Surveyors evaluate actual performance, not just
intent
 Failure to comply with a NPSG Requirement will
result in a “Requirement for Improvement”
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 NPSG Requirements are Compliant or Not
Compliant
Public Disclosure of Compliance with the
National Patient Safety Goals
Aggregate data
– Data from 2003 – 2007 surveys posted on
Joint Commission website
Individual health care organizations:
– Revised “Quality Reports” —
on website since mid-year 2004
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– Compliance with specific Requirements
For more information:
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The Joint Commission website
www.jointcommission.org