Transcript 2009 National Patient Safety Goal: PowerPoint

© Copyright, The Joint Commission
2009 National Patient Safety Goals
The purpose of The Joint Commission’s
National Patient Safety Goals (NPSGs) is
to promote specific improvements in
patient safety.
The Requirements focus on system-wide
solutions, wherever possible.
2009 National Patient Safety Goals – Pg. 2
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The Requirements highlight problematic
areas in health care and describe
evidence and expert-based solutions to
these problems.
National Patient Safety Goals
 Goals and Requirements are guided and
prioritized by the Sentinel Event Advisory Group.
 The updated Goals and their Requirements are
published annually by mid-year after extensive
vetting, public commentary and approval phases.
2009 National Patient Safety Goals – Pg. 3
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 Each year, the Sentinel Event Advisory Group
works with The Joint Commission to undertake a
systematic review of the medical literature and
available health care databases to identify
potential new Goals and Requirements.
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
 Systems engineers with practical knowledge of root
cause analysis (RCA), failure mode and effects
analysis, human factors engineering, etc.
2009 National Patient Safety Goals – Pg. 4
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 Experts in related fields such as pharmaceuticals,
information technology, medical equipment, etc.
The Sentinel Event Advisory Group
 Annually recommends core and program-specific
NPSGs for adoption by the Board of Commissioners
 Provides advice on the acceptability of alternative
practices implemented by accredited organizations
in lieu of the specific NPSG Requirements
 Recommends topics for future consideration in
Sentinel Event Alert
2009 National Patient Safety Goals – Pg. 5
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 Reviews draft patient safety recommendations for
potential publication in Sentinel Event Alert
The Joint Commission 2009 National
Patient Safety Goals
 Approved by The Joint Commission’s Board of
Commissioners in May 2008
 The Goals and Requirements are program-specific
– New numbering system for sorting in new electronic
manuals
– Minor language changes for consistency
2009 National Patient Safety Goals – Pg. 6
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 Include improvements emanating from the
Standards Improvement Initiative, including:
Patient Identification
Goal 1:
2009 National Patient Safety Goals – Pg. 7
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Improve the accuracy of patient identification
Patient Identification
 NPSG.01.01.01: Use at least two patient
identifiers when providing care, treatment and
services. [was Goal 1A]
Revised for 2009
2009 National Patient Safety Goals – Pg. 8
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• Applies to: Ambulatory, Behavioral Health Care,
Critical Access Hospital, Disease-Specific Care,
Home Care, Hospital, Lab, Long Term Care, OfficeBased Surgery
Patient Identification
 NPSG.01.02.01: Prior to the start of any surgical
or invasive procedure, individuals involved in the
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. [was Goal 1B]
• Applies to Home Care, Lab, Long Term Care
Revised for 2009
2009 National Patient Safety Goals – Pg. 9
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~ EPs Mirror the Universal Protocol ~
Patient Identification
 NPSG.01.03.01: Eliminate transfusion errors
related to patient misidentification.
New for 2009
2009 National Patient Safety Goals – Pg. 10
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• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Improve Communication
Goal 2:
2009 National Patient Safety Goals – Pg. 11
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Improve the effectiveness of communication
among caregivers
Improve Communication
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 12
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 NPSG.02.01.01: For verbal or telephone orders or
for telephone reporting of critical test results, the
individual giving the order verifies the complete
order or test result by having the person receiving
the information record and "read-back" the
complete order or test result. [was Goal 2A]
Improve Communication
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 13
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 NPSG.02.02.01: There is a standardized list of
abbreviations, acronyms, symbols, and dose
designations that are not to be used throughout the
organization. [was Goal 2B]
Improve Communication
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 14
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 NPSG.02.03.01: The organization measures,
assesses and, if needed, takes action to improve
the timeliness of reporting, and the timeliness of
receipt of critical tests, and critical results and
values by the responsible licensed caregiver. [was
Goal 2C]
Improve Communication
 NPSG.02.05.01: The organization implements a
standardized approach to hand-off communications,
including an opportunity to ask and respond to
questions. [was Goal 2E]
Revised for 2009 – medications added
2009 National Patient Safety Goals – Pg. 15
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• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
Medication Safety
Goal 3:
2009 National Patient Safety Goals – Pg. 16
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Improve the safety of using medications
Medication Safety
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Long Term
Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 17
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 NPSG.03.03.01: The organization identifies and,
at a minimum, annually reviews a list of lookalike/sound-alike medications used by the
organization and takes action to prevent errors
involving the interchange of these medications.
[was Goal 3C]
Medication Safety
• Applies to: Ambulatory, Critical Access Hospital, Hospital,
Office-Based Surgery
2009 National Patient Safety Goals – Pg. 18
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 NPSG.03.04.01: Label all medications, medication
containers (for example, syringes, medicine cups,
basins), or other solutions on and off the sterile field.
[was Goal 3D]
Medication Safety
 NPSG.03.05.01: Reduce the likelihood of patient
harm associated with the use of anticoagulation
therapy. [was Goal 3E]
Clarified and Revised for 2009
2009 National Patient Safety Goals – Pg. 19
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• Applies to: Ambulatory, Critical Access Hospital, Home
Care, Hospital, Long Term Care
Health Care Associated Infections
Goal 7:
New for 2009 - Addition of 3 Requirements
2009 National Patient Safety Goals – Pg. 20
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Reduce the risk of health care associated
infections
Health Care Associated Infections
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 21
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 NPSG.07.01.01: Comply with current World Health
Organization (WHO) hand hygiene guidelines or
Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines. [was Goal 7A]
Health Care Associated Infections
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 22
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 NPSG.07.02.01: Manage as sentinel events all
identified cases of unanticipated death or major
permanent loss of function related to a health care
associated infection. [was Goal 7B]
Health Care Associated Infections
 NPSG.07.03.01: Implement evidence-based
practices to prevent health care associated
infections due to multiple drug-resistant
organisms in acute care hospitals.
New for 2009
2009 National Patient Safety Goals – Pg. 23
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• Applies to: Critical Access Hospital, Hospital
Health Care Associated Infections
 NPSG.07.04.01: Implement best practices or
evidence-based guidelines to prevent central
line-associated bloodstream infections.
New for 2009
2009 National Patient Safety Goals – Pg. 24
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• Applies to: Ambulatory, Critical Access Hospital,
Home Care, Hospital, Long Term Care
Health Care Associated Infections
 NPSG.07.05.01: Implement best practices for
preventing surgical site infections.
New for 2009
2009 National Patient Safety Goals – Pg. 25
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• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Reconcile Medications
Goal 8:
Completely Revised for 2009
2009 National Patient Safety Goals – Pg. 26
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Accurately and completely reconcile
medications across the continuum of care
Reconcile Medications
 NPSG.08.01.01: A process exists for comparing the
patient’s current medications with those ordered for
the patient while under the care of the organization.
[was Goal 8A]
Revised for 2009
2009 National Patient Safety Goals – Pg. 27
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• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Long Term Care, Office-Based Surgery
Reconcile Medications
 NPSG.08.02.01: When a patient is referred or transferred from
one organization to another, the complete and reconciled list of
medications is communicated to the next provider of service and
the communication is documented. Alternatively, when a patient
leaves the organization’s care directly to his or her home, the
complete and reconciled list of medications is provided to the
patient’s known primary care provider, or the original referring
provider, or a known next provider of service. [was Goal 8B]
Revised for 2009
2009 National Patient Safety Goals – Pg. 28
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• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Long Term Care, Office-Based Surgery
Reconcile Medications
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Long Term Care, Office-Based Surgery
New for 2009
2009 National Patient Safety Goals – Pg. 29
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 NPSG.08.03.01: When a patient leaves the
organization’s care, a complete and reconciled list
of the patient’s medications is provided directly to
the patient, and the patient’s family as needed,
and the list is explained to the patient and/or
family.
Reconcile Medications
 NPSG.08.04.01: In settings where medications are
used minimally, or prescribed for a short duration,
modified medication reconciliation processes are
performed.
New for 2009
2009 National Patient Safety Goals – Pg. 30
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• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Long Term Care, Office-Based Surgery
Reduce Falls
Goal 9:
2009 National Patient Safety Goals – Pg. 31
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Reduce the risk of patient harm resulting
from falls
Reduce Falls
 NPSG.09.02.01: The organization implements a
fall reduction program that includes an evaluation
of the effectiveness of the program. [was Goal 9B]
2009 National Patient Safety Goals – Pg. 32
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• Applies to: Critical Access Hospital, Disease-Specific
Care, Home Care, Hospital, Long Term Care
Influenza & Pneumococcal Disease
Goal 10:
2009 National Patient Safety Goals – Pg. 33
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Reduce the risk of influenza and pneumococcal
disease in institutionalized older adults
Influenza & Pneumococcal Disease
 NPSG.10.01.01: The organization develops and
implements protocols for administration of the flu
vaccine. [was Goal 10A]
2009 National Patient Safety Goals – Pg. 34
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• Applies to: Disease-Specific Care, Long Term Care
Influenza & Pneumococcal Disease
 NPSG.10.02.01: The organization develops and
implements protocols for administration of the
pneumococcus vaccine. [was Goal 10B]
2009 National Patient Safety Goals – Pg. 35
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• Applies to: Disease-Specific Care, Long Term Care
Influenza & Pneumococcal Disease
 NPSG.10.03.01: The organization develops and
implements protocols to identify new cases of
influenza and to manage outbreaks. [was Goal
10C]
2009 National Patient Safety Goals – Pg. 36
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• Applies to: Disease-Specific Care, Long Term Care
Surgical Fires
Goal 11:
2009 National Patient Safety Goals – Pg. 37
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Reduce the risk of surgical fires
Surgical Fires
• Applies to: Ambulatory Care, Office-Based Surgery
2009 National Patient Safety Goals – Pg. 38
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 NPSG.11.01.01: The organization educates staff,
including licensed independent practitioners who are
involved with surgical procedures and anesthesia
providers, on how to control heat sources, how to
manage fuels while maintaining enough time for
patient preparation, and establish guidelines to
minimize oxygen concentration under drapes.
[was Goal 11A]
Patient Involvement
Goal 13:
2009 National Patient Safety Goals – Pg. 39
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Encourage patients’ active involvement in
their own care as a patient safety strategy
Patient Involvement
 NPSG.13.01.01: Identify the ways in which the
patient and his or her family can report concerns
about safety and encourage them to do so. [was
Goal 13A]
New for 2009 - Addition of 2 elements of performance
2009 National Patient Safety Goals – Pg. 40
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• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care,
Hospital, Lab, Long Term Care, Office-Based Surgery
Pressure Ulcers
Goal 14:
2009 National Patient Safety Goals – Pg. 41
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Prevent health care associated pressure
ulcers (decubitus ulcers)
Pressure Ulcers
 NPSG.14.01.01: Assess and periodically reassess
each resident’s risk for developing a pressure ulcer
(decubitus ulcer) and take action to address any
identified risks. [was Goal 14A]
Applies to: Long Term Care
2009 National Patient Safety Goals – Pg. 42
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•
Risk Assessment
Goal 15:
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The organization identifies safety risks
inherent in its patient population
Risk Assessment
 NPSG.15.01.01: The organization identifies
patients at risk for suicide. [was Goal 15A]
2009 National Patient Safety Goals – Pg. 44
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• Applies to: Behavioral Health Care, Hospital
(applicable to psychiatric hospitals and patients
being treated for emotional or behavioral
disorders in general hospitals)
Risk Assessment
 NPSG.15.02.01: The organization identifies risks
associated with home oxygen therapy such as
home fires. [was Goal 15B]
2009 National Patient Safety Goals – Pg. 45
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• Applies to: Home Care
Changes in Patient Condition
Goal 16:
Clarified for 2009
2009 National Patient Safety Goals – Pg. 46
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Improve recognition and response to
changes in a patient’s condition
Changes in Patient Condition
• Applies to: Critical Access Hospital, Hospital
2009 National Patient Safety Goals – Pg. 47
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 NPSG.16.01.01: 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. [was
Goal 16A]
Universal Protocol
The organization meets the expectations
of the Universal Protocol.
Revised for 2009
2009 National Patient Safety Goals – Pg. 48
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• Applies to: Ambulatory, Critical Access Hospital,
Disease-Specific Care, Hospital, and Office-Based
Surgery
Universal Protocol
 UP.01.01.01: Conduct a pre-procedure verification
process.
Revised for 2009
2009 National Patient Safety Goals – Pg. 49
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• Applies to: Ambulatory, Critical Access Hospital, DiseaseSpecific Care, Hospital, and Office-Based Surgery
Universal Protocol
 UP.01.02.01: Mark the procedure site.
Revised for 2009
2009 National Patient Safety Goals – Pg. 50
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• Applies to: Ambulatory, Critical Access Hospital,
Disease-Specific Care, Hospital, and Office-Based
Surgery
Universal Protocol
 UP.01.03.01: A time-out is performed
immediately prior to starting procedures.
Revised for 2009
2009 National Patient Safety Goals – Pg. 51
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• Applies to: Ambulatory, Critical Access Hospital,
Disease-Specific Care, Hospital, and Office-Based
Surgery
Submitting Alternative Approaches
 Proposed alternatives must be at least as effective as the
published Requirements in achieving the Goals.
 Proposed alternatives must be formally approved by The
Joint Commission based on the Sentinel Event Advisory
Group’s review.
• http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/npsg_rfr.htm
2009 National Patient Safety Goals – Pg. 52
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 Forms to submit a “Request for Review of an Alternative
Approach to a NPSG Requirement ” are found at:
Submitting Alternative Approaches
 If an alternative approach is not formally accepted
by The Joint Commission, the organization will
need to further revise the alternative approach until
it is approved…
2009 National Patient Safety Goals – Pg. 53
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 And continue to implement the original Goal
Requirements as issued by The Joint Commission
until the alternative approach approval is achieved.
Surveying and Scoring the National Patient
Safety Goals
 All applicable Goals & Requirements, or acceptable
alternative approaches, must be implemented.
 Surveyors evaluate the actual performance, not just
the intent of meeting the Goals and Requirements.
 Failure to comply with a NPSG Requirement will
result in a “Requirement for Improvement” (RFI).
2009 National Patient Safety Goals – Pg. 54
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 NPSG Requirements are scored as either Compliant
or Not Compliant.
Public Disclosure of Compliance with the
National Patient Safety Goals
 Aggregate data:
– Data from 2003 - 2007 surveys are posted on The
Joint Commission website
 Individual health care organizations:
– Revised “Quality Reports” on website since midyear 2004
2009 National Patient Safety Goals – Pg. 55
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– Compliance with specific Requirements
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2009 National Patient Safety Goals – Pg. 56
For more information:
2009 National Patient Safety Goals – Pg. 57
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www.jointcommission.org