The Joint Commission’s 2010 National Patient Safety Goals…how MEDITECH is making the grade

Tuesday, 01 December 2009 07:00

Guest Spot: The Joint Commission’s 2010 National Patient Safety Goals…how MEDITECH is making the grade

By: Kathleen Catalano, RN, JD, FHIMSS

Executive Summary

For 2010, the Joint Commission has significantly shortened the list of National Patient Safety Goals (NPSGs) (Source: http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-8858-0D5FAA4322F2/0/RevisedChapter_HAP_NPSG_20090924.pdf). As a matter of fact, the number of NPSGs has gone from 20 in 2009 to 11 in 2010. Seven NPSGs have been integrated into the Joint Commission standard, one was deleted and the jury is still out as to the fate of the NPSG dealing with medication reconciliation. This article will focus on the NPSGs that will be surveyed in 2010, and how MEDITECH’s Health Care Information System (HCIS) measures up against those goals.

Throughout this article, reference will be made to the NPSGs applicability to the Hospital, Ambulatory Health Care, and/or Office-Based Surgery Accreditation Program.

Brief Recap of the Evolution of the National Patient Safety Goals

The Joint Commission’s NPSGs were first surveyed in January 2003. Since that time these NPSGs have undergone eight iterations. Some NPSGs have remained throughout the eight years while others have been removed due to the fact that compliance with the NPSG was at a high level. In addition, the numbering of the NPSGs has remained static except for the change accorded through the Standards Improvement Initiative (SII) first begun in October 2006 and coming to a conclusion in January 2010. Once given a number (i.e., NPSG 1), the number will only be used for that specific goal. All new goals will be given a different number. This is to afford easy tracking of NPSG compliance.

The Joint Commission’s Sentinel Event Advisory Committee formulates the NPSGS annually and then forwards them to the Joint Commission’s Board of Commissioners for their “stamp of approval”. After which the NPSGs are published with a lead time of a few months so that organizations can prepare for the actual “go live” the following January.

Goal 1

The first goal, NPSG.01.01.01, has remained the same for eight years and is applicable to all three accreditation programs (Hospital, Ambulatory Health Care and Office-Based Surgery). Its purpose is to eliminate the errors caused when a procedure or treatment is performed on the wrong patient.

Goal 1 is to “improve the accuracy of patient identification. ” There are two Elements of Performance (EPs) for this goal; both of which are “direct impact requirements”. A standard or EP is a “direct impact requirement” if non-compliance is likely to create an immediate risk to patient safety or quality of care.

Goal 1 requires that at least two patient identifiers be used when administering medications; when providing treatments or procedures; when collecting blood, or blood components; and when collecting blood samples and other specimens. Note that the patient’s room number or physical location is never to be used as an identifier due to the fact that the patient’s location often changes throughout their stay at a facility. Additionally, all containers used for blood and other specimens are to be labeled in the presence of the patient.

An augmentation to Goal 1 is NPSG.01.03.01 which became a goal in 2009 and requires the organization to “eliminate transfusion errors related to patient misidentification”. This Goal has three EPs, all of which are direct impact requirements” and applicable to the Hospital, Ambulatory Health Care and Office-Based accreditation programs.

Goal 2

Goal 2 used to include NPSG 02.01.01, that for verbal or telephone orders or for telephone reporting of critical test results, there was a read-back verification process in place between the person receiving the information and the person giving the order; NPSG 02.02.01, necessitating that each organization have a standardized list of abbreviations, acronyms, symbols, and dose designations that were not to be used in the organization; and NPSG.02.05.01 regarding hand-off communications. All of these Goals have been moved to the Joint Commission standards and are no longer included as NPSGs.

Now Goal 2 consists only of NPSG.02.03.01 which is applicable to the Hospital accreditation program only and requires the organization to “improve the effectiveness of communication among caregivers.”

Goal 3

NPSG.03.03.01 referring to the handling of look-alike/sound-alike medications has been moved to the standards and will be surveyed there. That leaves NPSG.03.04.01, pertinent to all three accreditation programs, and NPSG.03.05.01, applicable to the Hospital and Ambulatory Health Care accreditation programs only, for discussion here.

Goal 3 is to “improve the safety of using medications.” NPSG.03.04.01 is very important to the perioperative areas as it pertains to the labeling of all medications, medication containers, and other solutions, both on and off the sterile field. Of course, the rationale is to decrease the chance of error when a medication or other solution is placed in an unlabeled container.

NPSG.03.05.01 is specific to “reducing the likelihood of patient harm associated with the use of anticoagulant therapy.” This Goal has eight EPs that address how the medication is prepared and distributed, the use of approved protocols, baseline and ongoing coagulation tests, programming of pumps for consistent and accurate dosing, and education of the patient and families regarding compliance, drug-food interactions and the potential for adverse drug reactions and interactions. Most of these requirements will be fulfilled by actions taken by the pharmacy and the nursing units which is why elaboration is not considered necessary.

Goal 7

Goal 7 is to “reduce the risk of health care-associated infections” and encompasses NPSG.07.01.01, NPSG.07.03.01, NPSG.07.04.01, and NPSG.07.05.01. Each will be discussed separately.

NPSG.07.01.01 is applicable to all three accreditation programs and requires the organization to comply with the Centers for Disease Control and Prevention (CDC) or World Health Organizations (WHO) hand hygiene guidelines.

Note that as of September 9, 2009, NPSG.07.02.01 has been deleted and will no longer be surveyed under any accreditation program. This Goal relates to managing as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care-associated infection.

NPSG.07.03.01 refers to the implementation of evidence-based health care-associated infections due to multidrug-resistant organisms in acute care hospitals. Thus, this Goal is only required for the Hospital accreditation program and has nine EPs that require risk assessments, surveillance, measurement and monitoring of prevention processes and outcomes, and education of all staff and licensed independent practitioners (LIPs) regarding health care-associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter.

Then there is NPSG.07.04.01 that is also only applicable to the Hospital accreditation program. This Goal has to do with implementing evidence-based practices to prevent central line-associated bloodstream infections.

NPSG.07.05.01 is the Goal most pertinent to perioperative services under this subset. This Goal requires the organization to “implement evidence-based practices for preventing surgical site infections”. This Goal is applicable to all three accreditation programs and has eight EPs.

Goal 8

As of this writing, The Joint Commission has not yet published changes for NPSG.08.01.01 through NPSG.08.04.01. This affects all three accreditation programs. There was a great deal of question regarding implementation carrying out of the Goal and as of January 1, 2009, Goal 8 has been continuously evaluated during onsite surveys, however the findings have not been included into the organization’s accreditation decision and no Requirements for Improvement (RFIs) have been generated as a result of the surveyors findings. The Joint Commission expects to have a revised version of Goal 8 early in 2010 and after field review is conducted should have a surveyable Goal by mid-2010 and possibly sooner .

Goal 15

The overarching premise of Goal 15 is that “the hospital identifies safety risks inherent in its patient population” and is applicable to the Hospital accreditation program only. NPSG.15.01.01 focuses on the identification of patients at risk for suicide. Generally, perioperative areas do not deal with suicidal patients. That said it is still prudent to know and understand the organization’s policy for this Goal.

Goals 9, 11, 13 and 16

NPSG.09.02.01 regarding the implementation of a fall prevention program that includes an evaluation of the effectiveness of the program has been moved to the standards. This affects the Hospital accreditation program and was never applicable to the Ambulatory Health Care or Office-Based Surgery accreditation programs.

Likewise, Goal 13 that encouraged the patient’s active involvement in their own care as a patient safety strategy and Goal 16 requiring improved recognition and response to changes in a patient’s condition, have been moved to the standards.

However, Goal 11 that was specific for the Ambulatory Health Care and Office-Based Surgery accreditation programs has been deleted from these programs all together. Goal 11 was to “reduce the risk of surgical fires. ” This is still a very important aspect of patient safety that should be exercised even though it is no longer a Goal of in the standards.

Universal Protocol

The Universal Protocol (UP) is undergoing a fairly dramatic change in 2010. The Joint Commission determined, through field study and comments from many facilities, that there was a need to focus on the “Goals” of the UP rather than specifics. The Joint Commission has removed several of the detailed processes found in the 2009 UP because they were seen as confusing and were causing a lack of compliance with the UP. Now, a focus on safety can be maintained and the UP requirements are more achievable across various types of situations. Of course, the main goals of the UP are to perform surgery on the correct patient, at the correct site, and with the correct procedure. Note that the entire UP is applicable to all three accreditation programs without exception.

UP.01.01.01 – Conduct a Preprocedure Verification Process

According to the Joint Commission, the rationale for this UP is that, “Hospitals should make sure that any procedure is what the patient needs and is performed on the right person. The frequency and scope of the verification process will depend on the type and complexity of the procedure. ”

UP.01.02.01 – Mark the Procedure Site

In the commentary regarding the “marking of the procedure site”, the Joint Commission notes that while marking of the procedure site is a hotly debated topic, the LIP who will be performing the procedure should mark the procedure site.

UP.01.03.01 – a Time-Out is Performed before the Procedure

Of course the purpose of the time-out is to be certain that the correct patient is about to undergo the correct procedure, and that the correct site will be used. A designated member of the perioperative team must be responsible for initiating and conducting the time-out and ALL members of the perioperative team must participate through the use of active communication.

In Summary

The NPSGs and UP are not new to healthcare and yet they continue to be surveyed in an effort to ensure that the patient’s care is delivered in a safe and effective manner, and that the patient’s outcomes are measurably improved. The following table demonstrates how MEDITECH’s HCIS is providing the tools necessary to meet the NPSGs. (Source: http://www.meditech.com/IndustryNews/pages/jcaho.htm)

The Joint Commission Goal	The Joint Commission Goal Description	MEDITECH Tools
Goal #1: Improve the accuracy of patient identification	NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, or services. NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification.	MEDITECH's HCIS ensures positive patient identification. Caregivers can use medical numbers, health insurance numbers, account numbers saved within the MEDITECH system, and swipe technology to identify their patients prior to taking blood samples, administering medications, or blood products. MEDITECH's HCIS helps to ensure safe medication administration through the Five Rights of medication management: Right Patient, Right Medication, Right Dosage, Right Route, and Right Time. To ensure that the right patient gets the right medication, MEDITECH's system offers a variety of patient identifiers, including the ability to scan bar codes on patient wristbands and medications to correctly identify the patient and the appropriate medication. Caregivers utilize bar code scanning technology prior to administering medications to confirm patient identity and medication information against data readily available via MEDITECH's on-line Medication Administration Record. MEDITECH's system offers a variety of patient identifiers, including the ability to scan bar codes.
Goal #2: Improve the effectiveness of communication among caregivers	NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis.	MEDITECH provides physician desktops and nursing status boards as a global view of the caregiver's patients and serves as a central point from which to process all aspects of the patient's care. MEDITECH's fully-integrated system facilitates comprehensive, enterprise-wide communication throughout a health care organization. MEDITECH's table-driven system can assist in meeting The Joint Commission's list of do not use abbreviations, acronyms, and symbols throughout your organization. Relevant clinical data displays provide real-time patient information that is readily available when managing medication therapies, both at the point of order entry and during medication administration. Whether ordering or administering medications, clinicians have the right information, which provides critical decision support. Capabilities from throughout the MEDITECH HCIS are integrated to ensure a coordinated and safe ordering process. Pharmacists, nurses, laboratory and radiology technicians, and the rest of the care team are all included in the physician-initiated process. Physicians can also sign any verbal orders and view results from wherever they may be.
Goal #3: Improve the safety of using medications	NPSG.03.04.01 Label all medications, medication containers (e.g. syringes, medicine cups, basins), and other solutions on and off the sterile field in perioperative and other procedural settings. NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Note: This requirement applies only to hospitals that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis where the clinical expectation is that the patient's laboratory values for coagulation will remain outside normal values.	In order to limit and standardize drug concentrations, the MEDITECH system helps control and manage inventory, analyze supply usage, and manage maintenance equipment throughout your health care organization. To help pharmacists comply with government regulations, organizations can track inventory more closely by identifying stock medications at all stock locations and record the use of controlled substances. Pharmacists can also create robust reports including Controlled Drug Dispensed Report, Controlled Medication Log, and Daily Controlled Drug Inventory Report. MEDITECH can also support users in providing the capability of printing labels in supporting applications.
Goal #7: Reduce the risk of health care-associated infections	NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. NPSG.07.03.01 Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms (MDRO) in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug- resistant gram-negative bacteria. NPSG.07.04.01 Implement evidence-based practices to prevent central line-associated bloodstream infections. Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines. NPSG.07.05.01 Implement evidence-based practices for preventing surgical site infections (SSI). * These requirements have a one year phase in period that includes defined expectations for planning and development milestones at 3, 6, and 9 months in 2009. Implement by January 1, 2010.	The infection control functionality of MEDITECH's Laboratory Information System helps providers to effectively and efficiently identify health care-associated infections. An organization's infection control group can easily track patient infections by automatically flagging organisms by markers or through other customer-defined screens. Staff has the ability to generate reports based on patient, location, physician, site of the infection and type of organism – whether sensitive or resistant to certain antibiotics. Depending on the outcome of the reports, the infection control group can automatically receive alerts, which will assist them in tracking nonsocomial infections. Clinicians can also pull data from throughout the MEDITECH HCIS and store it in a secure database for robust reporting and benchmarking by authorized users. Organizations can thereby track and report on a variety of issues such as patient and visitor incidents, adverse drug events, employee health and safety, blood utilization, and infections with complete confidentiality. Staff has the ability to effectively analyze their efforts and devise strategies for improving outcomes and regulatory compliance.
Goal #8: Accurately and completely reconcile medications across the continuum of care	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 hospital. NPSG.08.02.01 When a patient is referred to or transferred from one hospital 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 hospital's care to go directly to his or her home, the complete and reconciled list of medications is provided to the patient's known primary care provider, the original referring provider, or a known next provider of service. NPSG.08.03.01 When a patient leaves the hospital's care, a completed and reconciled list of the patient's medications is provided directly to the patient and, as needed, the family, and the list is explained to the patient and/or family. NPSG.08.04.01 In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Note: This requirement does not apply to hospitals that do not administer medications.	MEDITECH's integrated and dynamic order management features provide users with the ability to capture and update medication information from a variety of settings. Whether at an associated physician practice, or in an ambulatory setting such as a clinic or the emergency department, medications that the patient currently takes at home are captured or updated, creating a profile list of medications for clinicians to view throughout the health care enterprise. Any medications written for the patient during the current visit are added to the medication profile. In addition, when the patient is discharged from the facility, medications from the inpatient stay can be converted to outpatient prescriptions. The comprehensive medication profile list can be viewed throughout the enterprise, for patients who are transferring within the organization. Conversely, a list of the patient's active prescriptions can be generated and made available when the patient transfers outside the network.
Goal #15: The organization identifies safety risks inherent in its patient population.	NPSG.15.01.01 Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.	MEDITECH's clinical applications offer assessments that can be used to identify any patient that may be at risk, with the additional ability to track and trend those outcomes.
Universal Protocol	UP.01.01.01 Conduct a preprocedure verification process. UP.01.02.01 Mark the procedure site. UP.01.03.01 A time-out is performed before the procedure.	MEDITECH's Operating Room Management solution offers a Multidisciplined Surgical Profile, which includes: • Ability to view the patient's electronic enterprise medical record and nursing assessments from pre-testing to recovery • Routines for identifying and maintaining patient allergies and risks for all past and future care • Reports for capturing outcome data used in risk management and quality assurance • Document and track implant and explants. The Multidisciplined Operating Room Management Documentation allows users to document the entire peri-operative episode. The system automatically captures who entered the information and the time of documentation. The information entered becomes part of the patient's surgical profile, as well as part of the statistical database of operating room events.

Compliance with the NPSGs and the UP is non-negotiable. Results of care are being reported more frequently by the media and patients and their families and friends are more than willing to expound, to anyone that will listen, about their harrowing healthcare experiences. It is recommended that every MEDITECH customer be aware of these NPSGs and the UP, document how their HCIS is meeting these goals, and be fully prepared to demonstrate it during any Joint Commission survey.

Kathleen Catalano is an RN with over 30 years of healthcare experience. Ms. Catalano has a Juris Doctor degree and a Bachelor of Science degree in law, a Science Degree and Nursing Degree, and is a Fellow of HIMSS. She is a keynote speaker, subject matter expert and educator on Joint Commission Standards and National Patient Safety Goals, Regulatory Compliance, HIPAA, ARRA and the HITECH Act, Hospital Quality Measures, CMS Compliance, Sentinel Events, Risk Management, Performance Improvement and Patient Safety. To learn more about Kathleen Catalano, visit her LinkedIn profile at: http://www.linkedin.com/pub/kathleen-catalano-rn-jd-fhimss/3/612/633.

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