- Email: [email protected]
2007 National Patient Safety Goals
ACCREDITATION ISSUES
2007 National Patient Safety Goals Nancy M. Saufl, MS, RN, CPAN, CAPA THE PURPOSE OF the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems.1 The NPSGs focus on system-wide solutions, whenever possible, in an effort to promote the delivery of safe, high-quality health care. Accredited health care organizations are evaluated for continuous compliance with the specific requirements associated with the National Patient Safety Goals, and organizations are permitted to design alternative approaches to meeting goal requirements and to request Joint Commission consideration and approval of such alternatives. The Joint Commission also provides guidance on how to achieve effective compliance with each of the goal’s requirements.1 The National Patient Safety Goals are derived primarily from informal recommendations made in the Joint Commission’s safety newsletter, Sentinel Event Alert. The goals are not derived solely from information contained in the Sentinel Event database. A Sentinel Event Advisory Group works with Joint Commission staff on a continual basis to determine priorities and develop the goals and associated requirements.1 NOTE: JCAHO is now The Joint Commission. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has shortened its name to The Joint Commission. The change was made official in January when The Joint Commission launched a redesigned website. Check out the new website at: http://jointcommission.org and see the new Joint Commission logo as well.
Journal of PeriAnesthesia Nursing, Vol 22, No 2 (April), 2007: pp 125-127
On June 2, 2006, the Joint Commission’s Board of Commissioners approved the 2007 National Patient Safety Goals. The goals and requirements for each accreditation program (Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long-Term Care, Office-Based Surgery) are available on the Joint Commission website at: http://www.jointcommission.org. As of January 1, 2007, all Joint Commission-accredited health care organizations and the DiseaseSpecific Care– certified programs are surveyed for implementation of applicable 2007 goals and requirements (or acceptable alternatives), as appropriate to the services provided by the organization or program. Compliance with applicable requirements (or an acceptable alternative) will be scored at the associated implementation expectation(s) for that requirement in the NPSGs chapter of each standards manual.1
2007 Goals The 2007 Hospital/Critical Access Hospital Goals and related requirements are listed below (Table 1).1 Changes to the goals and requirements are indicated in bold. Gaps in the numbering indicate that the goal is inapplicable to the program or has been “retired,” usually because the requirements were integrated into the standards.
Nancy M. Saufl, MS, RN, CPAN, CAPA, is a past President of the American Society of PeriAnesthesia Nurses, and the Coordinator of the Preadmission Testing Center at Florida Hospital-Memorial Division, Ormond Beach, FL. Address correspondence to Nancy M. Saufl, MS, RN, CPAN, CAPA, 114 Pinion Circle, Ormond Beach, FL 32174; e-mail address: [email protected]. © 2007 by American Society of PeriAnesthesia Nurses. 1089-9472/07/2202-0008$35.00/0 doi:10.1016/j.jopan.2007.01.006 125
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Table 1. 2007 Hospital/Critical Access Hospital Goals and Requirements Goal 1 1A
Improve the accuracy of patient identification. Use at least two patient identifiers when providing care, treatment, or services.
Goal 2 2A
Improve the effectiveness of communication among caregivers. 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. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. 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. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
2B 2C 2E Goal 3 3B 3C 3D
Improve the safety of using medications. Standardize and limit the number of drug concentrations used by the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
Goal 7 7A 7B
Reduce the risk of health care-associated infections. Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Goal 8 8A 8B
Accurately and completely reconcile medications across the continuum of care. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. 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.
Goal 9 9B
Reduce the risk of patient harm resulting from falls. Implement a fall-reduction program, including an evaluation of the effectiveness of the program.
Goal 13 13A
Encourage patients’ active involvement in their own care as a patient safety strategy. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
Goal 15 15A
The organization identifies safety risks inherent in its patient population. The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals—NOT APPLICABLE TO CRITICAL ACCESS HOSPITALS.]
© The Joint Commission, 2007. Reprinted with permission.1
ACCREDITATION ISSUES
127
Conclusion
● reduce the risk of postoperative complica-
The NPSGs are reviewed and updated annually and are designed to require health care organizations to protect patients from the negative impact of specific health care errors. The Joint Commission has already begun to look at NPSGs for 2008. Draft goals under consideration include requiring health care organizations to:
tions for patients with obstructive sleep apnea, ● prevent patient harm associated with health care worker fatigue, and ● prevent catheter misconnections.2
● improve recognition and response to changes in a patient’s condition,
The full text of the 2007 NPSGs and requirements, as well as frequently asked questions and facts, are posted on the Joint Commission’s web site: http://www.jointcommission.org.
References 1. The Joint Commission. 2007 National Patient Safety Goals. Available at: http://www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/. Accessed June 13, 2006.
2. The Joint Commission. News releases: Joint Commission seeks input on potential national patient safety goals. Available at: http://www.jointcommission.org/newsroom/newsreleases/ nr_120406_npsgs. Accessed December 14, 2006.
2007 National Patient Safety Goals Nancy M. Saufl, MS, RN, CPAN, CAPA THE PURPOSE OF the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems.1 The NPSGs focus on system-wide solutions, whenever possible, in an effort to promote the delivery of safe, high-quality health care. Accredited health care organizations are evaluated for continuous compliance with the specific requirements associated with the National Patient Safety Goals, and organizations are permitted to design alternative approaches to meeting goal requirements and to request Joint Commission consideration and approval of such alternatives. The Joint Commission also provides guidance on how to achieve effective compliance with each of the goal’s requirements.1 The National Patient Safety Goals are derived primarily from informal recommendations made in the Joint Commission’s safety newsletter, Sentinel Event Alert. The goals are not derived solely from information contained in the Sentinel Event database. A Sentinel Event Advisory Group works with Joint Commission staff on a continual basis to determine priorities and develop the goals and associated requirements.1 NOTE: JCAHO is now The Joint Commission. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has shortened its name to The Joint Commission. The change was made official in January when The Joint Commission launched a redesigned website. Check out the new website at: http://jointcommission.org and see the new Joint Commission logo as well.
Journal of PeriAnesthesia Nursing, Vol 22, No 2 (April), 2007: pp 125-127
On June 2, 2006, the Joint Commission’s Board of Commissioners approved the 2007 National Patient Safety Goals. The goals and requirements for each accreditation program (Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long-Term Care, Office-Based Surgery) are available on the Joint Commission website at: http://www.jointcommission.org. As of January 1, 2007, all Joint Commission-accredited health care organizations and the DiseaseSpecific Care– certified programs are surveyed for implementation of applicable 2007 goals and requirements (or acceptable alternatives), as appropriate to the services provided by the organization or program. Compliance with applicable requirements (or an acceptable alternative) will be scored at the associated implementation expectation(s) for that requirement in the NPSGs chapter of each standards manual.1
2007 Goals The 2007 Hospital/Critical Access Hospital Goals and related requirements are listed below (Table 1).1 Changes to the goals and requirements are indicated in bold. Gaps in the numbering indicate that the goal is inapplicable to the program or has been “retired,” usually because the requirements were integrated into the standards.
Nancy M. Saufl, MS, RN, CPAN, CAPA, is a past President of the American Society of PeriAnesthesia Nurses, and the Coordinator of the Preadmission Testing Center at Florida Hospital-Memorial Division, Ormond Beach, FL. Address correspondence to Nancy M. Saufl, MS, RN, CPAN, CAPA, 114 Pinion Circle, Ormond Beach, FL 32174; e-mail address: [email protected]. © 2007 by American Society of PeriAnesthesia Nurses. 1089-9472/07/2202-0008$35.00/0 doi:10.1016/j.jopan.2007.01.006 125
NANCY M. SAUFL
126
Table 1. 2007 Hospital/Critical Access Hospital Goals and Requirements Goal 1 1A
Improve the accuracy of patient identification. Use at least two patient identifiers when providing care, treatment, or services.
Goal 2 2A
Improve the effectiveness of communication among caregivers. 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. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. 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. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
2B 2C 2E Goal 3 3B 3C 3D
Improve the safety of using medications. Standardize and limit the number of drug concentrations used by the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
Goal 7 7A 7B
Reduce the risk of health care-associated infections. Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Goal 8 8A 8B
Accurately and completely reconcile medications across the continuum of care. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. 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.
Goal 9 9B
Reduce the risk of patient harm resulting from falls. Implement a fall-reduction program, including an evaluation of the effectiveness of the program.
Goal 13 13A
Encourage patients’ active involvement in their own care as a patient safety strategy. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
Goal 15 15A
The organization identifies safety risks inherent in its patient population. The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals—NOT APPLICABLE TO CRITICAL ACCESS HOSPITALS.]
© The Joint Commission, 2007. Reprinted with permission.1
ACCREDITATION ISSUES
127
Conclusion
● reduce the risk of postoperative complica-
The NPSGs are reviewed and updated annually and are designed to require health care organizations to protect patients from the negative impact of specific health care errors. The Joint Commission has already begun to look at NPSGs for 2008. Draft goals under consideration include requiring health care organizations to:
tions for patients with obstructive sleep apnea, ● prevent patient harm associated with health care worker fatigue, and ● prevent catheter misconnections.2
● improve recognition and response to changes in a patient’s condition,
The full text of the 2007 NPSGs and requirements, as well as frequently asked questions and facts, are posted on the Joint Commission’s web site: http://www.jointcommission.org.
References 1. The Joint Commission. 2007 National Patient Safety Goals. Available at: http://www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/. Accessed June 13, 2006.
2. The Joint Commission. News releases: Joint Commission seeks input on potential national patient safety goals. Available at: http://www.jointcommission.org/newsroom/newsreleases/ nr_120406_npsgs. Accessed December 14, 2006.