Perspectives Jan '09 Vol 29 #1Pg01-Update: National Patient Safety Goals Undergoing Review During 2009—No New NPSGs for 2010Based on compliance difficulties and feedback from the field, TJC has decided to perform 'an extensive review' of NPSG during 2009. Using the Standards Improvement Initiative (SII) process, NPSG will be clarified, revised and some redundant ones may be eliminated. No new goals are to be developed for 2010 when SII recommended changes would take effect. State hospital JCSCand LDR are encouraged to participate in the current survey… On 1/6/09 we made contact with TJC. Their representatives were not aware of the problem and are researching to find an appropriate link. They have promised to follow up. Stay tuned.
Pt. Safety Jan '09 Vol 9 #1 Pg02-Preventing MRSA in the Neonatal Intensive Care Unit at Beth Israel Medical Center Ensuring accuracy of medication reconciliation lists across the continuum as required by NPSG #8 is an ongoing challenge for psychiatric hospitals, P&T, MD. During internal patient tracer activities, most of our hospitals identify some significant inaccuracies on their lists. A close study of accuracy of emergency department medication lists revealed that 56% had omissions and 80% had dosing or frequency errors; 87% had at least one error.
Feb 2009
Perspectives Feb '09 Vol 29 #2 Pg05-Errata: 2009 Accreditation Manuals, All Programs[**Alert**] Two and a half pages of corrections are provided. Those relevant to psychiatric hospitals include standards in IC, LS,MM, NPSG, UP and PC. Since the corrections are effective immediately, those JCSCexpecting survey soon should review the details.
Pt. Safety Feb '09 Vol 9 #2Pg08-Establishing a Patient Advisory CouncilLDR, PtAd and SFT should seriously consider involving patients and their families in performance improvement work as one approach to address National Patient Safety Goal 13. The Patient Advisory Council (PAC) is a mechanism to structure this involvement utilizing a group of volunteer patients/family and staff who meet on a regular basis to address key hospital issues. The article provides a fairly detailed description of how to create the Advisory Council and how to use it to improve safety. A sidebar also delineates items to include on the hospital’s application form for Advisory Council membership.
Mar 2009
Pt. Safety Mar 09 Vol 9 #3Pg02-Patient Safety Pulse: Your Patient Safety News[*ALERT: IC*] The US Department of Health and Human Services has established a set of five-year “national prevention targets” to prevent HAIs. The plan targets some infections that many state hospitals have experienced, including MRSA, Clostridium difficile, and catheter associated infections The HHS plan includes prioritized, recommended clinical practices and can be accessed atwww.hhs.gov/ophs/initiatives/hai/index.html. Also remember that the Joint Commission NPSG #7 requires management of identified HAI cases as sentinel events.
Perspectives Mar 09 Vol 29 #3Pg06-Top Standards Compliance Issues for First Half of 2008 [ALERT:JCSC, PPR, E&M, P&T] Standards most frequently identified in surveys as “not compliant” are listed for each program. Forty percent (40%) or more hospitals received RFI’s for EC.5.20regarding Life Safety code compliance; NPSG #2C regarding measurement and improving timeliness of critical tests, results and values; and IM.6.50 regarding verbal and telephone orders.Download 17 Most Challenging Standards for First Half of 2008
Apr 2009
Pt Safety Apr 2009 Vol 9 #4 Pg01-Spell It Out: Ensuring Compliance with Do-Not-Use Abbreviation Policies[••REF••] JCSC, MD, P&T, PHRM. There is some concern that compliance with NPSG 0202.01 may have fallen off since its implementation in 2004. We are reminded that between 2004 and 2006 almost 30,000 abbreviation-related medication errors were reported to the U.S. Pharmacopeia (USP) MEDMARX program and most of those originated with the prescriber. [Pearl] Some real life examples are provided along with 10 recommended strategies you should read for improving/maintaining compliance. Download free DNU list, brochure, poster, slide show and training video (3.5 min).
Source June 09 Vol 7 #6 Pg06-Tracer Methodology 101: The Fall Reduction Tracer[••REF••] Although this is officially a program-specific tracer for home care, JCSC are strongly encouraged to incorporate this as a practice tracer for survey preparation/standard compliance (i.e., NPSG.09.02.01) and an RN/ PI strategy for the reduction of patient falls. The article includes a scenario and sample questions that can be adopted to your setting.
July 2009
Perspectives July 2009 Vol 29 #7 Pg03- Top 10 Standards Compliance Issues for 2008[•• REF••] The top 10 are provided on tear-out cards in the hard copy edition of Perspectives. JCSC and those expecting survey soon should be aware that the 10 include EC.5.20 (45%), IM.6.50 (43%), MM.2.20 (37%), NPSG 2C (37%), IM.6.10 (31%), EC.5.40 (26%), NPSG 3D (25%), HR.1.20 (22%), UP 1C (21%) and NPSG 8A (19%).
Patient Safety July 09 Vol 9 # 7 Pg01-Protecting the Patient: The Joint Commission Collaborates on Developing Infection Prevention and Control Compendium: [••REF••] Four major healthcare organizations (SHEA, IDSA, AHA, APIC) have joined with TJC to produce the A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals that organizes all the evidence- based strategies that have been found to prevent those HAIs causing the greatest mortality (including MRSA and CDI) into practical guideline that can serve as a one-stop prevention resource. Strategies are organized into 4 categories. Basic practices and Special approaches for certain high-risk populations have good or moderate evidence to support their use (i.e., A or B-level recommendation). Level C recommendations are categorized as 'Unresolved issues'. There is a final category of approaches that should not be implemented. The guideline also includes performance measures and patient guides (http://www.preventinghais.com/) for each HAI. IC and related PPR should not only review relevant sections of the compendium, but strongly consider performing a gap analysis between your current approaches and their A or B-level recommendations to better ensure compliance with NPSG.07.03.01, NPSG.07.04.01 and NPSG.07.05.01 that TJC says were directly influenced by the compendium.
Aug 2009
Sep 2009
Perspectives, Sept 2009 Vol 29 #9 Pg09-Free Help for Meeting Infection-Related NPSG[••REF••] TJC allotted one year (with quarterly milestones) for the full implementation of HAI-related NPSG 7 by January 1, 2010. Longer lead times usually suggest a greater effort is needed to comply. It can also be the basis for greater accountability once the measure is fully in effect. With that in mind, IC and RN should take advantage a free online education program offered by TJC to support compliance and implementation for NPSG 07.03.01, 07.04.01 and 07.05.01. Just be aware that the 76-slide webinar with narration by Louise Kuhny, RN, MPH, MBA, CIC and Barbara Soule, RN, MPA, CIC lasts a little over 58 minutes. You will need to log on to your TJC Connect website to access it.
Oct 2009
Perspectives, Oct. 2009, Vol 29 #10 Pg01-Approved: 2010 National Patient Safety Goals[••REF••] The 2010 NPSG were released on 9/25/09. While there are no new goals, there are language refinements and a significant number of deletions (6) and movement of requirements into standards (18). Much of the content is retained somewhere in the standards, but only five Goals (1-3 and 7-8) remain for hospitals/BHC. [ALERT: JCSC] "Effective immediately, during the on-site survey, surveyors will not evaluate compliance with requirements that have been deleted." It should also be noted that NPSG 8, which is still being evaluated/refined, is not included in these changes and is not being scored during survey (refer to March RTP for more details). The other changes will to into effect on January 1, 2010. The article includes a useful table of changes and a full description of the goals themselves. The pre-publication version of the 2010 NPSG chapter and outline are now available online at TJC.
Nov 2009
Pt. Safety, Nov. '09, Vol9 #11 Pg01-Special Report! 2010 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them[••REF••] Although there are no new NPSG for 2010 there have been a significant number of refinements. JCSC and PPR may want to pay particular attention to the numerous changes in EP criticality and scoring. Remember, no matter when your survey occurs, scoring is based on continuous compliance from the first of the year. The article also provides a brief review of NPSG scoring and confirms the 'on hold' status of NPSG 8 while it's re-evaluation continues. Surveyor findings related to NPSG 8 will not affect accreditation decisions or generate RFI.
Dec 2009
Reference Articles
Pt. Safety, Nov. '09, Vol9 #11 Pg01-Special Report! 2010 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them[••REF••] Although there are no new NPSG for 2010 there have been a significant number of refinements. JCSC and PPR may want to pay particular attention to the numerous changes in EP criticality and scoring. Remember, no matter when your survey occurs, scoring is based on continuous compliance from the first of the year. The article also provides a brief review of NPSG scoring and confirms the 'on hold' status of NPSG 8 while it's re-evaluation continues. Surveyor findings related to NPSG 8 will not affect accreditation decisions or generate RFI.
Patient Safety, 2008 April Vol 8 #4Pg01-Implementing National Patient Safety Goal Requirement 3E: A Model Plan [**REF**] Although the article is written from the perspective of acute care hospitals, Phrm and P&T should find the suggested implementation steps and checklist a useful resource. Note: The first milestone should now be in place!
Useful Guidelines & Resources
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Joint Commission International: Pt Safety Practices (PSP) - includes TJC suggested practices for NPSG compliance
Patient SafetyJune 2008, Vol 8, #6 Pg09-Implementing the Stroke Alert Program at Lutheran General [**REF**] This article describes a stroke-specific program that is a specialized part of a rapid response team to address NPSG 16A. The number of strokes that occur in psychiatric hospitals is not known, but an estimated 25% of all stroke victims are hospital inpatients. Stroke Program Alert may be appropriate to adapt to psychiatric settings. A sidebar on pg11 outlines the model and websites used to educate staff members on common stroke signs. FYI: PtEd, MD, RN. - by VKArticle references include:
National Stroke Association's Stroke Factsheet (PDF)
National Institute of Neurological Disorders and Stroke (NINDS) Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke {HTML}. Includes useful recommendations
EOC June 2008 Vol 11, #6 Pg08-To Catch a Falling Star: How Edward Hospital Uses Branding in Its Fall Prevention Program [**REF**] To address NPSG 9B, this is a program that uses “branding” in the form of yellow STARS on patient’s charts and wrist bands to alert staff of fall risk as well as teaching at risk patients the logo: “Call, Don’t Fall”. The discussion includes some ideas that could be useful to augment existing falls prevention programs in psychiatric hospitals. FYI: RN, PtEd, IM.- by VKArticle references that should be useful for any falls program included:
JCI Center for Patient Safety: Patient Safety Practices Related to Patient Safety Goal 9B: {Info}
Falls Toolkit offered by the National Center for Patient Safety (NCPS) of the U.S. Department of Veteran’s Affairs {Info}
Perspectives, Sept 2009 Vol 29 #9 Pg09-Free Help for Meeting Infection-Related NPSG[••REF••] TJC allotted one year (with quarterly milestones) for the full implementation of HAI-related NPSG 7 by January 1, 2010. Longer lead times usually suggest a greater effort is needed to comply. It can also be the basis for greater accountability once the measure is fully in effect. With that in mind, IC and RN should take advantage a free online education program offered by TJC to support compliance and implementation for NPSG 07.03.01, 07.04.01 and 07.05.01. Just be aware that the 76-slide webinar with narration by Louise Kuhny, RN, MPH, MBA, CIC and Barbara Soule, RN, MPA, CIC lasts a little over 58 minutes. You will need to log on to your TJC Connect website to access it.
Perspectives, Oct. 2009, Vol 29 #10 Pg01-Approved: 2010 National Patient Safety Goals[••REF••] The 2010 NPSG were released on 9/25/09. While there are no new goals, there are language refinements and a significant number of deletions (6) and movement of requirements into standards (18). Much of the content is retained somewhere in the standards, but only five Goals (1-3 and 7-8) remain for hospitals/BHC. [ALERT: JCSC] "Effective immediately, during the on-site survey, surveyors will not evaluate compliance with requirements that have been deleted." It should also be noted that NPSG 8, which is still being evaluated/refined, is not included in these changes and is not being scored during survey (refer to March RTP for more details). The other changes will to into effect on January 1, 2010. The article includes a useful table of changes and a full description of the goals themselves. The pre-publication version of the 2010 NPSG chapter and outline are now available online at TJC.
Patient Safety Vol 8 #7Pg06-Medication Reconciliation: Taking a Systematic Approach to National Patient Safety Goal 8 [**REF**] This is a good review of NPSG 08 expectations. The article discusses individuals who are at high risk for inadequate medication reconciliation, including older patients, those who receive care from multiple specialists, people with chronic conditions who take many medications, and those whose health literacy is low. The article discusses the importance of providing a format for medication reconciliation and developing an interview process that staff can follow when using the tool. The expectation is that responsibility for medication reconciliation will be clear and that involved staff, providers, and patients will be educated. Also, the success of the program needs to be measured. (Sample tools* to address medication reconciliation are provided on page 13 and 14.) FYI: P&T, MD, RN, PtEd, PI- by VK*See also: S.Carolina Hospital Association's Universal Medication Form for patients
