Joint Commission has published the new 2009 National Patient Safety Goals. There are several new additions and several modifications of previous NPSG’s. Most are in keeping with the quality and patient safety focus being fostered by the new Medicare reimbursement policies regarding potentially preventable adverse outcomes or involve activities your organization may already be performing under such quality improvement collaboratives with IHI or SCIP (the surgical care improvement project). Hot topics are healthcare-associated infections, medication reconciliation, and safe site surgery.
Joint Commission has also redone the numbering scheme to make the format similar to that used for all the other Joint Commission standards. Our recommendation to Joint Commission: Add “NPSG.02.02.01” to your list of “Do Not Use Abbreviations”! For an organization that stresses the important techniques we use in patient safety, such as simplification and improved communication, Joint Commission certainly doesn’t practice what it preaches. It clearly needs to simplify its nomenclature and use descriptors that readily convey to all the nature of the standard under discussion.
Our railing about the less-than-useful nomenclature aside, these new and/or revised NPSG’s make a lot of sense from both a patient safety and business perspective and your hospital should already be doing most of the required activities.
Some changes have been made to the Universal Protocol. Several elements present in the New York State Surgical and Invasive Procedure Protocol (NYSSIPP) are now in the Joint Commission Universal Protocol. That includes a separate timeout when more than one procedure is being performed on the patient. It also requires use of a checklist during the pre-procedure verification process. The checklist can be paper or electronic or even on a wall-mounted white board and needs to include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed.
We’ve long been advocates of using the surgical timeouts for far more than originally intended. In our April 9, 2007 Patient Safety Tip of the Week “Make Your Surgical Timeouts More Useful” we advocated using either the pre-surgical timeout and/or the final verification timeout to also focus on some of the more common complications you wish to avoid. For example, use the timeout to ask questions such as following:
Consider adding these questions to your checklist. And see our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”.
And the Universal Protocol now clarifies issues regarding marking the procedure site. This applies to all procedures involving incision or percutaneous puncture or insertion. The updated goal/standard addresses who does the marking, method of marking, and additional requirements for verifying the site for spinal procedures.
The new NPSG’s have a phase-in period where leadership has assigned responsibility for oversight and coordination by April 1, 2009, an implementation plan is in place by July 1, 2009, pilot testing is being done on at least one clinical unit by October 1, 2009, and full implementation across the hospital is done by January 1, 2010. They also have requirements for educating appropriate healthcare workers, patients and their families, conducts assessments and measurements, and reports the results and outcome measures to key stakeholders.
Three new NPSG’s focus on prevention of nosocomial infections: healthcare-associated infections resulting from multiple drug-resistant organisms (“MDRO’s”) such as MRSA or VRE or C. diff infections, central line-associated bloodstream infections, and surgical site infections. Hospitals are expected to use evidence-based practices or best practices in their programs to prevent these potentially preventable infections. These include things like use of CDC guidelines for reducing transmission of MDRO’s, surveillance programs for MDRO’s based on risk assessment, laboratory-based alert system that identifies new patients with MDRO’s and systems to alert patients readmitted or transferred with MDRO’s. The central line-associated bloodstream infection (“CLAB”) standard applies to both central venous catheters and PICC lines. The evidence-based/best practices include use of checklists and protocols for line insertion, proper hand hygiene prior to insertion or manipulation, avoidance of femoral catheters where possible, standardized all-inclusive supply kits, standardized sterile barrier precautions, chlorhexidine-based antiseptic for skin preparation (for patients over 2 months of age) unless contraindicated, standardized protocols for disinfecting catheter hubs and injection ports before accessing the ports, and routine evaluation for continued necessity of catheters. And the surgical site infection standards focus on some of the SCIP recommendations such as use and timing of antimicrobial prophylaxis and their discontinuation, and use of clippers or depilatories (rather than shaving) in those cases where hair removal is appropriate.
We expect that the evidence-based interventions for preventing infections in all three categories are likely to be expanded by the time full implementation of these new NPSG’s are required.
We spend a great deal of time in our infection control activities attending to the local patient environment, meaning their room and the personnel and equipment entering their room. But we also need to pay attention to some of the other areas in which transmission of infection is a potential threat. One such area is the radiology suite. Many of the patients at highest risk for transmission of nosocomial pathogens are also the likeliest to get high tech imaging studies in the radiology suite, such as CT or MRI scanning. Dr. Peter A. Rothschild has been running an excellent series on “Preventing infection in MRI: Best practices for infection control in and around MRI suites” on the radiology website AuntMinnie.com.
A new goal/standard was added to eliminate transfusion errors related to patient misidentification.
On the medication reconciliation side, Joint Commission has clarified some issues about medication reconciliation in those areas where medications are used minimally or prescribed for a short duration (such as ER’s, urgent care, convenient care, office-based surgery, outpatient radiology, ambulatory care, and behavioral health care). Facilities are still required to obtain a list of all the medications a patient has been taking at home but are not required to know the dose, route, or frequency of use. Another new requirement is that facilities provide at discharge from the hospital a complete and current list of reconciled medications directly to the patient (and document this interaction). Lists of reconciled medications should also be sent to the primary care provider, next provider of care, and referring provider.
Requirements for patient education and active involvement in their care have been emphasized in standards on patient identification, anticoagulation, and prevention of infection. The anticoagulation standard has been clarified and does not apply to short-term prophylactic anticoagulation (eg. DVT prophylaxis) where laboratory coagulation parameters are not expected to be significantly outside the normal range.
Overall, the new NPSG’ are very reasonable standards and hopefully most of you are already in significant compliance with these because they make sense from multiple perspectives.
Update: See our March 2009 What’s New in the Patient Safety World column “Joint Commission Puts a Hold on Medication Reconciliation Scoring”.
Joint Commission. 2009 National Patient Safety Goals.
Joint Commission. Renumbering Scheme for National Patient Safety Goals.
Rothschild PA. Preventing infection in MRI: Best practices for infection control in and around MRI suites. Auntminnie.com 2008
WHO surgical safety checklist