Joint Commission releases proposed 2009 NPSGs

Changes in medicine reconciliation

The Joint Commission has released its proposed 2009 National Patient Safety Goals (NPSGs), and as one quality expert has opined, "It probably contained no surprises."

The proposals focus on new and revised NPSGs for the following topics:

  • Goal 1: patient identification ;
  • Goal 3: safe use of medications (laboratory accreditation program only);
  • Goal 7: hospital-acquired infections focusing on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile-associated disease (CDAD); catheter-associated bloodstream infections (CABSI); and surgical site infections (SSI) in acute care hospitals;
  • Goal 8: medication reconciliation;
  • Goal 13: patient involvement in their care;
  • universal protocol.

"Your readers will probably want to spend the most time reading about medication reconciliation," says Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission.

"This turned out to be a goal everybody agreed with in concept, but it has been highly complicated to implement," Angood concedes. "As a result of comments from the field we reviewed all the issues; the components are essentially the same, but the language is refined."

So, for example, under the proposed new goal, a medication reconciliation list will still need to be generated; there needs to be ongoing reconciliation when a patient is transferred to another facility; the receiving facility needs to have an updated list as well as the patient; and when the patient actually leaves care they need to receive an updated list — as does the next provider of service.

"What is somewhat new is that for patient care areas where the medications are prescribed for a short term, a modified process can be utilized," says Angood. So, for example, if a patient goes to an outpatient facility for contrasts, they can have the meds list reviewed, but all the specifics of medication administration will not have to be determined.

"We assume that if they then receive no other medications, they will be able to be discharged without having to go through full medication reconciliation," he explains. "We've also made it more clear what the key steps and expectations are, to try to make it more practical."

"I guess they have addressed the issue, although we have not yet had to apply it in real life, so we're not sure it works," says Patrice L. Spath, of Brown Spath Associates, Forest Grove, OR.

Spath believes that Goal 8b could still present some difficulties. "When patients leave the hospital and are sent home, a complete list must be given to the primary care provider or the referring provider or known next provider. What if a patient had [emergency] surgery? They will have a surgeon, but the hospital may not always know who the primary care provider is, so this needs to be clarified." Spath predicts that "as people respond to these proposals, you would think they might raise this issue."

HAIs are new

Perhaps the most significant new goal for quality managers is the one dealing with hospital-acquired infections, says Angood. "We have an existing Goal 7, which initially focused on hand hygiene and reporting of HAIs where major disability occurs. However, we have added requirements related to multi-drug resistant organism infections, MRSA and Clostridium difficile — often called CDAD (Clostridium difficile-associated disease)."

In addition, he says, The Joint Commission has added some requirements in the universal protocol. "We held a summit in early 2007; a variety of professional organizations — as well as our own — had noted that even though it had been out for a year there had not been a change in the frequency of reported wrong-site surgery events. Everyone agreed the components were correct and we should continue to use them, but there needed to be a little more prescriptive language." The details, he says, have been made "a little tighter."

"There has been a debate about whether the surgeon was the one who should mark the surgical site, and that was cleared up with the 2009 proposed standards," says Spath. "I'm sure it will stay in because hospitals will be given RFIs [requirements for improvements] if they do not have the surgeon do it."

In the past, she notes, some hospitals were allowing nurses to mark the site, but "that will no longer be an acceptable practice," says Spath.

In addition, says Angood, the proposed new goals include added language concerning patient involvement in their own care, as well as patient identification.

The latter "could be problematic," warns Spath. "It requires a two-person identification process if you do not have bar-coding, but that kind of double check is considered weak from a human factors engineering perspective — because the second person will often see what they expect to see." Still, she concedes, "It may be better than doing nothing." She also adds that this goal, as many of the new proposals do, "makes good common sense."

A shift in alignment?

Spath notes that the more recent versions of the NPSGs (which were started in 2003) "seem to align more with Medicare [standards] than with sentinel event [reports]. Take surgical infections," she offers. "How many sentinel alerts do they — [The Joint Commission] send out on infections? Yet what does Medicare push?" MRSA and bloodstream infections, she points out, "are things Medicare is focusing on now; this looks like a shift to more closely align the goals with [Medicare] priorities."

While "killing two birds with one stone" may make sense on some levels, Spath has her concerns. "I'm not sure we move as effectively towards improved quality and safety if all groups are focused on the same things," she offers. "For example, medication reconciliation is not something Medicare is focused on, so we might not have had it if the two were that closely aligned; the same thing goes for patient identification." In other words, she summarizes, there needs to be a balance.

Angood says the final goals will be published in May or June, and it is hard to predict how much the proposals will be changed — if at all. "It varies year by year in terms of what occurs between our [proposal] short list and the final goals depending on the feedback we get and the general discussion within our advisory group," he says. "The program is only five years old so we are still building and refining it; we will continue to get more rigorous as to how we choose our goals, how we review them, and whether or not they are adopted in some form." (For more information on the proposed goals, go to: www.jointcommission.org.)

[For more information, contact:

Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.

Patrice L. Spath, Brown Spath Associates, P.O. Box 721, Forest Grove, OR 971116. Phone: (503) 357-9185. E-mail: Patrice@brownspath.com.]