New 2008 NPSGs target early intervention, medication safety

Organizations still struggling with existing goals

Just three new National Patient Safety Goals (NPSGs) were added by The Joint Commission this year, but the requirements — both new and old — pose some challenges for organizations and quality professionals.

"The overall feedback that we have been hearing from the field in the last couple of years during review of potential goal topics has been that it's difficult to keep up with the pace of too many new goals and requirements," says Peter B. Angood, MD, The Joint Commission's vice president and chief patient safety officer. "So last year and again this year, we have by design made only a few changes and suggestions."

While some organizations have incorporated the NPSGs very well, many others continue to struggle, says Angood.

"An interesting change this year is how much more detailed the language is for how the goals are to be met and monitored," says Frederick P. Meyerhoefer, MD, a consultant based in Canton, OH. "This will present a challenge to almost all hospitals, but particularly to smaller hospitals with fewer resources that are already stretched to the limit. Because of the complexity of developing the processes to meet the goals, no hospital can avoid starting the compliance process immediately."

Here are the three new goals with compliance suggestions for each:

• Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

The goal's rationale is that anticoagulation is a high-risk treatment that often leads to adverse drug events (ADEs) due to the complexity of dosing these medications, monitoring their effects, and ensuring patient compliance with outpatient therapy.

"What we have heard from several areas is that patients who require anticoagulation therapy have several risks involved with their care. The Sentinel Event Advisory Group felt that this was an important topic," says Angood.

If therapeutic ranges are either undermet or overmet, patients are at increased risk for complications. "Because of the potential magnitude of these complications, all patients on anticoagulant therapy, both inpatients and outpatients, need to be followed and monitored closely. That is the intent of this goal," says Angood. The requirements are consistent with existing guidelines from professional organizations on the management of anticoagulation therapy, he notes.

To reduce harm related to use of anticoagulation, The Joint Commission has established very specific actions to be taken, says Patrice Spath, RHIT, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates.

"The first step is for hospitals to create a task group to address each of these steps and analyze current processes related to the goal," she says. This may involve the development of a process flow chart showing the current way things are done, and a chart that describes how the process needs to change to meet the intent of the NPSG.

The goal will be easier to accomplish for inpatients than for those receiving outpatient therapy, says Kathleen Catalano, RN, JD, director of health care transformation for Plano, TX-based Perot Systems. Facilities already monitor inpatients on anticoagulation medications, but this goal also requires patient compliance with outpatient therapy, she explains.

"How will this be accomplished? This may be the hardest NPSG to accommodate yet," says Catalano. "Standardized practices are necessary, but that's easier said than done. Now the onus is on the health care facility to basically attain buy-in from patients — humans with their own ideas about compliance with doctor's orders."

The focus on patients receiving anticoagulant therapy is an attempt to prevent problems by instituting awareness and closer monitoring, says Patti Muller-Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant who works with hospitals on performance improvement and regulatory compliance.

"Although some of the treatments with anticoagulants have been in use for a long time, they are, in fact, high-risk treatments because of the complexity of dosing and patient responses," she says. This will require additional education of all staff, and a method of identifying patients on therapy so they can be monitored more closely.

The goal points to the need for nurses to perform assessments of each patient on each shift, according to Muller-Smith. "I don't think that nursing assistive personnel are adequately trained to make some of the judgments that are required," she says. "Documentation should be sufficient to support the identified patient response to treatment and prevention of any injury, especially falls."

Baptist Hospital of Miami has been addressing safety measures regarding anticoagulation therapy for many years, says Faith D. Solkoff, RN, BSN, MPA, assistant vice president. "We have seen improvements in our patients' care and outcomes," she says. "We are currently addressing other measures across our system, such as consolidating teaching and follow-up into a post-care clinic."

• Comply with current hand hygiene guidelines from the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC).

The CDC guidelines have been well recognized for some time and will continue to be the guidelines most commonly used by organizations, says Angood. "In our work internationally, we have come to appreciate that the WHO guidelines are commonly used. And so we wanted to make sure that those institutions have the opportunity to use the WHO guidelines if they so choose," he explains.

The guidelines are fairly similar to the CDC guidelines, and in fact, many of the experts who authored the CDC guidelines also participated in writing the WHO guidelines, notes Angood.

"There really is no difference in the guidelines. The verbiage and recommendation strength rating scale look identical to the CDC's," says Doe Kley, RN, BS, CIC, infection control coordinator at McKay-Dee Hospital in Ogden, UT. For this reason, facilities using the CDC guidelines will probably continue to do so, says Catalano. "Others that do not have a policy and practice in place will adopt one or the other," she says.

Whichever guideline is used, there is no question that evaluating compliance is difficult. "Direct observation remains the best approach for evaluating compliance," says Angood. "We recognize that monitoring the volume of different solutions is another method, but it should be substantiated by direct observation."

At McKay-Dee, each unit has a designated staff member who acts as the "official observer" for their area. This individual is required to complete a hand hygiene compliance form once a month, so that Kley can calculate and graph the results.

Most of the time, the observer watches the comings and goings at a given patient's room or work area for the observation period, and documents who came and went and whether hand hygiene was practiced — for example, if the health care provider washes three out of four opportunities, a score of 75% is given.

"They try to do their observations secretly — if staff know they are being watched, you just don't get 'real' data," says Kley. "It typically doesn't take more than 30 minutes to complete the observations."

• Improve recognition and response to changes in a patient's condition: The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening.

Early response for critical events such as cardiopulmonary and respiratory arrests or changes in patient vital signs may reduce cardiopulmonary arrests and patient mortality. "Many facilities have already established rapid response teams, and that is probably the answer to this goal," says Catalano. "Facilities that have not yet breached this approach will need to do so in the near future."

Though many institutions already have implemented rapid response teams, Angood says, "we also recognize that the medical literature and research on that topic continues to remain somewhat ambiguous and not fully strong in support of the use of rapid response teams."

The purpose of this goal is more basic — organizations must have a process in place to identify when a patient's condition is changing and recognize that there are opportunities for those situations to be managed by notifying other providers.

"However an organization chooses to identify those patients, and however they choose to respond to those deteriorating patients, is up to the organization, at this stage," says Angood. "I think a significant number have not addressed the implementation of any type of program to identify and respond to deteriorating patients."

At Baptist Hospital, a Code Rescue program was implemented in February 2005, which has significantly reduced Code Blues outside the critical care unit. "We are seeing improvements in survival rates, too," reports Solkoff.

Rescue events in medical/surgical areas were increased to almost 40 per 1,000 admissions, whereas the Institute for Healthcare Improvement's best practice benchmark is 25 per 1,000 admissions, says Jill M. Szymanski, RN, MS, CHE, CPHQ, quality manager at the hospital. "At the same time, we have reduced the frequency of resuscitation events from over two per 1,000 admissions to less than one and a half per 1,000 admissions," says Szymanski. "Now, over 25% of our resuscitated patients survive at Baptist Hospital, while the national average is 15%."

Depending on available resources, implementing a rapid response team might pose a problem to some organizations, says Muller-Smith.

The Joint Commission indicates several elements to comply with this goal:

  1. Selection of a method.
  2. Criteria for calling additional assistance.
  3. Education of staff, patients, and families concerning requesting additional assistance.
  4. Formal education regarding the process.
  5. Ongoing monitoring of the method's effectiveness.
  6. Pre- and post-statistics on cardiac and pulmonary arrests and mortality.

"Many of these practices may already be in place but will require review and monitoring to demonstrate that the method is working," says Muller-Smith. She suggests monitoring the number of times the team is called, and comparing the pre and post implementation numbers of cardiac or respiratory arrests.

"The rapid response team is an effort to reduce the number of Code Blue episodes that occur, by getting the team in before an actual arrest occurs," Muller-Smith says. "The number of codes called pre- and post-implementation and mortality rates are good indicators of success."

[For more information, contact:

Kathleen Catalano, RN, JD, Perot Systems, Healthcare Transformation, 2300 W. Plano Parkway, Plano, TX 75075. Phone: (214) 709-7940. E-mail:

Doe Kley, RN, BS, CIC, Infection Control Coordinator, McKay-Dee Hospital Center, 4401 Harrison Boulevard, Ogden, UT 84403. Phone: (801) 387-3294. Fax: (801) 387-3244. E-mail:

Frederick P. Meyerhoefer, MD, 1261 White Stone Circle NE, Canton, OH 44721. Phone: (330) 966-6717. E-mail:

Patti Muller-Smith, RN, EdD, CPHQ, Administrative Consulting Services, Box 3368, Shawnee, OK 74802. Phone: (405) 878-0118. E-mail:

Faith D. Solkoff, RN, BSN, MPA, Assistant Vice President, Baptist Hospital of Miami, 8900 North Kendall Drive, Miami, FL 33176. Phone: (786) 596-2685. Fax: (786) 596-5983. E-mail:

Patrice L. Spath, BA, RHIT, Health Care Quality Specialist, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: Web:

Jill M. Szymanski, RN, MS, CHE, CPHQ, Manager, Quality Management, Baptist Hospital of Miami, 8900 North Kendall Drive, Miami, FL 33176-2197. Phone: (786) 596-6049. Fax: (786) 596-2404. E-mail:]