New safety goals will be phased in over a year

It may be difficult to meet milestones

For its 2008 National Patient Safety Goals, The Joint Commission has prescribed a one-year phase-in period with defined milestones for compliance at three, six, and nine months. "Some of these goals are complicated by the nature of their topic. We recognize that there will need to be a process and system redesign to successfully meet the goals," says Peter B. Angood, MD, The Joint Commission's vice president and chief patient safety officer.

However, it will be a challenge for many organizations to meet the milestones, predicts Michelle H. Pelling, MBA, RN, president of ProPell Group, a Newberg, OR-based consulting firm specializing in regulatory compliance.

"Some organizations have not implemented the existing National Patient Safety Goals within the required time frames, tending to put off tackling new requirements, no doubt feeling overwhelmed by NPSGs in general," she says. "They may not have had formalized processes for implementation planning."

The phase-in period is a sign that The Joint Commission has recognized this problem, says Pelling. Here are time frames that your organization will have to meet:

• By April 1, 2008, your organization's leadership must have assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG requirements.

• By July 1, 2008, an implementation work plan must be in place that identifies adequate resources, assigned accountabilities, and a timeline for full implementation. This will require an assessment of current processes, interdisciplinary discussions, collaborative review and analysis of potential problems that process changes may create, and tactical planning.

Most organizations will be able to achieve the April 1 deadline, but the July 1 deadline will be a much bigger challenge, says Pelling. "Many organizations may not have the resources or staff experienced in developing an implementation plan with these elements," she says.

• By Oct. 1, 2008, pilot testing must be initiated in at least one clinical unit. Plans must be tested, results measured, and the potential effects of full implementation evaluated. "This again requires organizational skills, time, and staff resources," says Pelling. "It may be a very different way of approaching these goals for some organizations. They will need to scramble to get the staff the skills and resources they need to meet the milestones."

The Joint Commission is introducing two new goals that reflect international consensus on focus areas that can potentially enhance patient safety and save lives, says Judy B. Courtmanche, president and CEO of Courtemanche & Associates, a consulting firm specializing in regulatory compliance and outcomes management, based in Charlotte, NC.

"The World Health Organization, [Institute for Healthcare Improvement], [Agency for Healthcare Research and Quality], and others agree that these goals are worthy of our consideration," says Courtemanche.

However, organizations are struggling to meet the National Patient Safety Goals already in effect, Courtemanche affirms. "We monitor regulatory compliance and have seen organizational noncompliance with several NPSGs continue to increase over the past two years," she says.

In 2006, The Joint Commission found noncompliance at 59% for NPSG Goal 2 for improved communication, 38% for NPSG 8 on medication reconciliation, 28% for universal protocol, and 18% for NPSG 3 on medication safety.

"When organizations are not able to meet current expectations, raising the bar doesn't necessarily make patient care safer," says Courtemanche. "Instead, it creates competing priorities and divided focus as organizations attempt to meet new requirements without fully meeting prior expectations."

As NPSGs have been introduced, organizations have had to re-evaluate current practices and redesign their health care systems to meet the requirements. Often, designing their approach was the easy part, while implementation, reinforcement, and support of the new process lacked ongoing resources. "In our work with organizations, we find that enforcing the new expectations is difficult in most organizations, as accountability structures may not support practice change," says Courtemanche.

Take these steps for noncompliance:

  • Determine how far along you are in implementation, using data gathered by the quality department or other departments. "If problem areas still exist, it's time to reconvene a task group to determine how best to resolve these problems," says Patrice L. Spath, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates.
  • Enforce practice changes. For example, staff may be aware of the requirement to label all medications on the sterile field, but it may not be getting done. "People are being told to do this, but what happens when they don't? If there is no oversight and accountability, physicians and staff can easily slip back into their old habits," says Spath.
  • Celebrate achievements. Whatever progress your hospital is making toward achieving full compliance with the NPSGs should be celebrated. Provide physicians and staff with data that show the level of compliance. "Keeping compliance information front and center helps to maintain the momentum and sustain gains," says Spath.
  • Build in accountability with the new process.

By setting performance expectations, it becomes clear to the organization and the individual what needs to occur and what to do when it isn't happening. "Lay the groundwork by focusing first on the defining the process, developing the documents and structures that set expectations, and support those that enforce them," says Courtemanche.

For example, if governance documents do not focus on patient safety, accountability is hard to enforce. On the other hand, if medical staff bylaws, rules, regulations, policies, and job descriptions contain language supporting performance for patient safety initiatives, the medical staff have the foundation for self-governance and discipline accountability. "The same is true for other disciplines in the organization," says Courtemanche.

[For more information, contact:

Judy B. Courtemanche, President and CEO, Courtemanche & Associates, P.O. Box 17127, Charlotte, NC 28227. Phone: (704) 573-4535. E-mail: Web:

Michelle H. Pelling MBA, RN, President, ProPell Group, PO Box 910, Newberg, OR 97132. Phone: (503) 538-5030. Fax: (503) 538-0115. E-mail: Web:]