SDS Accreditation Update

Here are ways to ensure compliance with The Joint Commission's National Patient Safety Goals

Complying with The Joint Commission's National Patient Safety Goals (NPSGs) can be a challenge, and managers are developing a variety of approaches to ensure compliance.

Medical Arts Surgery Centers in Miami has developed a grid system that spell out what staff member has which responsibilities, reports Kate Moses, RN, CNOR, CPHQ, quality management nurse. Moses developed one grid for staff and one for physicians. [A copy of the grid is available.]

"We want to make it clear what they're required to do to be compliant," she says.

When creating her first grid, Moses realized that each goal has a who, what, when, where, and how. The "who" means who is responsible. The "how" is how they are responsible and how they are they going to document it. "Why" means the purpose. For example, for the goal requiring two patient identifiers, she indicated that the "who" was everyone who has direct patient contact. The "what" is by name and birthday (their facility policy). The "when" is every time patient care is passed from one person to another or when something is being done to the patient. The "where" is everywhere. The "why" is to ensure the correct patient is having the correct procedure. The "how" is that the patient says his or her name, confirms the birthday, and the birthday is confirmed against the paperwork.

"Breaking it down that way makes it simpler for staff to do," Moses explains. "It's better than saying, 'Just use two identifiers.'"

To ensure staff members comply with the grid, managers at Medical Arts Surgery Centers conduct random observations on a regular basis. Also, as part of chart auditing, charts are checked for NPSG compliance. The compliance level is shared with several boards and committees and is posted for staff to see, Moses says.

To educate staff, she conducts inservices. She laminates the grid and posts it in areas where it is likely to be seen, such as on the safety board, and in the OR. The physician grid is posted by the physician dictation area, in the locker room, and in the lounge.

Getting docs to comply

The medical board at the centers dictates that physicians must comply with their grid, Moses says. Compliance is monitored through activities such as documentation review, she says. "When I'm reviewing, if I notice that a certain physician isn't fulfilling the safety goals, such as using [do-not-use] abbreviations or not doing his part in medication reconciliation, I'll notify those physicians individually that they need to comply," Moses says. A quarterly newsletter includes reminders and news about changes, she says.

The benefits of the grids? Consistency across the continuum, she says. "Everyone is aware of their responsibilities," she says. "It makes it so there is a little less opportunity for staff to get creative." When you do the same things the same way every time, it becomes second nature, Moses says.

"The grid takes the mystery out of it, rather than just posting what the goals are," she adds.

As far as the safety goals go, measuring compliance with the Universal Protocol is a challenge, says Kathy Hale, director of patient safety at the University of Pittsburgh Medical Center.

"To measure accurately, there needs to be an observer to verify that each step in the process took place at the right point in time and that the appropriate staff were involved, rather than just verifying that the appropriate paperwork was completed," says Hale.

At Presbyterian Healthcare in Charlotte, NC, the "timeout" process was analyzed over one year. The staff listed all the elements one should consider just prior to the beginning of a procedure. "It was determined that there was so much 'noise' imposed over the timeout process," says Paula Swain, RN, MSN, CPHQ, director of clinical and regulatory review.

The entire organization, including operating rooms and procedural areas, decided to include only those elements critical to the prevention of wrong-site surgery and other procedural mishaps caused by preparation steps. "It was felt there were other processes and policies in place to manage the antibiotic and consent issues," she says.

Measuring the handoff

At UCLA Medical Center in Los Angeles, a process was implemented in which the orderly coming to move the patient had to verify with the nurse the existence of the order for the procedure. "Even though doctors were not active participants, they had to be permissive for it to occur," says Thomas Rosenthal, MD, chief medical officer. "They had to be tolerant of the two extra minutes for the handoff to occur correctly, instead of saying, 'I don't want any delays. Just get my patient down here.'"

"It was difficult to get all those pieces in place and, furthermore, it was difficult to measure whether we were accomplishing anything," he adds. "We had to find a way to measure that this handoff was actually occurring. You couldn't have that be self-supported."

Students observed handoff

A novel program was created in which undergraduate students were trained to observe the handoff procedure. The student checks to see that the transporter provides a written document for the nurse, the nurse checks for an order in the chart, and both the transporter and nurse check for two patient identifiers.

"You would think if you are being observed, you would be compliant 100% of the time, but that was not the case," says Rosenthal. "When we started, our compliance was 40%. That confirms for me that people don't always do it perfectly just because they know they are being watched."

Observed compliance with all measures is now greater than 95%, but this accomplishment took two years to achieve. "For me, that illustrates that asking for a change of this magnitude is not trivial," Rosenthal says.


For more information on compliance with National Patient Safety Goals, contact:

  • Thomas Rosenthal, MD, Chief Medical Officer, UCLA Medical Center, Los Angeles. Phone: (310) 825-4686. E-mail:

Strategies for compliance with national safety goals

Here are some proven strategies for national patient safety goals (NPSGs) that might be especially difficult to monitor:


Have a daily monitoring of one case per day, suggests Kate Moses, RN, CNOR, CPHQ, quality management nurse, Medical Arts Surgery Centers in Miami. The monitor can observe the timeout to make sure all parties have stopped what they are doing and are involved, she says.

"We don't load the scalpel and the first tool is not within the doctor's reach until the timeout is completed," she says. "It's a way to keep them from jumping the gun."

Everyone in the room has to verbally acknowledge that they are in agreement, Moses says.

Although it's not part of the NPSG, Moses' facility has a policy that the music is muted during the timeout so everyone in the room can hear.

Mark on the surgical site.

Moses' facility spells out that physicians will mark the site, regardless of the procedure. "We don't move the patient into the OR without a mark," she says.

The staff are empowered to say stop, Moses says. "If the identify is not matching up, maybe they printed it wrong on the paper, the patient doesn't move forward until it's corrected," she says.

Medication reconciliation.

There has been some confusion over what outpatient surgery providers are required to do in terms of medication reconciliation.

Medication reconciliation can be cumbersome in the ambulatory setting, so Moses called The Joint Commission to find out exactly what staff responsibilities entail. She included that information in a grid that spells out individual responsibilities.

"It says to be mindful of what the patient has been on at home, those that have allergies, for example, so that in the procedure itself, you don't use something that's contraindicated," Moses says. By using the grid to refresh every staff person's mind about medication safety in areas such as allergies, "it's a quick way to get it done and meet the goals," she says.

Handoff communications.

Implement a standardized approach to handoff communications, with an opportunity to ask and respond to questions, sources say.

Charles Emerman, MD, associate chief of staff in charge of quality at The MetroHealth System in Cleveland, says, "We can have checkboxes to say that people did this, but I can't always be sitting there listening while people talk to each other."

At the University of Pittsburgh Medical Center, the "Ticket to Ride" program is the mechanism used to comply with the handoff goal. The "ticket" can be printed from the computer system and handed to the receiving staff. The sheet includes instructions about where the patient is going and why. The program provides standardization of communication among caregivers at all handoff points, with the goal of reducing serious events related to patient transport and handoffs.

"The program started as a pilot in one hospital and is now being spread throughout our system," says Kathy Hale, director of patient safety. "We monitor compliance through our event reporting system, by investigating and tracking events that occur during patient transport or that are in some way a result of a handoff."

Hand hygiene.

Just as you can't listen to everything staff say when they are handing off a patient, you can't watch everybody washing their hands, says Emerman. At MetroHealth, spot checks are done by staff to observe hand washing, but this system isn't foolproof, he says.

"We have a nice process where everybody takes ownership of watching everybody else wash their hands," Emerman says. However, it's difficult to implement, he acknowledges.

"It's hard to get a 20-year-old care associate to go up and tell a physician to go back and wash their hands, even though we tell them it's OK to do that," he says. There is no magic bullet, Emerman says. "It won't be a permanent fix," he says. "It will be something that you have to constantly monitor."


For more information, contact:

  • Charles Emerman, MD, Associate Chief of Staff/Chair, Department of Emergency Medicine, The MetroHealth System, 2500 MetroHealth Drive. Cleveland, OH 44109.