ED Accreditation Update

No new NPSGs, but no time for EDs to relax

ED managers might breathe a small sigh of relief following the announcement from The Joint Commission (TJC) that there will be no new National Patient Safety Goals (NPSGs) developed for 2010, but experts say that doesn't mean they should pay any less attention to improving patient safety strategies.

"I don't know any place that has [patient safety] down. I don't know anyone who has completely hardwired all the elements," asserts Becky Petersen, RN, MS, manager of emergency services at Alta Bates Summit Medical Center in Berkeley, CA. "I can't believe there'd be any reaction other than, 'We have another year go at this.'"

Regardless of any regulations, nurse managers always should work with physicians, staff, and patients to improve operational safety, because it is the "right thing to do," adds Diana Contino, RN, MBA, FAEN, senior manager in the healthcare practice of McLean, VA-based BearningPoint Management & Technology Consultants, which provides management and technology consulting services. "The 2009 safety goal delay shouldn't impact department operations," she says.

The Joint Commission noted on its web site that "over the next year, the current National Patient Safety Goals will undergo an extensive review process" as TJC examines comments it has received from the field, thus the one-year hiatus. How can ED managers make the most of this opportunity to improve current practices?

Identify your weaknesses

Clearly, every department has different areas of weakness to address; the first step, which Peterson has already taken, is to identify them. "For my ED, the three issues that need the most attention over the next year are handoff communication, monitoring patient response to medication, and moderate sedation," she says.

"I am a zealot about handoffs — especially in the ED," adds Peterson, who notes that her department has just implemented an electronic documentation system. The system has been a great improvement for documentation, but it creates a barrier to giving reports at the bedside, she says. "I strongly believe it is a best practice for all clinicians to hand over care at the bedside, so that will be a major goal for 2009," Peterson says.

As for monitoring patient response to medication, "I am on a campaign to increase awareness of the need to make patients pain-free, whether it be with medication or other means," Peterson says. "Constantly checking on pain levels is a must." EDs, she adds, "are notorious for undermedicating for pain."

In terms of moderate sedations, Peterson says her department recently implemented an alert in Pyxis when a medication that was used for moderate sedation was removed. "It reminds the nurse to have the medical record and moderate sedation forms reviewed by the charge nurse," she explains. "We are auditing all charts for nurse and physician compliance to the pre- and post- procedure requirements for timeout, consent, patient monitoring, and sedation assessments."

In addition, Peterson plans to keep a keen focus on things "that never go off the radar screen," such as hand washing. "Our hospital has a policy whereby we observe each other anonymously during the month, seeing that people wash before going into and out of a room," she says. "One of the things I do is wander around the department and remind people not to come out of a room with gloves on."

Know the key areas of safety improvement

If your department has identified that your processes with the following issues are not evidence- based best practices for your environment — in that there have been errors or near misses that could have been avoided with a different process — then the manager and safety teams should be working to improve these key areas below. This advice comes from Diana Contino, RN, MBA, FAEN, senior manager in the health care practice of McLean, VA-based BearningPoint Management & Technology Consultants, which provides management and technology consulting services. Areas of improvement include:

  • elimination of transfusion errors;
  • improvement of the effectiveness of communication among caregivers;
  • safety of using medications;
  • hospital-acquired infections;
  • encouragement of patient involvement in their own safety;
  • improvement of recognition and response to changes in condition;
  • universal protocol for procedures;
  • prevention of patient falls.

There are also several key elements to creating a safe environment, Contino adds. They are:

  • a robust and nonpunitive event reporting process;
  • a departmental safety team or committee, which includes key process stakeholders, including staff physicians and, when appropriate, patients;
  • regular review of events and a process by which to identify and prioritize solutions.

"Solutions should not be focused on adding forms, but rather on decreasing steps and improving accountability with the defined process," says Contino. "For example, if the entire team determines that lab specimens will be labeled at bedside, then enforcement is not the manager's sole responsibility, but also a peer and team responsibility."

Managers, she adds, step in when peer enforcement hasn't been successful. "Every member of the health care team is responsible to ensure we care for patients in a safe environment and through safe, accurate processes," she says.