Joint Commission releases 2007 NPSGs

The 'devil,' as always, is in the details, experts say

The 2007 National Patient Safety Goals (NPSGs) recently announced by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) do not at first glance seem to impose any onerous requirements on quality managers — nor do they seem to call for any dramatic changes in what are probably fairly standard practices. However, notes one quality expert, the "devil is in the details" when it comes to compliance, and when you drill down beyond the basic standard outlines, the picture becomes more murky.

The 2007 NPSGs actually include only one new goal that applies to hospitals. The Joint Commission also extends to hospitals a 2006 goal that at first did not apply to them. The new goal, 15/15A, is as follows:

"The organization identifies safety risks inherent in its patient population.

"The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.]"

The extension is for goal 13/13A. It reads:

"Encourage patients' active involvement in their own care as a patient safety strategy.

"Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so."

Concerning the new goal, Richard Croteau, MD, executive director for patient safety initiatives at the Joint Commission International Center for Patient Safety, says: "The requirement is that these patients be assessed for risk of suicide, and based on that assessment, that appropriate precautions be taken." Usually, he says, these precautions involve continuous observation and checking for any kind of 'contraband,' such as pills or knives.

"A lot of people in psychiatric hospitals conduct assessments, and based on those assessments, provide continuous observation," says Patrice L. Spath, of Brown Spath & Associates, in Forest Grove, OR. "The difficult part will be determining what is meant by 'emotional and behavioral disorders' in general hospitals. What if this is a secondary diagnosis — if, for example, they are really being treated for CHF but they also have a personality disorder? That will be the hard part to sort out."

Spath continues: "I don't know how in the survey process something as nebulous as this is measured." In other words, she explains, the goal could mean that if the patient has any diagnosis that suggests an emotional or behavioral disorder it needs to be part of the nursing assessment at the time of admission, and an assessment of risk for suicide should be conducted. "There are formal assessment tools available, but I don't know if they are used in a general hospital when seeing someone who has an emotional disorder," says Spath. "After all, what is an emotional disorder?"

Spath says she's thinking, for example, about patients such as a teenager who comes in for a broken leg and who is also known to be anorexic. "Based on what the Joint Commission is requiring, I would say that teenager needs to be assessed as to whether they are at risk for suicide," she declares. "How in-depth that is will be dependent on the protocol the hospital uses."

An acute care general hospital, she suggests, may need to develop a more detailed assessment "to play it safe for the Joint Commission, as well as to keep patients safe." However, she notes, since JCAHO does not specify an assessment tool, "You get to pick the one you want to use. I would guess that most facilities that don't have a psych unit have a pretty minimal risk assessment tool — if at all — but the assessment needs to be done."

Partnering with patients

As for goal 13, says Croteau, "The patient needs to be advised as to how they can express concerns about their safety. If they observe anything they think is unsafe, they need to be able to report that, so the hospital needs to provide those means and encourage them to do it."

He suggests that a nurse might say, if appropriate, something like this: "Here at 'St. X Hospital' we are very concerned about safety. We want everyone and anyone to be alert and to help us keep everyone safe — including you." Accordingly, he continues, the patient can be advised that if they see something that doesn't look right or appears hazardous, they should tell the first nurse or doctor they see. "Your don't want the patient to feel you are transferring the responsibility for their safety to them, but you should state your philosophy of safety and engage them in the process," he adds.

But, notes Spath, "although the NPSG of involving patients in patient safety seems to suggest that we are supposed to embrace patients as partners, the implementation expectation actually reads more like a compliance or grievance process, e.g., 'educate patients/family on methods available to report concerns related to care, treatment, services, and patient safety issues,'" she says.

The goal and its implementation, she continues, seem to be two different things. "The expectation is that patients and families should report concerns. But to me, this expectation is more like a reporting process — like Medicare has a process for complaints," Spath observes. "To me, having a method to report concerns and educating patients and families on that method is different than involving the patient in his or her own care."

The word "report" is what gets in the way, says Spath. For example, she notes, one hospital "has a poster up on all the walls in patients' rooms that says, 'Here's what we are going to do to keep you safe,' and lists certain processes, like validating the patient's name. Then, at the bottom it says, 'And if we forget, remind us.' Does a patient 'reminding' you cover the goal?"

Let's say, Spath posits, that a family member was told to make sure caregivers wash their hands, and if they forget, to remind them. "If the family member says, 'You did not wash your hands,' is that a 'report' or a 'reminder'"? Spath asks. "Does that constitute a report? The goal sounds like it's talking about some formal way of filling out a grievance."

In some ways, Spath says, the goal doesn't go far enough. "The problem with just telling people to report concerns is, if you don't also tell them what's supposed to be happening to them, the patient will not have a good understanding about what to report," she notes.

Spath further advises that quality managers look at all the goals — not just the ones that specifically apply to hospitals. "Some of the goals that are not directed to hospitals may be extended down the road, so consequently quality managers should look at all of them," she says. "Also, I think that instead of simply having a 'checklist' mentality when it comes to these goals, we need to keep making safety as our goal. If something recommended for ambulatory care is something that would be a good thing to do for your patients, you should do it; you don't necessarily wait until the Joint Commission enacts it."

For more information, contact:

Richard Croteau, MD, Executive Director for Patient Safety Initiatives, Joint Commission International Center for Patient Safety. Phone: (401) 855-0281.

Patrice L. Spath, Brown Spath Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: