New NPSGs for 2007 will be big challenge

The JCAHO’s proposed National Patient Safety Goals (NPSGs) for 2007 aren’t a big surprise but will pose additional challenges for quality professionals. "The 2007 proposed goals are not too much of a surprise when you add them in with the NPSGs already in effect," says Kathleen A. Catalano, RN, JD, director of regulatory compliance services for Dallas, TX-based PHNS Inc. "Quality leaders will be able to build upon what is already in place and broaden the scope of review."

However, the proposed goals will pose a significant challenge to hospitals, especially with personnel charged with developing policies, procedures, and protocols, and measuring compliance, says Frederick P. Meyerhoefer, MD, a Canton, OH-based consultant specializing in JCAHO and regulatory compliance.

Quality professionals commonly express frustration with trying to continually meet the requirements of the NPSGs, says Meyerhoefer.

"This frustration comes from the frequently changing interpretation of the NPSG requirements," he says. "I’ve commonly heard quality managers complain that just when they roll out a program to meet the goal requirements, there is a new twist found in the posted FAQs."

In addition, staff often have difficulty seeing the benefit of compliance with the goals, adds Meyerhoefer.

"They are upset when just as they are coping with the first policy, they have to add to or change what they are doing," he says. "Quality managers will have difficulty dealing with this attitude."

Quality managers also will have to develop measures and perform audits to assure the required compliance on an ongoing basis, adds Meyerhoefer.

Here are some of the proposed goals and implications for quality professionals:

• Proposed Goal 3E requires reducing harm associated with the use of anticoagulation therapy.

This includes the elimination of heparin flushes for peripheral intravenous lines and ensuring that coagulation test results are received and reviewed before subsequent doses are adjusted or administered, says Catalano. "I believe most institutions are already in the process of reviewing anticoagulants and the use of strategies to reduce dosing and monitoring errors," says Catalano. "The question to ask is, "Are all of these strategies being monitored and data recorded?"

Pharmacist involvement is required for inpatient anticoagulation services for both heparin and warfarin.

"Also included is education for the patient," says Catalano. "At the point of discharge, an inpatient is to practice administering their own medication under the supervision of medical staff. The quality leaders will need to be certain that this NPSG is carried out to the letter."

• NPSG Goal 15 requires the organization to identify safety risks inherent in the patient population, including reducing the risk of patient harm resulting from falls.

"Quality leaders have already been involved in this goal, and so there should be no added monitoring responsibilities, except that now the fall reduction program is to include inservices involving patients and their families, and the development and implementation of transfer protocols as applicable," says Catalano.

• NPSG Goal 15 B involves the prevention of health care-associated pressure ulcers.

"This is an age-old problem and this goal will require assessing and periodically reassessing each patient’s risk for developing a pressure ulcer," says Catalano. "That may be difficult to measure."

High-risk patients have always been assessed for pressure ulcers, but now JCAHO is broadening this to include all patients, adds Catalano. The goal requires an effective plan for the prediction, prevention, and early treatment of pressure ulcers in addition to assessment and prevention plans and educational programs, she says.

• NPSG Goal 15E requires identifying patients at risk for suicide.

Since January 1, 1995, 464 patient suicides have been reported to the JCAHO as sentinel events. "Part of the reason for this is the patient suicide is often picked up by the media and reported," says Catalano. "JCAHO notes that suicide is the 11th most frequent cause of death in the United States. It seems a natural progression for the NPSGs to encompass patient suicide."

• NPSG Goal 16A requires the organization to take steps to discourage disruptive behavior.

"This may be a bit difficult for quality leaders. The disruptive behavior is not just that of physicians — it refers to unacceptable behaviors anywhere in the organization," says Catalano. "The goal will require development of a code of behavior that encourages reporting of disruptive behavior without fear of retaliation by the institution."

• NPSG Goal 17A requires that orientation be provided to temporary and agency workers.

This goal will require a full orientation program that includes environment of care, clinical and departmental policies, procedures and practices, and a written test to assess the level of comprehension.

"This will not be too difficult but will need to be applied uniformly across the organization," says Catalano. "It goes without saying that many of the issues that arise in an institution are because of lack of education and communication. I believe this goal is trying to stem the tide when it comes to temporary and agency staff."

• NPSG Goal 18A requires that the organization improve recognitions and response to changes in patient condition, such as implementing a "rapid response team."

The development and implementation of such a team will require a task force to review current literature and develop criteria, education, and monitoring of the team’s intervention and rescue rates, says Catalano. "Codes are already monitored. Now mortality rates before and after implementation of early recognition and response team involvement will be added," she says.

• NPSG Goal 19A will help prevent patient harm associated with health care worker fatigue.

The organization will need to manage work hours and periods of on-call in order to minimize fatigue, says Catalano. "This will not be easy. This may already be under review by human resources but will probably need to be more in-depth to accommodate the requirements of this goal."

[For more information, contact:

Kathleen A. Catalano, RN, JD, Director of Regulatory Compliance Services, PHNS Inc., One Lincoln Centre, 5400 LBJ Freeway, Suite 200, Dallas, TX 75240. Telephone: (214) 257-7112. Fax: (214) 707-7403. E-mail:

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