Abbreviations, falls risk top compliance issues

Monitor staff for compliance

Only 76.8% of home health agencies surveyed by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations were found to be in compliance with the National Patient Safety Goal (NPSG) that requires standardization of abbreviations in 2005. For the patient safety goal that requires evaluation of patients for risk of falls, only 82.4% of home health agencies were found to be in compliance.

"Standardization of abbreviations has been a continuing problem for home health organizations for years," reports Maryanne L. Popovich, RN, MPH, executive director of the Joint Commission's Home Care Accreditation Program. "While we have seen some important progress there are still problems," she says.

Surveyors are reporting that most of the noncompliance is related to individuals within agencies, as opposed to agencies, who are not putting processes into place to meet the patient safety goal, says Popovich. "Agencies seem to have the standardized lists and other tools needed but there are staff members who still use 'u' for unit and other prohibited abbreviations," she explains.

"It's important to note that surveyors do not survey computer systems for compliance," Popovich points out. This means that if an agency's software was created before standardization of abbreviations and creation of "do not use" lists and the agency has no reasonable way to alter the automated programming, surveyors will not count this as a sign of noncompliance. "If, however, a staff member sits at the computer and types in a prohibited abbreviation, this is cited as noncompliant," she explains.

"The abbreviation issue goes beyond developing processes, tools, and educational sessions," Popovich points out. "We are asking people to change behavior that they may have learned 30 years ago in nursing or medical school." It is not easy to alter behavior but it is necessary for home health managers to be diligent and continuously monitor their staff for compliance, she adds.

"As with any performance improvement project, chart audits can help identify the problem," suggests Popovich. When reviewing charts for compliance with abbreviation requirements, be sure that the sample reviewed includes some charts from every employee, professional, and nonprofessional, she recommends. "We don't just have RNs making notes in the chart, we also have home health aides," she says. Every employee must comply with the patient safety goal, she points out.

"We have narrowed the focus of the patient safety goal to emphasize medications and physician orders, so the audit can focus on these items alone," says Popovich. This focus may help larger agencies with many staff members, she says.

"If you discover a few employees that consistently use prohibited abbreviations, it is simple to work one-on-one with them to retrain, monitor, and change their behavior," Popovich says. "If the problem is widespread, it requires more creativity and more effort to change the behavior," she admits.

A widespread problem with the abbreviation safety goal might also indicate a need to invest in software that ensures the use of correct abbreviations, suggests Popovich. "If your problem is widespread, be sure you address system changes that might support your staff's efforts," she adds.

Assess all patients for falls risk

In the 2005 NPSGs, Goal 9A required home health agencies to assess the risk of all patients for falls. Because home health agencies have always known the risk of falling in the home, the 82.4% level of compliance with this goal might surprise some people. "It is surprising, but surveyors find that with this safety goal, also, agencies have the procedures in place, but individuals don't always follow them," says Popovich.

Surveyors find that while agencies may assess high-risk patients, they are not assessing all patients as required, says Popovich. "Elderly patients almost always are assessed for their falls risk, but other patients may appear to be without ambulatory or cognitive problems, so they are not assessed," she says.

Pediatric patients are almost never assessed for risk of falls because everyone assumes that it is normal for them to fall, she points out. This doesn't let the home care nurse off the hook though, she adds. "Why wouldn't we check for gates on the stairs, raised rails on the cribs, and no access to items that will tip over when climbed upon, such as chairs?" Popovich asks. Even if the nurse knows that children will fall, it is important to minimize the risk of falls to prevent unnecessary injury, she asserts.

"We also discovered that even when assessments are done, they are not always comprehensive," Popovich points out. "A nurse may assess the physical environment but not look at medications that increase the risk of falls." To perform a complete assessment, the nurse must assess the patient's physical and cognitive condition, the environment, medications, and the type of illness or injury, she suggests.

In addition to the assessment, the surveyor is looking for strategies to reduce the risks identified in the assessment, Popovich points out. Even if an agency relies on OASIS data, the nurse must perform a separate assessment to ensure compliance, especially if the patient is a child, she adds.

The big change between the 2005 NPSG and the 2006 NPSG related to falls prevention is that the 2006 goal requires the implementation of a falls reduction program throughout the agency, Popovich says. This means that agencies surveyed in 2006 have had to show a comprehensive effort to reduce falls throughout their entire population.

First-quarter data on compliance for 2006 show no significant improvement for the goals related to abbreviations and falls, and even show a slight decline, says Popovich. "Of course, this trend may change as more agencies are surveyed throughout the year, but we know that these have been the two most difficult challenges for home care and they will continue to be so for some time."

Source/Resources

For more information about National Patient Safety Goal compliance, contact:

Maryanne L. Popovich, RN, MPH, Executive Director, Home Care Accreditation Program, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5742. Fax: (630) 792-5005. E-mail: mpopovich@jcaho.org.

To view a full copy of the 2005 National Patient Safety Goal compliance data, go to www.jointcommission.org. Choose "patient safety" on the top navigational bar and then click on "National Patient Safety Goals." Scroll down the page to "Additional Resources" and choose "NPSG 2005 Compliance Data." Also located on the National Patient Safety Goals page are FAQs related to specific goals, including falls reduction programs; a "do not use" abbreviation list; a list of look-alike, sound-alike medications; and implementation tips for standardizing abbreviations.

For copies of reports and presentations related to the Missouri Alliance of Home Care Falls Reduction project, go to www.homecaremissouri.org and click on "MAHC Benchmark Projects" on the right navigational bar, and then choose "Falls Reduction Project."