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SDS Accreditation Update
Tips for meeting national safety goals
Can you prove you are in compliance with National Patient Safety Goals (NPSGs)? Compliance is mandatory for facilities undergoing an accreditation survey by The Joint Commission (TJC), and many surveyors ask for measurement data as proof of compliance, says Sue Dill Calloway, RN, Esq., BSN, MSN, JD, medical legal consultant in Dublin, OH. Dill Calloway recently spoke on "2010 Joint Commission National Patient Safety Goals and How to Comply" at an audio conference sponsored by AHC Media, publisher of Same-Day Surgery and SDS Accreditation Update.
Failure to comply with NPSGs will result in a requirement for improvement (RFI), she says. However, TJC states that there are no prescribed requirements for measurement or data collection relative to most of the NPSGs, but you do need to know how you are in compliance, Dill Calloway says. The exception used to be 2C on timely reporting critical tests and results, but that exception was removed in 2010, she says. Performance improvement (PI) standards require data collection related to PI priorities, Dill Calloway adds.
Have policies and procedures for each NPSG, she advises. Additionally, the leadership standards require leaders to set priorities for improving the safety and quality of care, Dill Calloway emphasizes.
Using an alternative approach
Alternative approaches must be at least as effective as the Joint Commission selected approaches.
Complete the "Request for Review of an Alternative Approach" form. (Editor's note: Go to www.jointcommission.org. Under "Patient Safety," select "National Patient Safety Goals." Under "2010 Additional Resources," select "Request for Review of an Alternative Approach to a National Patient Safety Goal Requirement.")
If the alternative approach is not accepted, The Joint Commission staff will tell the facility leaders the rationale behind that decision. The leaders then can revise their request if they wish.
Here are some selected NPSGs, with compliance tips:
Goal on patient identification.
The intent of that goal is to reliably identify the right patient and, second, to match the service or treatment with that patient, Dill Calloway says.
TJC clarified that you have to use patient identifiers when performing other treatments and procedures, she says. For example, you must make sure you have the correct patient for procedures such as moderate sedation, she says.
Compliance can be achieved by matching the patient name and medical record number with the bracelet. Two identifiers on an arm band are more reliable than the memory of another staff member. If your patients wear armbands, they must be attached to the patient and not taped to the bed, Dill Calloway emphasizes.
Bar coding that matches two identifiers is acceptable as long as one is not a room number.
The requirement for two identifiers assumes that there is a process in place on admission and that there are identifiers are attached to the patient, Dill Calloway says. However, you don't have to ask the patient his or her name every time blood is taken, Dill advises.
Goal on hand hygiene.
The facility must provide an alcohol-based hand rub (ABHR) product, Dill Calloway says. However, the staff aren't required to use it, she says. Staff members may use soap and water.
The Life Safety Code allows installation of ABHR gel dispensers in egress corridors, but it's best to perform hand hygiene in the presence of patients, Dill Calloway says. Performing hand hygiene in front of patients demonstrates to them they you have done it and gets staff members into a good routine, sources say.
Dispensers in egress corridors have some limitations, she says. For example, the corridor must be six feet wide, and the dispensers must be at least four feet apart, she says. Additionally, dispensers can't be placed over power outlets, and they can't hold more than 1.2 liters when they are in rooms and corridors, Dill Calloway says. The same rules apply to alcohol-based foam, she says.
If hands aren't visibly soiled, use an alcohol-based hand rub in all settings, Dill Calloway says. If hands are visibly soiled or contaminated with protein material, blood, or other body fluids, then use soap and water, she says. Also, use soap and water with patients who have Clostridium difficile (C. diff), Dill Calloway says.
Monitor the volume of ABHR used per 1,000 patient days, she advises. Periodically monitor and record adherence to hand hygiene compliance, and give feedback to staff, she advises. This direct observation is necessary for corrective action, Dill Calloway adds.
Ambulatory surgery providers are making progress with hand hygiene, says Virginia McCollum, MSN, RN, associate director of the Standards Interpretation Group at The Joint Commission. In fact, handwashing has dropped to no. 10 on the list of noncompliant areas by ambulatory organizations, McCollum says. "Surgery centers seem to be leading they way in their handwashing practices," she says.
Joint Commission makes correction to NPSG
The following correction to the 2010 National Patient Safety Goals (NPSGs) is effective immediately and affect the NPSG for ambulatory care, critical access hospitals, hospitals, and office-based surgery organizations. The correction will appear in the July 2010 update to the E-dition and in the print manuals.
In NPSG.07.03.01, Element of Performance (EP) 3, "prevention" was added so that it now reads: Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care-associated infection prevention strategies.
What are requirements for Sentinel Event Alerts?
Although providers aren't scored on their compliance with Sentinel Event Alerts, unless they are National Patient Safety Goals or standards, they are an important safety area that should not be ignored, says Sue Dill Calloway, RN, Esq., BSN, MSN, JD, medical legal consultant in Dublin, OH.
Dill Calloway advises the following: