JCAHO revisits patient safety goals: What your facility must do to comply
Almost all facilities surveyed in 2003 had Type Is for safety goals
Are you relieved to find that six of the Joint Commission on Accreditation of Healthcare Organization’s seven new National Patient Safety Goals are much the same as for 2003? If so, you should think again.
"This speaks volumes," warns Kathleen Catalano, director of regulatory compliance at Addison, TX-based Provider HealthNet Services. "The Joint Commission is saying that the facilities surveyed during 2003 have not effectively addressed the safety goals. Thus, those same goals will be revisited in 2004." Many quality managers underestimated the length of time and commitment required to implement the 2003 safety goals, she says.
"During 2003 surveys, very few facilities went unscathed," Catalano points out. "Almost everyone received at least one Type I recommendation because they failed to meet one of the patient safety goals."
As a result, the same six goals and 11 recommendations will be repeated in 2004, with only one new goal on health-acquired infections, she says.
The seven National Patient Safety Goals for 2004 are as follows:
Goal 1: Improve the accuracy of patient identification.
Goal 2: Improve the effectiveness of communication among caregivers.
Goal 3: Improve the safety of using high-alert medications.
Goal 4: Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
Goal 5: Improve the safety of using infusion pumps.
Goal 6: Improve the effectiveness of clinical alarm systems.
Goal 7: Reduce the risk of health care-acquired infections.
To comply with the 2004 goals, do the following:
• Understand how the goals will be scored.
"Remember that the scoring for surveys is changing along with the process in 2004," Catalano stresses.
Although the safety goals and recommendations are not standards, they are requirements of the accreditation process as part of a new "Accreditation Participation Requirement" and will be scored with a corresponding "Special Type I" grid element, she adds.
"The surveyors will be fair, but they will take into account the fact that the National Patient Safety Goals were in effect in 2003," Catalano says. "I believe they will be especially hard on organizations that have taken little or no action to comply."
• Ensure that all managers understand goals that apply to their areas.
The numerous Type Is received by facilities in 2003 for failing to comply with the safety goals resulted not only because of the major changes that needed to be made to processes facilitywide but also because the changes affected such a large number of people, Catalano says. "A housewide effort should be under way for each goal."
All managers and directors must know what has been implemented to comply with each goal that affects their area, she stresses. "They should be able to speak to how they are implementing each goal and recommendation that is applicable to them," she says.
• Focus on changing behavior.
According to Catalano, the hardest goals to comply with are reading back of verbal orders, use of appropriate abbreviations, acronyms and symbols, and wrong-site, wrong-patient, wrong-procedure surgery.
"These are the heavy hitters, in my opinion, mainly because of the need to change behavior," Catalano says. "For example, how do you ensure that everyone who takes a verbal order reads that order back to the physician? And wrong-site, -patient, -procedures surgery is another entire can of worms," she says. "How do you make physicians do what you say?"
The key is to obtain buy-in from senior management, Catalano stresses. "If you receive flack from a physician, you can then let the higher-ups know — and watch them enforce the rules," she says. "If your vice president of nursing doesn’t back the rule that verbal orders are read back to physicians, you’ll have a heck of a time changing behavior."
• Be able to demonstrate compliance.
You must be able to produce documentation to show how your various performance improvement teams addressed compliance with each goal, Catalano advises.
"Even if your facility was in compliance with the recommendations for a goal, you must still justify that you have reviewed your processes and have determined that you are handling the goal appropriately," she says.
• Make necessary changes to comply with Goal #7.
The only new goal requires you to reduce the risk of health care-acquired infections. Surveyors will focus on the two specific requirements for this goal, according to Richard Croteau, MD, the Joint Commission’s executive director for strategic initiatives:
— Has the organization implemented the Centers for Disease Control and Prevention (CDC) recommendations, and are they being followed consistently?
— Does the organization include in its definition of "sentinel event" all patient deaths or major injuries, even if they are associated with a health care-acquired infection, and are they doing a root-cause analysis on those cases when they are identified?
Quality control managers and infection control (IC) professionals should make a concerted effort to work together, communicate frequently, and share data related to health care-associated infections, says Barbara M. Soule, RN, MPA, CIC, president of the Washington, DC-based Association for Professionals in Infection Control and Epidemi-ology (APIC).
She suggests the following strategies to reduce risk:
— Take steps to understand the populations served and their risk factors.
— Use evidence-based guidelines to direct IC practice.
— Perform surveillance on high-risk populations or procedures.
— Analyze data and take subsequent action to reduce and/or prevent nosocomial infections through performance improvement processes.
Most IC professionals perform prospective surveillance on high-risk, problem-prone, or specific populations of patients, as opposed to surveillance on all patients in the hospital, Soule notes.
Therefore, as a quality manager, you should work with IC, epidemiology, and information technology specialists to develop additional methods to capture data from medical records, laboratories, and financial systems, with the goal of identifying potential sentinel events, she advises.
"The technology to provide this type of integrated information may be challenging for many institutions," Soule acknowledges.
The guidelines and practice standards published by APIC, the Atlanta-based Healthcare Infection Control Practices Advisory Committee (HICPAC), and the Mt. Royal, NJ-based Society for Healthcare Epidemiology of America are excellent evidence-based resources, Soule says.
"Quality managers should become familiar with these references to reduce risk and improve patient safety," she recommends.
These are available free of charge on the web sites of the respective organizations, says Soule, pointing to the new hand hygiene guideline recently published by HICPAC.
"It is well researched, extensively referenced, and gives both rationale and recommendations for hand hygiene that are applicable across the continuum of health care organizations," she adds.
In addition, you should work collaboratively with IC professionals to implement your facility’s procedure for identifying and analyzing infection-related sentinel events, including the root-cause analysis process, Soule advises.
Infection control professionals have always investigated and analyzed serious infections, either individually or in the aggregate, and brought these to the attention of the epidemiology team, infection control committee, or others to determine improvement strategies, Soule notes.
First, you should work with both infection control professionals and risk managers to establish general criteria for what is an "unexpected" death from an infection, she recommends.
You also must develop specific strategies to investigate potential sentinel events, taking numerous factors into consideration, says Soule.
For example, you’ll need to determine whether the infection was the cause of death and whether the death was unexpected in light of the patient’s underlying condition, she explains.
"Some cases will clearly be a potential sentinel event, such as the healthy patient admitted for a hernia operation who gets a surgical-site infection and dies," she says.
Others will be more difficult to assess, such as an immunosuppressed oncology patient on chemotherapy with several underlying diseases or comorbidities, who requires several invasive procedures or devices, becomes septic, and subsequently dies, explains Soule.
Again, quality managers and IC professionals should work together to develop systems with three goals in mind: assessing current sentinel events, learning from past events, and preventing future events, says Soule.
"It will be important to review the Joint Com-mission’s database of sentinel events related to nosocomial infections as it expands," she advises.
• Comply with new recommendation for Goal #2.
The only other change for 2004 is a new recommendation added for Goal #2, which requires that you implement a process for taking verbal or telephone orders or critical test results with verification read back of the result.
First, departments need to define what the critical results are for their area, says Michelle H. Pelling, MBA, RN, president of the Newberg, OR-based health care consulting firm The ProPell Group.
These typically will include "stat" tests, "panic value" reports, and other laboratory, X-ray, or electrocardiogram results that require urgent response, Croteau says. "For most organizations, this will include all test results reported verbally or by telephone."
If a subset of "critical test results" is not defined by the organization, surveyors will consider all verbal or telephone reports of laboratory tests to be "critical," he adds.
Once you determine what constitutes critical results, the next step is for the departments to develop a process for calling in test results, and also for documenting when and to whom they reported the results, Pelling explains.
For example, technicians calling with results would ask for the name of the person they are speaking to, and then record the name and time of call in a critical value log or book, she says.
"Ideally, they should be able to record it electronically next to the critical results, so that anyone looking up the results can see when it was called and to whom," she adds.
In addition, the receiving departments, such as nursing units, operating rooms, or clinics, must establish a method for documenting the information they receive, and a method for communicating it to the physician, nurse, and other appropriate parties, Pelling says. She gives the example of "hot pink sheets" used exclusively for critical lab values.
However, those receiving the information also should use a method to document who they reported the results to, says Pelling.
"Perhaps the call with test results should always be given to a nurse, with a policy of not using a unit secretary or any other staff person to accept critical value results. If the nurse calls the physician with the results, they could then document it in the progress notes." Each organization is different and will have different capabilities and preferences, she notes.
The goals apply to the entire organization, to the extent that the requirements are relevant to the services provided, Croteau adds.
"This may include physician offices, if those offices are part of the hospital and included in the scope of the hospital’s accreditation," he says.
If information is called to a clinic that is considered part of the hospital, then the requirement will be the same and staff should document it in the record, says Pelling. "Or if results are called to a physician office that is not considered part of the hospital, then the surveyors do not have an ability to review those records," she says.
"They would look to the lab or other department reporting the results for the process they are using to document when they called and with whom they spoke," Pelling explains.
[For more information about the 2004 National Patient Safety Goals, contact:
• Kathleen Catalano, Director of Regulatory Compliance, Provider HealthNet Services, 15851 Dallas Parkway, Suite 925, Addison, TX 75001. Telephone: (972) 701-8042, ext. 216. Fax: (972) 385-2445. E-mail: [email protected].
• Richard Croteau, MD, Executive Director for Strategic Initiatives, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Fax: (630) 792-5005. E-mail: [email protected].
• Michelle H. Pelling, MBA, RN, President, The ProPell Group, P.O. Box 910, Newberg, OR 97132. Telephone: (503) 538-5030. E-mail: michelle@propell group.com. Web site: www.propellgroup.com.
• Barbara M. Soule, RN, MPA, CIC, President, Association for Professionals in Infection Control and Epidemiology Inc., 1275 K St., N.W., Suite 1000, Washington, DC 20005-4006. Telephone: (202) 789-1890. Fax: (202) 789-1899. E-mail: [email protected].]
Are you relieved to find that six of the Joint Commission on Accreditation of Healthcare Organizations seven new National Patient Safety Goals are much the same as for 2003? If so, you should think again.
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