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How to learn about acceptable alternatives
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, has published examples of acceptable alternative approaches to complying with its 2003 National Patient Safety Goal recommendations. In July 2002, the Joint Commission’s Board of Commissioners approved the 2003 National Patient Safety Goals — the first to be issued by JCAHO.
Each goal includes no more than two succinct evidence- or expert-based recommendations. To ensure a stronger focus on high-priority safe practices, no more than six goals are established for any given year. Each year, the goals and associated recommendations are re-evaluated; some may continue, while others will be replaced because of emerging new priorities. New goals and recommendations are announced in July and become effective on Jan. 1 of the following year.
As of Jan. 1, 2003, all JCAHO-accredited health care organizations were to be surveyed for implementation of the following recommendations (or acceptable alternatives) as appropriate to the services the organization provides:
1. Improve accuracy of patient identification.
— Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
— Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure, and site, using active — not passive — communication techniques.
2. Improve the effectiveness of communication among caregivers.
— Implement a process for taking verbal or telephone orders that require a verification "read-back" of the complete order by the person receiving the order.
— Standardize the abbreviations, acronyms, and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use.
3. Improve the safety of the use of high-alert medications.
— Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, and sodium chloride >0.9%) from patient care units.
— Standardize and limit the number of drug concentrations available in the organization.
4. Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
— Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
— Implement a process for marking the surgical site, and involve the patient in the marking process.
5. Improve the safety of the use of infusion pumps.
— Ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in the organization.
6. Improve the effectiveness of clinical alarm systems.
— Implement regular preventive maintenance and testing of alarm systems.
— Ensure alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
Alternatives must be at least as effective as the published recommendations in achieving the goals, says JCAHO. "Failure by an organization to implement any of the applicable recommendations (or an acceptable alternative) will result in a special Type I recommendation," says the JCAHO web site (www.jcaho.org).
Organizations that wish to submit alternative approaches can do so by filling out a "Request for Review of an Alternative Approach to a NPSG (National Patient Safety Goal) Recommendation" form. The form is available on the JCAHO web site and can be submitted electronically, by fax, or by mail. A separate form must be submitted for each alternative and must be submitted by the accredited organization or health care system — not by consultants — and should be submitted to JCAHO no fewer than 60 days prior to a scheduled survey.
Acceptable alternatives published on web site
The organization will be told whether its alternative is acceptable prior to its scheduled survey. If the alternative isn’t accepted, the organization will be told why and will need to either revise the alternative until it is approved or implement the recommendation issued by JCAHO.
Acceptable alternatives to the NPSG-related recommendations, if potentially relevant to other organizations, will be published in Joint Commission Perspectives and will be posted on the JCAHO web site for other organizations to consider, says the Joint Commission. During the survey, the organization can tell the surveyor it is using a published alternative, and the surveyor can verify that the organization is doing what the acceptable alternative says.
(Editor’s note: A list of sample alternatives may be found at: www.jcaho.org/accredited+organizations/patient+safety/npsg/. Click on "Samples of Alternative Approaches to the Recommendations.")