TJC tweaks patient safety goal
The Joint Commission has revised one National Patient Safety Goal (NPSG) for 2014 for ambulatory care organizations, office-based surgery practices, hospitals, and critical access hospitals. The revised goal is NPSG.07.05.01 on using proven guidelines to prevent infection after surgery. The new wording below in underlined.
Implement evidence-based practices for preventing surgical site infections.
Element of Performance for NPSG.07.05.01:
A 5. Measure surgical site infection rates for the first 30 or 90 days following surgical procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices based on National Healthcare Safety Network (NHSN) procedural codes. The [organization’s] measurement strategies follow evidence-based guidelines.
Note 1: Surveillance may be targeted to certain procedures based on the [organization’s] risk assessment.
Note 2: The NHSN is the Centers for Disease Control and Prevention’s health careassociated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate health careassociated infections. For more information on NHSN procedural codes, see http://www.cdc.gov/nhsn/CPTcodes/ssi-cpt.html.
In addition, hospitals and critical access hospitals have a new NPSG for 2014 to "Reduce the harm associated with clinical alarm systems." Specifically, the goal states that hospitals should "Make improvements to ensure that alarms on medical equipment are heard and responded to on time." The NPSG does not apply to ambulatory care facilities or office-based surgery facilities. (For more information, see "NPSG on clinical alarms will start with phase one," Same-Day Surgery, September 2013, p. 103.)