Assess your compliance for new requirements
If you’ve taken a look at the Joint Commission on Accreditation of Healthcare Organization’s proposed 2006 National Patient Safety Goals (NPSGs) for hospitals, the long list may seem overwhelming at first glance.
"I was amazed when I saw how many proposed patient safety goals there are," notes Kathleen Catalano, director of regulatory compliance services at Addison, TX-based PHNS Inc. PHNS provides information technology, health information management, coding, transcription, and receivables management services to approximately 160 hospitals. "I doubt they will all be adopted — and the good thing is that JCAHO has asked for comments from the field," she adds.
The newly proposed goals address providing an organizationwide culture of safety; encouraging patient involvement; preventing patient harm associated with health care worker fatigue; preventing health care-associated decubitus ulcers; eliminating patient harm from the use of anticoagulants, insulin, and narcotic analgesics; and reducing risk of harm from emotional and behavioral crises.
"Quality managers will have more to worry about — but when you review the majority of these patient safety goals, many of these have already been adopted by some organizations," Catalano says.
The biggest challenge for quality managers will be to develop a methodology to effectively monitor the 2006 goals, determine compliance, and implement further education and any other changes necessary for the organization, says Frederick P. Meyerhoefer, MD, principal of the Canton, OH-based Meyerhoefer Organization, a consulting firm that specializes in compliance with Joint Commission standards.
"Many of the requirements for these goals will be hard to assess in order to determine the effectiveness of the organization’s compliance, since measurable objective criteria for some of the new NPSGs to readily or easily perform this assessment will be difficult to come up with," he adds.
"Tied to these processes will be the added hours to do those and the associated staff needs," Meyerhoefer explains.
The Joint Commission’s proposal also includes additional requirements for existing goals, such as implementing a process to address handoff communications, such as interdisciplinary face-to-face debriefings for changes of shift.
"This is going to require a change in the way change-of-shift reports are typically done," says Catalano.
Your organization will need to determine what handoff communications will be necessary and how much information is to be provided, she explains. "The problem here may be learning what is or is not important. Organizations will need to define this very well."
Another proposal requires eliminating the use of multiple-dose medication vials when possible.
"This is an excellent consideration," Catalano says.
She points out that multiple-dose medication vials are not used as much with unit-dose medications, and mainly are used in the emergency department, operating rooms, and clinics.
When multiple-dose vials are used, JCAHO is calling for steps to be taken to reduce risk of transmission of infection between patients.
"Infection control will need to set some firm rules regarding use of multidose vials, and then someone will need to monitor their use," says Catalano.
"If there are not many of these vials in use, all the better for the facility," she adds.
[For more information, contact:
• Kathleen Catalano, Director, Regulatory Compliance Services, PHNS Inc., One Lincoln Centre, 5400 LBJ Freeway, Suite 200, Dallas, TX 75240. Phone: (972) 701-8042, ext. 216. Fax: (972) 385-2445. E-mail: Kathleen.Catalano@phns.com.
• Frederick P. Meyerhoefer, MD, 1261 White Stone Circle N.E., Canton, OH 44721. Phone: (330) 966-6717. E-mail: email@example.com.]