Accreditation

New 2009 National Patient Safety Goals

Accreditation Monthly, July 8, 2008

On June 17, The Joint Commission announced the new National Patient Safety Goals (NPSG) for 2009. Several changes and additions have been built into the 2008 NPSGs. Multiple drug–resistant organisms (MDRO), central line–associated bloodstream infections, and surgical site infections are additions to Goal #7: reduce the risk of healthcare-associated infections. These new changes should not come as a surprise to healthcare workers due to the recent national emphasis on MRSA, bloodstream infections, and surgical site infections. If your facility has been following the Institute for Healthcare Improvement’s programs, which were introduced several years ago, you will have already been working on these and be one step ahead of the others. Similar to the 2008 anticoagulation and rapid response NPSGs, these new changes will be phased in during 2009.
 
The following addresses only new NPSGs or those goals with new elements of performance.
 
 
NPSG.01.01.01 EP.1: Two identifiers—new element of performance
Patient identification must include the active participation of the patient, and, when needed, the family. The goal states: “When active patient involvement is not possible or the patient’s reliability is in question, the hospital will designate the caregiver responsible for identity verification.”
 
 
NPSG.01.03.01: Blood transfusions—new goal
Before initiating a blood or blood component transfusion, the patient is matched to the blood component during a two-personverification process:
  1. Two patient identifiers are used
  2. One person must be the person administering the transfusion
  3. The second person must be qualified to administer blood components
  4. When two persons are not available, an automated identity technology (e.g., bar coding) may be used in place of the second individual
  
NPSG.07.03.01: Multiple drug–resistant organisms)—new goal
Implement evidence-based practices to prevent healthcare-associated infections due to MDROs. One-year phase-in period.
 
2009
  1. April 1: Leadership assigns responsibility for development and oversight
  2. July 1: Work plan that identifies resources, accountabilities, and timeline for implementation
  3. October 1: Pilot testing for at least one clinical unit is under way
 By January 2010:
  1. Elements of performance fully implemented
  2. Implementation of a risk assessment
  3. Based on the results of the risk assessment, provide:
    1. Initial and annual education to caregivers
    2. Patient and family education to those patients who are infected or colonized with MDRO
  4. A surveillance program for MDROs, including monitoring of MDRO outcomes, data analysis, and reporting to key stakeholders
  5. Implementation of risk reduction strategies, including a laboratory-based alert system to identify new patients with MDRO
  
NPSG.07.04.01: Central line–associated blood stream infections—new goal
A process for surveillance for central line–associated blood stream infections. The phase-in is the same as NPSG.07.03.01: Multiple drug–resistant organisms, with the changes as follows:
       3. b. Provide patient and family education about central line–associated bloodstream infection prevention prior to the insertion of the central line
 
By January 2010:
  1. Implementation of policies and procedures aimed at preventing central line–associated bloodstream infections
  2. A checklist and standardized protocol for line insertion
  3. Avoidance of using the femoral vein as a line site for adults
  4. Using an all-inclusive standardized supply kit for central line insertion
  5. Protocol for maximum sterile barrier, the use of chlorhexidine-based skin antiseptic, and a protocol to disinfect hubs and injection ports before accessing ports
  6. Process to evaluate all central venous catheters routinely and remove nonessential catheters
  
NPSG.07.05.01: Surgical site infections—new goal
The phase-in is the same as MDRO and central line–associated bloodstream infection, with the changes as follows:
 
By January 2010
This goal establishes specific interventions for prevention of surgical site infections and includes:
  1. Staff education
  2. Education of patients, and families (as appropriate), who are undergoing a surgical procedure
  3. Risk assessment
  4. Policies and procedures aimed at the prevention of SSI
  5. Implementation of evidence-based guidelines for antimicrobial agents
  6. Guidelines for hair removal to include clippers and depilatories
  7. Measurement of surgical site infection data and prevention outcome measures and reporting to key stakeholders
  
NPSG.08.01.01: Medication reconciliation—new expectations
EP.1 now specifically requires dose, route, and frequency. This does not seem to be required for outpatient setting and the emergency department for short-term drug use (see NPSG.08.04.01).
 
EP.2 requires comparisons against the list of current medications as each new medication is ordered.
 
EP.3: Discrepancies are reconciled and documented.
 
EP.4: There must be communication among providers related to the up-to-date reconciliation list whenever there is a transfer within the hospital. This communication must be documented. There is also language about such communication during handoffs from one caregiver to another, but it is not clear whether this handoff must now be documented.
 
 
NPSG.08.02.01: Communication of reconciliation list—new expectations
This version seems to revert to sending the list to the patient’s primary care provider, next provider, or referring physician. This may be given to the patient only if short-duration medications are to be taken after discharge (see NPSG.08.04.01).There is also a new requirement related to transfers: The next provider must be given information about how to obtain clarification on the list.
 
 
NPSG.08.03.01: Patient education—new expectations
This issue used to be addressed under NPSG #8B but is now its own standard. When the patient leaves the hospital’s care, the current list of reconciled medications is provided to the patient and their family as needed. This interaction must be documented.
 
 
NPSG.08.04.01: Minimal use/short-duration medication reconciliation
It seems that dose, route, and frequency are not required for the current medication list in some settings (e.g., the emergency department, outpatient surgery, radiology, or ambulatory care). EP.2 requires the creation of a short-term medications list. The complete medication reconciliation process is used when there is a new or changed long-term medication. This essentially gives more guidance for the outpatient setting.
 
 
NPSG.13.01.01: Patient involvement in safety—existing goal, new elements of performance
EP.2 There must now be documented education about hand hygiene, respiratory hygiene practices, and contact precautions according to the patient’s condition and within 24-48 hours of admission. Comprehension is evaluated. This pertains to patients and families.
 
EP.3 goes on to require additional education for surgical patients to include measures that will be taken to prevent adverse events in surgery e.g., patient identification, prevention of surgical site infections. Patient’s understanding must be documented.
 
 
UP.01.01.01: Universal Protocol/procedure verification—existing requirement with new expectations
EP.2 now requires the use of a pre-procedure checklist when the patient moves from the pre-procedure setting. This will be a change for endoscopy, catheterization laboratories, and invasive radiology. 
 
 
UP.01.02.01: Universal Protocol: Site marking—new/clarified expectations 
EP.1: Site marking: This now pertains to all procedures involving incision or percutaneous puncture.
 
EP.2 is more specific about the site is marked prior to moving the patient to the procedure area and with the patient’s participation if possible.
 
 
UP.01.03.01 Universal Protocol: Timeout—new expectations
EP.5: The timeout must now include consent, the need to administer antibiotics or fluids for irrigation purposes, and “safety precautions based on patient history or medication use.”
 
EP.6 now requires that all components of the Universal Protocol are documented, not just the timeout (as in current requirements).
 

We recommend getting a jump on the new NPSGs as soon as possible; don’t wait until December before introducing them to your facility. Several of these changes will take time and effort to affect compliance before next year.

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