Accreditation

Joint Commission Announces 2008 National Patient Safety Goals

Accreditation Monthly, June 25, 2007

In a special July 2007 issue of The Joint Commission Perspectives, the Sentinel Event Advisory Group recommended National Patient Safety Goals and implementation expectations for 2008. Two new goals were announced, and interestingly, they each include a one-year phase-in period that will require organizations to meet date-certain milestones in 2008 with full implementation required by January 1, 2009.

In requiring the achievement of these milestones, The Joint Commission is evidently trying to prevent the inordinately lengthy implementation period that occurred with the implementation of the Medication Reconciliation National Patient Safety Goal. Recall that Goals 8A and 8B (Medication Reconciliation) were first announced in mid-2004, with the expectation that 2005 be a process planning and design phase, and full implementation required by January 1, 2006. Now we are in mid-2007, and, as most of you know, few hospitals can say that they have mastered each implementation expectation and frequently-asked-question for this goal. For whatever reason, hospitals failed to plan, develop, test, and execute properly to implement Medication Reconciliation by January 1, 2006.

Anxious to avoid a repeat performance in the implementation execution of a NPSG, The Joint Commission in its July 2007 Perspectives announced two new goals: one labeled 3E that addresses the management of anticoagulant therapy and one labeled 16A that addresses early recognition and response to changes in patient condition. For the first time, The Joint Commission included planning and development and testing milestones that must be achieved in 2008 lest organizations receive a Requirement for Improvement during a 2008 onsite survey.

As category "A" implementation expectations, each of these quarterly milestones will be easy to meet. For example, by April 1, 2008, documentation must show that the organization's leaders have assigned responsibility for the "oversight and coordination of development, testing, and implementation" of requirements 3E and 16A.

Similarly, by July 1, 2008, an "implementation work plan" must be in place that "identifies adequate resources, assigns responsibilities and includes a time line for full implementation" of 3E and 16A by January 1, 2009.

By October 1, 2008, pilot testing of the process for addressing 3E and 16A must be occurring on at least one clinical unit. Finally, the processes designed for 3E and 16A must be fully implemented in the entire organization by January 1, 2009.

So, our work is cut out for us. Many organizations have already installed processes to address the management of anticoagulation therapies and have put in place "Rapid Response" teams. For other hospitals that have not yet perfected these processes, The Greeley Company stands ready to offer you design and implementation consultation services using proven best practices. Naturally, all of us will need to be watching carefully for the inevitable release of Joint Commission Frequently Asked Questions (and answers) that usually appear (frustratingly so) after we are well on our way down a process design path and often result in our having to retrace our steps somewhat.  But with proper planning and achievement of these quarterly milestones, we should be ultimately successful in meeting each of these new goals by January 1, 2009.

Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to assist you in fine-tuning your response to these changes including helping to craft policies and effective processes designed specifically to fit your organization. It may also be time to schedule an Unannounced Survey Vulnerability Visit by one of our Greeley mock survey teams. For more information please call our Director of Client Relations, Stacy Koch, at 888-749-3054, ext. 3193 or click here.

Sincerely,

John Rosing, MHA, FACHE
Practice Director, Accreditation and Regulatory Compliance
The Greeley Company

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