• E-mail
• Print
• RSS
• Reprints

Deadlines come fast and furious on National Patient Safety Goals

Briefings on Infection Control, June 1, 2009

This is an excerpt from a member only article. To read the article in its entirety, please login.

Procrastinators take note: The Joint Commission has a number of deadlines looming in your future. The Joint Commission?s (formerly JCAHO) National Patient Safety Goals (NPSG) are of particular concern for IPs throughout the remainder of 2009. A number of new NPSGs this year require specific IC interventions in accordance with defined deadlines. The Joint Commission has outlined a specific time- table hospitals should adhere to when implementing these measures (see ?Dates to remember,? on p. 9). As of April 1, hospital leadership should have assigned responsibility for the oversight of all phases of IC prevention measures, particularly for MDROs (NPSG.07.03.01), central line?associated bloodstream infections (CLABSI) (NPSG.07.04.01), and surgical site infections (SSI) (NPSG.07.05.01). The next deadline on July 1 requires implementation of a work plan that includes adequate resources, assigned accountabilities, and a timeline for full implementation of the prevention measures by January 1, 2010. By October 1, pilot testing for these three interventions should be underway in at least one critical unit. Fortunately, most hospitals are already implementing prevention measures for some of the major HAIs such as MDROs, CLABSIs, and SSIs, according to Peg Luebbert, MS, MT(ASCP), CIC, CHSP, owner of Healthcare Interventions, Inc., in Omaha, NE. The trick will be providing evidence to Joint Commission surveyors. ?I don?t think the goals themselves are anything new to the average hospital that is on top of their infection prevention, but it tweaks it and forces us to put it into a nice, pretty package,? Luebbert says. Assessing your program A crucial part of creating that package will be doing a risk assessment. This is specifically mentioned in NPSG.07.03.01, element of performance (EP) 5, which requires hospitals to conduct periodic risk assessments for MDROs as of January 1, 2010. The same risk assessments are required for CLABSIs and SSIs in EP 8 of NPSG.07.04.01 and NPSG.07.05.01, respectively. These risk assessments can be documented and presented to the surveyors to prove you meet the required NPSGs. Ideally, these risk assessments should have been completed already to find weaknesses in your program, says Connie Steed, RN, MSN, CIC, director of infection prevention and control at the Greenville (SC) Hospital System University Medical Center. ?Instead of developing an action plan for each one, we are putting what we will do for these in our strategic priorities and integrating them into our infection control objectives for the year,? Steed says. ?And we will incorporate these time requirements as we need to address them.?

This is an excerpt from a member only article. To read the article in its entirety, please login.

• E-mail to a Colleague
• Print
• RSS
• Archive
• Reprints / Permissions