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doi: 10.1097/01.ORN.0000270150.21666.a3

NPSGs New goals, same mission

Catalano, Kathleen RN, JD

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Kathleen Catalano is a director of healthcare transformation support at Perot Systems, Plano, Tex.

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Is your OR meeting The Joint Commission's National Patient Safety Goals?

The Joint Commission's (formerly the JCAHO) ever-evolving National Patient Safety Goals (NPSGs) have become synonymous with patient safety. The organization has required compliance with the NPSGs since January 1, 2003.

It's important for you to ensure you're doing all you can to help your OR remain in compliance with the NPSGs. Here, brush up on how and why the NPSGs were created, how they've changed since their inception, and the impact they've had on patient care in the OR and beyond.

The Joint Commission has always been a major proponent for patient safety, as evidenced by the organization's mission “…to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations…”1 The Joint Commission's focus on patient safety intensified following the release of two Institute of Medicine (IOM) reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century.2,3 These landmark reports discuss the number and types of medical errors that have occurred in healthcare institutions across the United States.

There are three parts to the Joint Commission's patient safety agenda: the sentinel event program, the patient safety program, and NPSGs. A little background regarding the first two is essential to understand the whys and wherefores of the NPSGs.

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2007 NPSGs

For our purposes we'll review the NPSGs for perioperative areas in ambulatory and office-based surgery and hospitals and critical access hospitals. Goals 10 and 12 do not apply to the OR and are not listed here.

NPSG #1: Improve the accuracy of patient identification.4 This was one of the original goals. Usually referred to as NPSG 1A, this goal requires clinicians to use at least two patient identifiers (neither to be the patient's physical location or room number) when administering medications or blood products, taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.

The organization may choose the two patient identifiers that clinicians will use for compliance with this NPSG. Many organizations choose two patient identifiers from the patient's armband, which can be the patient's age, birthday, name—even the patient's medical record or account number. All departments aren't required to use the same two patient identifiers, however, uniformity is best whenever possible. For outpatient labs and diagnostics when the patient has no armband, clinicians must check another medium. Perhaps the organization will choose to use the lab or X-ray request sheet and ask the patient his or her name and birth date.

NPSG #2: Improve the effectiveness of communication among caregivers.4 Though this is another NPSG original, over time this goal has received additions, so now there are four parts with which to comply. Goal 2A requires any caregiver responsible for taking verbal or telephone orders or receiving critical test results to complete a “read-back.” Caregivers could be hospital staff, physicians, or nurses. Implementation of the organization's “read-back” policy will be observed by the Joint Commission surveyors in all areas of the facility, including perioperative services. Goal 2A will mainly affect those staff in the ambulatory care surgery setting, holding areas, and postanesthesia care units (PACU).

Goal 2B requires each organization to standardize a list of abbreviations, acronyms, symbols, and dose designations that aren't to be used throughout the organization. The Joint Commission has published a list of abbreviations, acronyms, symbols, and dose designations that clinicians must not use, and all organizations must be in compliance. For 2007, this NPSG will apply to all handwritten orders and other medication-related documentation. Goal 2B also applies to all orders and other medication-related documentation entered as free text into a computer or found on preprinted forms. Goal 2B doesn't apply to computer-generated forms or displays. When the Joint Commission is on-site, the surveyors expect 100% compliance for all preprinted forms and 90% compliance for all handwritten orders and medication-related documentation.

The Joint Commission added Goal 2C in 2005, requiring organizations to measure, assess, and if appropriate, take action to improve the timeliness of reporting critical test results and values (and the timeliness of receipt by the responsible licensed caregiver). This is the performance improvement requirement. Goal 2C goes hand-in-hand with Goal 2A and requires the collection of data (for example, from the time the critical test was ordered to when the test results were reported. The appropriate turnaround time must be determined by the organization).

Goal 2E was added in 2006 and requires the organization to standardize an approach to “hand-off” communications. A hand-off occurs anytime a patient is moved from the care of one healthcare professional and placed in the care of another, or when a patient is moved from one unit to another. It's imperative that each of those involved in the hand-off have the opportunity to ask and respond to questions and relay up-to-date information. There's one caveat: the hand-off communication must be interactive in nature. This will have an effect on tape-recorded reports, but this shouldn't be an issue for the perioperative area. Note that if a tape-recorded report is used in the perioperative area, the opportunity to ask questions that clarify information provided in the report and the ability to respond to those questions in a timely manner so that those caring for the patient have complete and accurate information when needed, must be part of the report process. In addition, the goal will likely be problematic for providers who sign out to a covering provider without verbal communication.

NPSG #3: Improve the safety of using medications.4 Goal 3A, which covered the removal of concentrated electrolytes from patient care units, has been retired. The requirement regarding removal of concentrated electrolytes can be found in the Comprehensive Accreditation Manual for Hospitals (CAMH) under the Medication Management (MM) chapter, specifically MM.2.20 Elements of Performance (EP).4 Regardless of how frequently clinicians check perioperative area medications, it's recommended that they make another run through to ensure that all of the concentrated electrolytes have been removed.

A goal since 2003, Goal 3B requires the organization to standardize and limit the number of drug concentrations available. Of interest to pediatric and neonatal facilities is the fact that the “Rule-of-6” must transition to standardized concentrations by the end of 2008.

Goal 3C, added in 2005, requires an organization to identify and, at a minimum, annually review a list of the look-alike/sound-alike drugs used in the organization. The Joint Commission has tried to make compliance easier by publishing three tables of look-alike/sound-alike drugs on its website.5 These three tables are for critical access hospitals, office-based surgery, and hospitals. Each organization must follow the instructions that accompany the tables and choose 10 look-alike/sound-alike drug concentrations from these tables.

Goal 3D was added in 2006 and may have the greatest impact on perioperative areas. It requires an organization to label all medications, medication containers (such as syringes, medicine cups, and basins), or other solutions on and off the sterile field in perioperative and other procedural settings. The label must contain the name of the drug, the initials of the person preparing the label, and the drug's strength and volume. This goal must be followed even when all present clinicians know what's contained in the syringe, medicine cup, or basin, and even if there's only one medication on the sterile field. The only instance in which this goal doesn't apply is when a drug is drawn up and administered immediately.

NPSG #4: Eliminate wrong-site, wrong-patient procedure surgery. The Joint Commission retired this goal and replaced it with the Universal Protocol in July 2004. The Universal Protocol will be mentioned later in this article.

NPSG #5: Improve safety when using infusion pumps. Retired in 2006, this goal required free-flow protection on all general use and patient-controlled analgesia intravenous infusion pumps. The goal is now covered in the Management of the Environment of Care (EC) chapter at EC.6.20.

NPSG #6: Improve the effectiveness of clinical alarm systems. Retired in 2005, this goal involved the implementation of regular preventive maintenance and testing of alarm systems. As with NPSG #5, this goal is now covered in the EC chapter of the CAMH at EC.6.10.

NPSG #7: Reduce the risk of healthcare-associated infections (HAI).4 This goal is based on the Centers for Disease Control and Prevention's (CDC) hand hygiene guidelines.6 Goal 7A requires healthcare organizations to comply with current CDC hand hygiene guidelines. Specifically, organizations must be in compliance with all Category IA, IB, and IC CDC hand hygiene guidelines. Those guidelines found in Category II are suggested for implementation by the CDC.

Goal 7B requires organizations to manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a HAI. Thus, if a patient dies unexpectedly or suffers a major permanent loss of function that's associated with a HAI, organizations should classify the case as a sentinel event and perform a root cause analysis, with follow-up action plan and monitoring.

NPSG #8: Accurately and completely reconcile medications across the continuum of care.4 This goal was first proposed in 2005 as a goal that was to be developed that year with full implementation in 2006, giving organizations an entire year to develop a plan and determine the best ways to design their processes for this goal. Many organizations are still trying to plan the best process for compliance.

Goal 8A requires organizations to implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization, with the involvement of the patient. This process includes a comparison of the medications the organization provides to the patient with those on the patient's list. Goal 8B involves communicating the complete list of the patient's medications to the next provider of service when the organization refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization and also requires that the organization provide the patient with a complete list of medications when the patient is discharged from the facility.

When you review these two requirements together, you begin to realize the full breadth of NPSG #8, which effects perioperative areas. The active list will most likely be initiated for inpatients prior to their transfer to the holding area. There's little need for an active list of medications in the operative suite. It's different for PACU. Here, if the patient's medications are changed, clinicians need to communicate this change to the next providers of care and update the active list. For outpatients, a complete list of medications will need to be initiated upon their arrival to the unit and then provided to them when they're discharged. You may be thinking, “But this is what occurs anyway, isn't it? And doesn't this go hand-in-hand with Goal 2E regarding hand-offs?”

The practice in perioperative areas often mirrors what's previously described. Remember, the organization is to design and implement a process to accomplish this goal. With that in mind, perioperative services must know what the organization's process is and incorporate that process into their daily routine.

NPSG #9: Reduce the risk of patient harm resulting from falls.6 This goal applies to critical access hospitals and hospitals, not to ambulatory care or office-based surgery.

Goal 9B replaced Goal 9A. This goal requires the organization to implement a fall program and evaluate the effectiveness of the program. Falls occur frequently throughout organizations. Many don't believe they occur within perioperative areas, but that's a fallacy. Sometimes falls occur when the patient is getting up from the stretcher in the holding area. There have been situations when a patient has slipped off the OR table in the OR suite and then there are those patients who lose their balance while readying for discharge. In any event, perioperative services should be part of the fall reduction program and should participate in the development of the risk assessment and data collection strategies that will be used organization-wide.

NPSG #11: Reduce the risk of surgical fires.7 For the Joint Commission's purposes, this goal is only surveyed for ambulatory care and office-based surgery programs. This goal is appropriate for everyone involved in perioperative areas. Goal 11A states that the organization is to educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels with enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.

To meet this goal, organizations must establish guidelines and educate and train staff who participate in surgery or other invasive procedures regarding ways to minimize oxygen concentration under drapes, avoid the use of flammable solutions and materials, respond to a surgical fire, and safely control potential ignition sources.

NPSG #13: Encourage patient's active involvement in their own care as a patient safety strategy.4 This was a goal in 2006 for the Joint Commission assisted living, disease-specific care, home care and laboratory accreditation programs. Now, in 2007, this goal has found its way into both the hospital/critical access hospital and ambulatory care/office-based surgery programs.

Goal 13A requires that the organization define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. By its very nature, this goal tends to affect the organization as a whole and not to single out just the perioperative areas. That said, the perioperative areas are sometimes the most misunderstood because they're outside the realm of the average person and thus what is done in these areas may seem strange or out of the ordinary to patients. This strangeness may give rise to questions and concerns that are best addressed as soon as they're asked. The Joint Commission has also listed organizations that provide information, tools, and strategies for involving patients in their own care. Among them is the Agency for Healthcare Research and Quality, Consumers Advancing Patient Safety, Speak Up Campaign of the Joint Commission, Institute for Healthcare Improvement, and the National Patient Safety Foundation.

NPSG #14: Prevent healthcare-associated pressure ulcers (decubitus ulcers). This goal addresses long-term care and requires assessment and periodic reassessment of each resident's risk for developing a pressure ulcer and to take action to address any identified risks.

NPSG #15: The organization identifies safety risks inherent in its patient population.4 This goal applies to hospital/critical access hospital programs only and does not apply to ambulatory care/office-based surgery.

Goal 15A requires each organization to identify patients at risk for suicide. This is applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals. This goal shouldn't have a major impact on perioperative services, but these areas should be aware of the organization's policies as they relate to patients at risk for suicide.

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Universal Protocol

The Universal Protocol became a mandatory requirement for all the Joint Commission-accredited organizations on July 1, 2004.8 You probably even remember the national “time out” day that was the official kick-off. The Universal Protocol wasn't only a replacement for NPSG #4, but a more in-depth approach to the handling of wrong-site, wrong-patient, and wrong-procedure surgery.

The Universal Protocol is composed of three parts:

1. preoperative verification process

2. marking the operative site

3. time out immediately before starting the procedures.

The preoperative verification process often takes the form of a checklist, although a checklist isn't the only approach organizations can use. The importance of the preoperative verification process is to ensure that all relevant documents are available, reviewed, and consistent with one another. This preoperative verification process can lead to the discovery of inconsistencies that may cause a procedure to be delayed or canceled.

Marking the operative site is an essential aspect of the Universal Protocol. The person performing the procedure should mark the operative site, with the participation of the patient if possible, and the marking should occur prior to the patient being moved into the OR suite or wherever the procedure is to be performed. Marking the operative site is required for procedures involving right/left distinction, multiple structures (such as fingers and toes), or levels (spinal procedures). Site marking isn't required if there's an obvious single wound or lesion that's the site of the intended procedure, or if it's a single organ case, such as a cesarean section or cardiac surgery. The site marking is to be visible after the patient is prepped and draped, unless technically or anatomically impossible or impractical. The mark must be unambiguous (for example, use of initials or “yes”). Marking an “X” may be considered ambiguous. The provider must make the mark using a marker that's sufficiently permanent to remain visible after the patient undergoes skin prep. Note that providers shouldn't mark nonoperative sites or use adhesive markers (“stickies”) as the sole means of marking the site.

A time out, also referred to as the “immediate preoperative pause,” must be conducted in the location where the procedure is being done (for example, when the patient is on the OR table) just before the start of the procedure. The time out must involve active communication from the surgical team and include documentation of at least the following:

* correct patient identity

* correct side and site

* agreement on the procedure to be done

* correct patient position

* availability of correct implants and any special equipment or special requirements.

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Safety first

All of the NPSGs play off of and enhance each other. They're patient safety building blocks that help nurses and other healthcare professionals deliver better, safer care. Remember, the Joint Commission's standards are considered minimum standards. The aim of the standards is to bring organizations to a national norm and continue to promote best practices. OR

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1. The Joint Commission. Facts about patient safety. Available at: http://www.jointcommission.org/AboutUs/joint_commission_facts.htm. Accessed January 16, 2007.

2. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C: National Academy Press; 2000.

3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.

4. The Joint Commission. 2007 Hospital/Critical Access Hospital National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm. Accessed January 16, 2007.

5. The Joint Commission. 2006–2007 Look-alike/sound-alike drug list. Available at: http://www.joint-commission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf. Accessed January 16, 2007.

6. Centers for Disease Control and Prevention. Hand Hygiene in Healthcare Settings. Available at: http://www.cdc.gov/handhygiene/. Accessed January 16, 2007.

7. The Joint Commission. 2007 Ambulatory Care/Office-Based Surgery National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_amb_obs_npsgs.htm. Accessed January 16, 2007.

8. The Joint Commission. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Available at: http://www.jointcommission.org/PatientSafety/UniversalProtocol/. Accessed January 16, 2007.

© 2007 Lippincott Williams & Wilkins, Inc.