National Patient Safety Goal Compliance
Each year, health care providers must meet the requirements of The Joint Commission’s National Patient Safety Goals (NPSGs) as part of the accreditation process. In 2006, seven goals and 16 requirements were identified and the compliance assessment results follow. "Compliance" means consistent performance of the requirement. When an organization is found to be "non-compliant," it does not mean that the organization is failing to do what is required at all; it means that the organization is not doing it consistently.
Hospitals must do more than simply perform specified tasks to achieve compliance with Joint Commission NPSGs. To assure safe health care environments, hospitals must continually analyze fundamental workflow systems and redesign those systems as needed. Hospitals must go beyond the tasks of removing a dangerous medication from a patient care unit or requiring a specific safety feature on a medical device. They must achieve goals such as “improve the accuracy of patient identification” by changing how individuals caring for patients do their jobs. Achieving this kind of behavioral change among providers takes time, motivation, reinforcement, reward, patience, and support.
The Joint Commission conceptually supports the National Quality Forum’s 30 consensus safe practices for health care organizations. However, The Joint Commission prefers an approach to improving performance that focuses on a smaller number of goals specifically because of the challenges posed by systems redesign and the culture change that needs to happen in order to keep error from reaching the patient.
HOW NATIONAL PATIENT SAFETY GOALS ARE DETERMINED
The Joint Commission’s Sentinel Event database maintains an active repository of information on serious adverse events reported by hospitals across the country. A Sentinel Event Advisory Group – composed of physicians, nurses, pharmacists, risk managers and other safety experts – works with Joint Commission staff to review these and other data and literature to identify potential new NPSGs and requirements on a continuing basis. As part of this development process, potential Goals and associated requirements are sent to organizations representing providers, consumers, purchasers and other interested parties for review and comment each year.
To determine its priority NPSGs and requirements each year, the Advisory Group considers evidence respecting measuring their potential overall impact on patient safety, as well as the cost and practicality of implementation. The proposed NPSGs and requirements are then presented to The Joint Commission’s Board of Commissioners for final review and approval. The Advisory Group may also recommend the retirement of selected NPSGs and requirements each year.
2006 PERFORMANCE
The compliance rates below are derived from 1,429 on-site surveys at Joint Commission-accredited hospitals during 2006.
Goal 1: Improve the accuracy of patient identification.
Requirement 1A: Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.
Requirement 1B: Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active—not passive—communication techniques.
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
Goal 2: Improve the effectiveness of communication among caregivers.
Requirement 2A: For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.
Requirement 2B: Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
Requirement 2C: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Requirement 2E: Implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions.
Goal 3: Improve the safety of using medications.
Requirement 3B: Standardize and limit the number of drug concentrations available in the organization.
Requirement 3C: Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
Requirement 3D: Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.
Goal 4: Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
Requirement 4A: Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
Requirement 4B: Implement a process to mark the surgical site and involve the patient in the marking process.
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
Goal 7: Reduce the risk of health care-associated infections
Requirement 7A: Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
Requirement 7B: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Goal 8: Accurately and completely reconcile medications across the continuum of care.
Requirement 8A: Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
Requirement 8B: A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.
Goal 9: Reduce the risk of patient harm resulting from falls.
Requirement 9B: Implement a fall reduction program and evaluate the effectiveness of the program.
NATIONAL PATIENT SAFETY GOALS COMPLIANCE TRENDS, 2003-2006
The following chart illustrates trends in National Patient Safety Goal compliance from 2003-2006. The compliance rates are derived from on-site surveys at Joint Commission-accredited hospitals during those years. The trends in the data should be interpreted with caution. At first glance, it looks like performance may be deteriorating. However, the more likely explanation is that Joint Commission surveyors are becoming more sophisticated in assessing and identifying non-compliance.
For example, the 2004 hospital compliance rate for conducting a “time out” before surgery was 92.0 percent, compared to 74.2 percent in 2006. When the "time out" requirement was first implemented, it was surveyed primarily in the operating rooms. In these areas, performance of the "time out" is generally quite consistent. But “time out” is not just an OR requirement; it applies wherever invasive procedures are done. More recently, surveyors are finding non-compliance with the "time out" requirement in endoscopy suites, catheterization labs, and even at bedside procedures.
Also, some requirements call for significant behavioral change. For example, the “do not use” abbreviations requirement asks practitioners to stop doing what they were taught to do in medical school and residency training. Writing out full names of medicines is seen as less efficient than using abbreviations and other “concise” notations.
The numbers represent percentages, except the second row, which represents the number of surveys conducted.
