2009 National Patient Safety Goals Major Changes Focus on Infection Control, Medication Reconciliation

The Joint Commission announced its 2009 National Patient Safety Goals (NPSG) and Elements of Performance (EP) yesterday. The biggest changes came in the form of new infection control requirements.

"I think more and more attention is going to be on infection control beyond 2009 because it's on the public's radar screen," says Leigh Chapman, RN, BSN, infection control coordinator at St. Joseph Medical Center in Towson, MD "They're coming to our hospital and expecting not to get an infection, so I think more measures like this will be coming out."

Crucial to understanding the 2009 NPSGs is a new method of numbering the goals, for which the Joint Commission has created a crosswalk available on its Web site. The Joint Commission says it created the new method for numbering the NPSGs and relating EPs to more easily sort electronic editions of the NPSGs, as well as to better allow for future goals.

In addition, what were formerly referred to as implementation expectations (IEs) are now referred to as elements of performance (EPs). All of the new organizational changes appear to make the NPSGs look more like the standards in the Joint Commission's Comprehensive Accreditation Manual for Hospitals (CAMH), which is also expected to be renumbered in the near future.

There are six brand new requirements, three of which pertain to healthcare-associated infections. These requirements have a one-year phase-in period during which hospitals, critical access hospitals, and ambulatory facilities will be expected to meet quarterly deadlines. New requirements include:

• NPSG.01.03.01: Elimination of transfusion errors that are related to misidentification of patients
• NPSG.07.03.01: (one-year phase-in period, with full implementation by January 1, 2010): Prevention of healthcare-associated infections resulting from multiple drug-resistant organisms (MDRO) using evidence-based practices
• NPSG.07.04.01: (one year phase in period): Prevention of central line-associated bloodstream infections using evidence-based practices
• NPSG.07.05.01: (one year phase in period): Prevention of surgical site infections using best practices
• NPSG.08.03.01: When a patient leaves a facility, the patient and his or her family receives a complete list of the patient's medications with an explanation of that list
• NPSG.08.04.01: In settings in which medications are prescribed minimally or for a short time, modified medication reconciliation processes are carried out

In addition to the new requirements, some of the NPSGs already in place have been modified:

• NPSG.01.01.01 (formerly Goal 1A): An EP for this goal about patient education has been added to include language about needing active patient and family involvement in the identification process. If the patient is unable to be involved in the process, the hospital will name a caregiver who will be responsible for being part of the identification process.
• NPSG.03.05.01 (formerly Goal 3E): In addition to the removal of the phase-in language, new language has been added to the goal about anticoagulation therapy, specifying that it only applies when the expectation is a patient's coagulation lab values remain outside normal values. It does not apply to routine situations in which short-term anticoagulation will take place. Further, some EPs have been modified to become more specific about patient education and improvement of anticoagulation practices.NPSG.08.01.01 (formerly Goal 8A): For this medication reconciliation goal, what was formerly IE 2, concerning comparing the list of medications ordered for a patient while in the hospital with the patient's medication list at admission, and reconciling discrepancies, has been separated into two EPs. Also, there is an addition concerning the importance of medication reconciliation during a patient handoff.
• NPSG.08.02.01 (formerly Goal 8B): Providing a list of a patient's medications to the patient's primary care provider has been reinstated in this Goal, and if this cannot possibly be done, providing that list to the patient and his or her family will suffice. It is acceptable to send the list to the next provider of care or referring provider, and this must be documented.
• NPSG.13.01.01 (formerly Goal 13A): Added to this goal on actively involving patients in their care are two new EPs concerning educating the patient about hand hygiene and respiratory hygiene measures, and contact precautions used in the facility, and when and how this should be done. Also, surgical patients should be educated about the methods the facility employs to prevent adverse events during surgery.
• NPSG16.01.01 (formerly Goal 16A): In addition to the removal of the phase-in language, this goal, which concerns recognizing and responding to change in a patient's condition, has been modified. EP 7 has been updated to say that just having a team in place (e.g., a rapid response team) is not enough to be in compliance with the goal.

Extensive changes have been made to the Universal Protocol (UP), most of which are used to make the existing UP more specific:

• UP.01.01.01 (formerly requirement 1A): The biggest change here involves incorporating a checklist when the patient moves from the pre-procedure setting. In addition to the existing relevant documentation and correct diagnostic and radiology results, The Joint Commission has required a signed consent form and any blood products that will be used be confirmed as a part of the checklist.
• UP.01.02.01 (formerly requirement 1B): EP1, concerning marking the site, now applies to all procedures that involve incision or percutaneous puncture. Also, this goal specifies that the surgeon or person performing the operative procedure marks the site with his or her initials. Additionally, there is added language about the way in which spinal procedures should be marked and that facilities must have an alternative process in place to identify the surgical site for patients who refuse the site marking and for certain procedures that are difficult to mark.
• UP.01.03.01 (formerly requirement 1C): This goal on performing the time out now includes language about the need for separate time outs to take place when more than one procedure is being performed. Also, the time out now should include an accurate procedure consent form, address if antibiotics or fluids will be needed, and mention any safety precautions that should be taken based on a patient's history or medication use. Lastly, all steps of the UP and time out must be documented, not just the time out.

Although the goals relating to infection prevention incorporate the biggest changes to the NPSGs, there is a general consensus that most facilities are already doing at least some of the requirements.

"This does not seem too much of a stretch from what is typical for IC programs across the country," says Claude (Bud) Pate, REHS, vice president for content and development at The Greeley Company in Marblehead, MA. Most hospitals are already doing surveillance on the populations of patients at risk for surgical site infections and central line-associated blood stream infections, he says.

The Centers for Disease Control and Prevention has reported that healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year in American hospitals. Of those healthcare-associated infections, 32% were urinary tract infections, 22% were surgical site infections, 15% were lung infections (pneumonia), and 14% were bloodstream infections.

Molly McDaniel, PharmD, medication safety officer at Sanford USD Medical Center in Sioux Falls, SD says that the Joint Commission's changes to the medication reconciliation goal are a step in the right direction. Limiting the requirements for areas where patients are only admitted for a short period of time eases a burden for caregivers, she says.

"This helps shift the focus onto the patient while not being bogged down with tons of documentation," McDaniel says. "Also, I appreciate the focus The Joint Commission has placed on discharge. Discharge can be a very complicated and confusing time for patients and their new medication list is one of the many pieces of information they need to understand."

The Joint Commission has made a larger effort in this release of the NPSGs to emphasize the importance of educating the patient and his or her family, a move lauded by Lisa Khanna, RN, BSN, patient safety officer at Cooley Dickinson Hospital in Northampton, MA.

"The goals seem to be moving in a more patient-centered direction," Khanna says." It seems that The Joint Commission has taken the feedback it has gotten and fine-tuned some existing goals to make the expectations of implementation clearer, and reasons for the goals more meaningful."