The standard has applied to hospitals and behavioral healthcare programs since 2007. Significant changes took effect this year.
Critical access hospitals (CAHs) accredited by The Joint Commission (TJC) will be expected to implement National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 starting July 1, 2020.
This standard, which aims to prevent suicides among patients, has been posted on the prepublications standards pages. In the December edition of The Joint Commission’s Perspectives announcing the requirement, the accreditor noted concerns about the very high rate of suicides in rural communities that critical access hospitals serve. Suicide rates in rural counties are 25% higher than in urban areas.
Those who want to learn more about the suicide prevention NPSG are asked to contact Stacey Paul, RN, MSN, APN, PMHNP-BC, project director, clinical, Department of Standards and Survey Methods.
An Institute for Healthcare Improvement expert puts landmark patient safety report into perspective.
November 29 marked the 20th anniversary of the Institute of Medicine report To Err is Human, which flipped conventional ideas about medical errors and prevention on their head and started the modern patient safety movement.
Since the report’s claim that as many as 98,000 patients die annually from medical errors, there have been major strides in changing healthcare organizations' systemic problems, workplace cultures, and improvement processes.
Patricia McGaffigan, RN, MS, CPPS, vice president of safety programs at the Institute for Healthcare Improvement (IHI), spoke with Accreditation Insider about how To Err is Human changed patient safety. The following is a lightly edited transcript of that conversation.
Accreditation Insider: What was the impact of To Err is Human when it came out? Why was it so groundbreaking?
McGaffigan: There had been other papers and stories related to adverse outcomes prior to the publication of To Err is Human about patients suffering severe injury as a result of care that should have healed and treated them. However, To Err is Human was published by an incredibly prestigious organization, it had selected a panel of highly credible experts, and they attributed a number of lives that were lost each year from preventable healthcare harm. If you go back and ask what people remember about the report, I think they’ll tell you that figure of 44,000 to 98,000 lives lost each year as a result of errors is emblazoned in their minds, history, and society.
It was probably the very first time we’d clearly swept away the curtains of silence that had defined the state of the healthcare at the time. A state that was somewhat complacent, and in many cases intentionally withholding the truth about healthcare. It was even the first time that many of us who worked in healthcare understood the magnitude of harm. It was such a sobering reality of what had been happening.
I think the other key thing about To Err is Human is that it was a real clarion call with its specific recommendations. Many recommendations that most of us in society would have already expected to be in place for our protection when we’re at our most vulnerable. Moreover, the industry that I think most of us expected, trusted, and believed was taking the best care of us possible, really showed some of its gaps and opportunities for improvement in a very powerful way.
Getting the report published at that time was really interesting. I’ve often thought about what if To Err is Human was published today, with the social media power that we have. Would it be any more or less impactful? Given we were in the more traditional world of reporting when it came out, the impact, breadth, and reach was impressive for something of that nature. There wasn’t anyone who could look at that title and say, “This isn’t important in my life in some way.”
AI: In what areas has the patient safety field improved in the past 20 years? And what areas still need improvement?
McGaffigan: There’s been some nice improvement that I think has occurred because of To Err is Human; there was some governmental investment in initiatives to improve safety. We’ve seen, over the years since the publication, progress in some key areas; mostly around some circumscribed projects, like efforts to reduce central-line infections or catheter-associated infections and falls. That’s been incredibly important, it’s probably saved more lives than we can realistically count, we have a difficult time measuring those harms and improvements to that extent.
Ironically, that’s emblematic of the problem we still have today, where we’re often tackling many of these problems with a piecemeal approach—often with great fervor and excitement. While we’re making progress in some of those areas, the approach is relatively reactionary and focused on fixing the circumscribed things. Particularly at the point of care, it has ignored the systemic issues that continue to allow fault lines in healthcare to prevail.
Some other areas of improvement are some great leaders who seem to have embraced the core values of safe and quality care as their business strategy. We’ve seen really bright spots of people and organizations who’ve identified the systemic issues that continue to get in the way of people’s great intentions. But some professionals are still working in systems that have not looked at and overhauled their system’s approach to safety. We continue to have some challenges.
Yet, there are some bright spots of systems that have unified their vision of safety for patients and their workforce in an effort to keep people free from harm. Because at the same time we’re talking about harms and safety of patients and families, the same challenges are pervasive in our workforce when you look at things like occupational injury rates.
So leaders have said, “I’m taking a unified approach to safety and everything we do in our organization matters, including to our most vital assets, our employees, those that provide care. That is how I’ll approach the problem.”
One of the things leaders have been able to do is say that they don’t rate safety as a higher or lower priority. They say, “It is my purpose; it’s my reason for being in this role in the first place, and not something that can be prioritized.” While leaders certainly need to make adjustments in how they invest in safety initiatives, these leaders have shown us that if you never accept anything less than zero harm for patients and workforce, then we will ultimately be successful in improving the health and vitality of our systems.
AI: What do you think the next big step in patient safety is going to be or needs to be?
McGaffigan: We talk about so many things when we talk about where we need to be to improve healthcare and quality of care. Lots of times, and we see this particularly in election years where we have discussions and debates about healthcare, what we’re really not getting at is saying, “Regardless of the models we have for healthcare, care must first and foremost always be safe.”
I think that’s going to be the real differentiator for people who will ascend to office at some point in time, and who will be in the driver’s seat saying, “We’re not going to let conflicts and other things get in the way of doing what we expect to be done in healthcare.” That includes not just policymakers and elected officials, but leaders and all of us caring for patients saying we’re going to be authentic, transparent, and cohesive in addressing care.
I think there’s a piece of this centered on the reality that if our leaders are not impatient about where we stand with patient safety right now, then we’ve got a lot of work to do. There are a number of people who’ll say, “I am impatient. I’m going to use this impatience to be constructive and unified in advancing care, particularly in putting the patient back in the driver’s seat of their health and their healthcare.”
I think we have viewed patients as commodities instead of real champions of the care that is right and appropriate for them, which is an interesting irony of healthcare. Don Berwick, founder of IHI, has always said, “We are guests in our patients’ lives.” Patients are at the forefront and including them meaningfully in all aspects of improving care is absolutely vital.
When it comes to understanding how to anticipate and address harms, recent experiences have shown it’s been smart people at the point of care with patients and families who’ve have pointed out risks in the system. They’ve been correct in identifying those areas of risk and the unfortunate harm that has occurred as a result.
Ideally, everyone could go to work without having to worry about harassment and reprisal. And when harassment happens in healthcare, the leaders in the organization must act. In an interview with Kate Fenner, PhD, RN, managing director of Compass Clinical Consulting, who specializes in organizational optimization, performance improvement, and regulatory compliance, talks about how harassment allegations should be handled and what preventive measures healthcare leaders can take.
This transcript has been edited for clarity and brevity.
PSQH: Should facilities expect more surveyor focus on sexual harassment?
Fenner: The public attention currently being paid makes it even more imperative that executives lead their organizations on this pressing issue. Prevention, detection, and remediation are the key components of a successful approach. Thoughtful leaders use all three to ensure a safe and productive care environment.
Regulators and surveyors (e.g., CMS and The Joint Commission) pay careful attention to the news and trends in public interest.
The Joint Commission requires that its accredited facilities meet all applicable laws (Civil Rights Act of 1964, Title IX, for example, the recognition of sexual harassment as an infringement on civil rights for employees), and CMS is stringent about protecting patient rights including the right to receive care without harassment. Attention to a harassment-free environment is good business, good public relations, good regulatory management, and just plain the right thing to do.
PSQH: How can hospitals demonstrate to staff/patients that they are taking sexual harassment claims seriously?
Fenner: With patients, it's pretty straightforward. [You need to have a] patients' rights statement that everyone is required to have and should be prominently promulgated and, of course, it includes the right to be cared for in a respectful manner.
The other piece of that is, hospitals promulgating how patients can complain. Usually, there are either patient representatives or an ombudsman system that allows patients to give their concerns and complaints.
For staff members, it's imperative that the hospital has clear, solid policies and, even more importantly, procedures and communication of those procedures for reporting problems around the hospital, including potential harassment. And the procedures for reporting need to be such that staff know things will be managed in confidence and there will be no retribution.
PSQH:What preventive steps can hospitals take regarding harassment?
Fenner: Several things: One is widespread education and communication of what is harassment and what isn't tolerated—what we do when we find and can prove incidences of harassment. Very straightforward, informative education across the system, across the environments. And this includes starting with a discussion of policy around harassment at the board level.
[Also, making] sure medical staff, as part of their orientation, understand the hospital's philosophy [on harassment]. And being quick and firm about responses to any incident of harassment.
PSQH: Walk me through the response and remediation of a sexual harassment claim. For example, one staff member accuses another of harassment. What happens next?
Fenner: The accusation needs to be followed by intense investigation … in an objective, unbiased way. So, how do we go about finding out the truth of what happened? [Determining whether] we have [a] pattern of harassment or abuse or [if this is] a one-time event. [This] is probably the most important piece. Harassers rarely commit only one act of harassment: Either they repeat the behavior with multiple people, or they focus on one particular person and persist in harassing behavior.
The investigation normally goes through HR so it can be kept confidential. If it's validated, if it's seen as a legitimate complaint, then an action appropriate to the level of concern needs to be taken.
PSQH: What about remediation and punishment?
Fenner: Each organization should have different levels of response depending on the severity of the incident. The punishment needs to fit the crime. If it's something really outrageous, regardless of the level of the staff member, pretty strong action needs to occur: suspension, termination, revocation of privileges. The actions need to be connected and appropriate to the validated complaint.
For example, if a staff member alleges another used inappropriate language, [and] if it's verified that [the incident] occurred, there needs to be some sort of proactive corrective step. That might be counseling, a performance improvement plan, or put the person on warning.
The reaction to the behavior needs to be uniform in terms of level of justice, regardless of the position of the individual.
PSQH: What's the process if the harasser is a patient?
Fenner: There's a court case on this where a staff member had been harassed by a patient in an outpatient setting. She complained about it to her supervisor, and they didn't take corrective action. It was a repetitive problem, and the patient wasn't dealt with. The staff member sued [the facility] and won.
We have an obligation to make certain patients know that staff members aren't to be harassed and that patients understand the rights and privileges of the staff member to work in a dignified and safe environment. And it starts with a supervisor's attention that if there's a concern about the patient, then that supervisor needs to take appropriate action. Meet with the patient and family and discuss appropriate behavior. Change out staff members; sometimes it's one particular person and if you put in a different person for that care, the behavior won't occur again.
PSQH: Is there ever a case where a patient's behavior is so outrageous they have to be removed from the facility or transferred? Is that ever a possibility?
Fenner: I've not encountered that.
The most typical cases, unfortunately, are with geriatric patients who might have Alzheimer's or other form of dementia and just don't have the same control over behaviors. Then you can enlist family members: "Hey, can you talk with Dad/Mom about what they're doing?"
I'm not aware of an institution discharging a patient [because of sexual harassment], but I am aware of the fact that institutions need to make proactive, firm efforts to manage patient behavior.
[Also,] the more typical incidents for harassment or hostile work environments come from within the institution itself. Employees to physicians, physicians to employees, supervisors [to staff]: that's way more typical.
PSQH: How can you tell when your anti-harassment program is working?
Fenner: There's several factors: One is the level of activity around respect and interpersonal behavior and the discussion about it is robust, but not necessarily trivializing.
Two, reported cases of harassment become few and far between. People are comfortable making complaints and know that their complaints are going to be kept confidential [and] that there's going to be a prompt investigation to see if they merit attention. And if they merit attention, then the appropriate consequences occur.
[Also,] you have a robust program for onboarding staff in a way that acquaints them to your policies and procedures and your zero-tolerance expectations. We really need to say, "We don't do this, period. We don't tolerate this, period. It's part of our values; a safe and respectful work environment is as important to us as safe and respectful patient care."
It all goes hand in hand; it's all part of the organization's ethics. It becomes woven into the fabric of how members of the organization treat each other and expect to be treated.
Three key takeaways from The Joint Commission's annual hospital executive briefings.
Editor's note: This article originally appeared on PSQH.
Highlight the zip codes where employees live so you can have a handy reference of where staff is available in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.
Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’sannual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.
Attendee Brian Pitt, safety director of SUNY Downstate Medical Center in Brooklyn, NY, said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency in what organizations — such as the CDC or the Association for the Advancement of Medical Instrumentation — you reference in your hospital policies.
“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt.
Here are some brief highlights from the day’s topics:
1. Suicide Prevention and Ligature Risk
Emily Wells, CSW, MSW, TJC’s project director, surveyor management and development, said that the accreditor has realized that no environment can be “ligature free,” so it’s changed the terminology to “ligature resistant.” That said, you still need to do risk assessments and have protocols to keep patient safe including removing as many ligature risks from a patient room as reasonably possible. Facilities should pay extra attention to standard EC.02.06.01 EP 1 which was the most cited standard related to Immediate Threat. The standard requires hospitals to maintain a safe environment and EP 1 RFI include self harm risks like door hinges, beds, and drop ceilings.
Kathryn Petrovic, MSN, RN-BC, TJC field director of surveyor management and development, stressed was the need to test ligature resistant products to ensure they’re properly installed. Buying special anti-pinch point doorknobs doesn’t matter if they’re put in the wrong way, seize up and create a ligature risk, she says. Surveyors test to see if your products work, not that you have them. And improperly installed equipment can result in a patient hurting themselves on something you thought was safe.
2. Emergency Management
Jim Kendig, MS, CHSP, CHCM, CHEM, LHRM, field director of surveyor management and development, recommends facilities run zip code tests to determine where most of their employees live. Most staff won’t come to work in during an emergency if their homes and family are in the affected area. Doing a zip code test can tell you ahead of time if you’ll need to call in help from other facilities.
Kendig also said security staff should work with local law enforcement on what to do in the event a hospital becomes a crime scene. There have been cases where a crime was committed in a hospital and police prevented hospital staff from re-entering the facility or move between rooms. That’s a possibility that needs to be dealt with before it happens, he said.
3. Physical Environment
Kenneth A. Monroe, PE, CHC, PMP, TJC director of engineering, started off the physical environment and environment of care section with a look at Legionella. There have been multiple cases of the bacteria in hospitals, he said, and facilities need to be vigilant to protect their patients.
He also noted that 98% of all surveyed hospitals had at least one finding in the EC chapter, with ligature risks as the leading driver of Immediate Threat findings. However, the most common EP finding in the red category was EC.02.02.01 EP 5 — hazardous material handling and storage.
Ninety-seven percent-of hospitals had a finding in the Life Safety chapter, with LS.02.01.35 (sprinklers) being the most cited. Facilities don’t clean their sprinklers, test them, or put things that block the spray. Easy ways to get a finding. That said, only about 12% of LS findings were in the moderate or high-risk range, with LS.01.02.01 EP 1 (No ILSM policy) being the most common high risk finding.
