Editor's note: This article is part two of a two-part series. To access part one, CLICK HERE.
Note: The Joint Commission is revising the 2009 National Patient Safety Goals (NPSGs) and the 2009 Universal Protocol to clarify language and make sure that they are relevant to the settings in which they apply. This initiative to review and revise the 2009 NPSGs and the 2009 Universal Protocol is a first step in the Joint Commission’s efforts to focus on those issues that are of highest priority to safety and quality. Proposed revisions for 2010 can be found, by program, at: http://www.jointcommission.org/Standards/FieldReviews/. In these documents, the current (2009) requirement is listed in regular type and the proposed revision follows it in bold type.
The Joint Commission (JC)’s National Patient Safety Goals (NPSGs) are a specific set of initiatives designed to promote improvements in patient safety by providing healthcare organizations with proven solutions to persistent patient safety problems. NPSG 7: “Reduce the risk of healthcare associated infections” contains requirements for appropriate hand hygiene and the management of sentinel events. In 2009, three new hospital and critical-access hospital requirements were added. These requirements are related to preventing deadly healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDROs), central line-associated bloodstream infections (CLABSIs), and surgical site infections (SSIs).1
The new requirements related to CLABSIs also apply to ambulatory care facilities and office-based surgery practices, home care organizations, and long-term care organizations. In addition, prevention of SSIs is a new requirement for ambulatory care facilities and office-based surgery practices.1
These new infection-related requirements have a one-year phase-in period that includes defined milestones, with full implementation expected by Jan. 1, 2010.2-3
This article, the second of a two-part series, reviews the three new requirements for NPSG 7 along with their elements of performance and recommendations for compliance.