The Joint Commission's National Patient Safety Goals: Implications for Infection Preventionists

Editor's note: To access part two of this two-part article, CLICK HERE.

IMPORTANT UPDATE: 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, by CLICKING HERE. In these documents, the current (2009) requirement is listed in regular type and the proposed revision follows it in bold type.  Elements of Performance and/or Implementation Expectations that are proposed for deletion or movement to standards are also identified. Feedback on the National Patient Safety Goals and Universal Protocol, if applicable, will be gathered for six weeks beginning on May 12, 2009.

The Joint Commission (JC)’s focus on healthcare-associated infections (HAIs) in its 2009 National Patient Safety Goals (NPSGs) underscores a growing concern within the healthcare community. Infection preventionists are on the front line in the battle against HAIs. As such, they are charged with understanding and interpreting the goals pertaining to HAIs and leading efforts to achieve those requirements within the mandated timeframe.

This article, the first of a two-part series, reviews the impact of HAIs and the latest NPSGs for hospitals and ambulatory care settings. Emphasis will be given to Goal No. 7: “Reduce the risk of healthcare-associated infections.”

The World Health Organization (WHO) has recognized HAIs as a worldwide concern due to their negative impact on patients, healthcare workers and facilities in both developed and resource-poor countries. These infections are a major issue for patient safety as they complicate the delivery of patient care.

HAIs contribute to patient deaths and disability, promote resistance to antibiotics and generate additional costs above those already incurred by the patient’s underlying disease.1-2

In the United States, the Centers for Disease Control and Prevention (CDC) estimates that more than 2 million patients develop HAIs each year.3 Nearly 100,000 die as a result.4 Among those at highest risk are those who require intensive care.5 Other contributing factors include: An aging population, more people in more crowded conditions, more immuno-compromised patients, more aggressive medical interventions, misuse and/or overuse of antibiotics, and failure of healthcare workers to follow basic infection-control practices.1,6

As the number of infections has increased, so too have efforts to combat them. Among relevant organizations and initiatives are the following:

• Institute for Healthcare Improvement’s 5 Million Lives Campaign and others (IHI.org)

• Surgical Care Improvement Project (qualitynet.org)

• National Quality Forum (qualityforum.org)

• Reduce Infection Deaths campaign (hospitalinfection.org)

• Centers for Medicare & Medicaid Services reimbursement-related regulation and guidance (cms.hhs.gov)

• Joint Commission accreditation surveys and compliance and guidance information (jointcommission.org)

The Joint Commission and Patient Safety

Since 2003, the JC has issued NPSGs annually. Announced in June 2008, the 2009 goals and related requirements are intended to “promote specific improvements in patient safety by providing heathcare organizations with proven solutions to persistent patient safety problems.”

The goals apply to more than 16,000 JC-accredited and certified hospitals and healthcare organizations. The goals were developed by the JC’s Patient Safety Advisory Group, consisting of experienced physicians, nurses, pharmacists, and other patient-safety experts. Annual revisions are based on data regarding near-misses, sentinel events and other related information.

The goals are in concert with the JC’s overall 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.”

According to the JC, “If an organization does the right things and does them well, there is a strong likelihood that its patients will experience good outcomes.” The motivation to do the right thing is high. Beyond the critical matter of potentially diminished patient outcomes, loss of accreditation can mean a decline in resources, including those from Medicare and Medicaid. It can also result in an erosion of trust by patients and referring physicians.

Goals Review

The 2009 NPSGs are delineated in the following tables (tables can be found in the June 2009 issue of ICT). Table 1 lists goals applicable to hospitals and Table 2 lists those that apply to ambulatory care facilities including office-based surgery centers, homecare organizations and long-term care centers.7-8

Table 1: Joint Commission 2009 NPSGs, Hospital

Goal 1: Improve the accuracy of patient identification.

Goal 2: Improve the effectiveness of communication among caregivers.

Goal 3: Improve the safety of using medications.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 8: Accurately and completely reconcile medications across the continuum of care.

Goal 9: Reduce the risk of patient harm resulting from falls.

Goal 13: Encourage the patients’ active involvement in their own care as a patient safety strategy.

Goal 15: Identify safety risks inherent in an organization’s patient population.

Goal 16: Improve recognition and response to changes in a patient’s condition.

UP: The organization meets the expectations of the Universal Protocol.

Table 2: Joint Commission 2009 NPSGs, Ambulatory Health Care

Goal 1: Improve the accuracy of patient identification.

Goal 2: Improve the effectiveness of communication among caregivers.

Goal 3: Improve the safety of using medications.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 8: Accurately and completely reconcile medications across the continuum of care.

Goal 11: Reduce the risk of surgical fires.

Goal 13: Encourage patients’ active involvement in their own care.

UP: The organization meets the expectations of the Universal Protocol.

Goal No. 7, “to reduce the risk of healthcare-associated infections,” includes requirements for hand hygiene and the management of sentinel events that affect both hospitals and ambulatory care settings. For hospitals, three new requirements address preventing infections related to multidrug-resistant organisms (MDROs), central line-associated bloodstream infections (CLABSIs) and surgical site infections (SSIs). The new requirements for CLABSIs and SSIs also apply to ambulatory services; the requirement for MDROs does not.

Goal No. 7 Requirements and Elements of Performance

The following sections review elements of performance for the requirements related to hand hygiene and sentinel events.

The five requirements for Goal No. 7, and mandated elements of performance, are as follows:

• Comply with current WHO hand hygiene guidelines or CDC hand hygiene guidelines. According to the JC, such compliance will reduce the transmission of infectious agents by staff to patients, thus decreasing the incidence of HAIs. This requirement includes a single element of performance: compliance with current WHO or CDC hand hygiene guidelines. They can be found at: who.int/patientsafety/events/05/HH_en.pdf and www.cdc.gov/Handhygiene9-10

• Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to an HAI. Root-cause analysis should be conducted to provide answers regarding patients with HAIs who died unexpectedly or suffered major, permanent function loss. Specific questions to be asked include: why the infection was acquired, and why the patient died or suffered loss of function. This requirement includes two elements of performance:

1. The hospital manages all identified cases of unanticipated death or major permanent loss of function associated with an HAI as sentinel events. That is, such cases require that a root-cause analysis be conducted.

2. The root-cause analysis addresses the management of the patient before and after the identification of infection.

• Implement evidence-based practices to prevent healthcare-associated infections due to MDROs in acute care (applies to hospitals only, not to ambulatory care facilities).

• Implement best practices or evidence-based guidelines to prevent CLABSIs. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter lines.

• Implement best practices for preventing SSIs.

Action Steps for New Requirements

The three new requirements (for MDROs, CLABSIs and SSIs) have a one-year phase-in period that includes milestones at three, six and nine months during 2009. The JC expects full implementation by Jan. 1, 2010. The milestones are as follows:

• By April 1, 2009, responsibility for oversight and coordination of the plan for each requirement should have been assigned by hospital leadership. Has this been done at your facility?

• By July 1, 2009, an implementation work plan should be in place. Is your facility well into developing and implementing a plan?

• By Oct. 1, 2009, pilot testing in at least one critical unit should be under way. Is your facility beyond the planning stage and now involved in implementation of a pilot?

• By Jan. 1, 2010, the elements of performance should be fully implemented. Is your facility prepared to meet this deadline?

Conclusion

The implementation of the JC’s National Patient Safety Goal No. 7: “Reduce the risk of healthcare-associated infections” is a critical aspect of any infection prevention program. Active involvement in this process will help ensure accreditation and improve patient safety and optimal outcomes.

Part two of this article (to appear in the July 2009 issue of ICT) will explore the newly added requirements and elements of performance for Goal No. 7 related to MDROs, CLABSIs and SSIs.

Kathleen B. Stoessel, RN, BSN, MS, is senior manager of clinical education for Kimberly-Clark Health Care.

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