JCAHOs New Patient Safety Focus: Tips for Survey Preparedness
By Diana Scott, RN, BSHA, CPHQ
In October 2002, the Centers for Disease Control and Prevention (CDC) announced that about 2 million patients in the United States get nosocomial infections with approximately 90,000 resulting in a significant untoward outcome. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has been heightening the awareness that a nosocomial infection resulting in death or permanent injury/loss of function should be treated as a sentinel event. As a result, JCAHO surveyors are now looking for a revision to an organizations sentinel event policy.
With this revision, healthcare organizations need to identify how they are going to identify and capture this data and incorporate it into their review process. Surveyors are looking closer at adverse event reporting processes during patient unit visits, leadership interviews, patient safety and medication management interviews. Through these sessions surveyors are digging deeper into how decisions are being made to conduct a root cause analysis on a reported adverse event. To identify if a sentinel event has occurred, organizations used to make a straightforward determination based on outcome. Now a mini root cause analysis needs to be conducted that focuses on the contributing factors and not solely on the event itself.
Sentinel Event alert No. 28, which was posted to JCAHOs Web site in January 2003, outlines root causes and risk reduction strategies identified in the 10 reported sentinel events representing 53 patients. Based on the wide media coverage of untoward events related to nosocomial infections, JCAHO is hoping for an increase in voluntary reporting that will help expand its database to identify improvement strategies. While the commission acknowledges the total cases reported are insufficient to determine any definitive conclusions, surveyors are scrutinizing infection control surveillance and processes and looking for implementation of the CDCs recently published guideline on hand hygiene.
Surveyors are noting the presence of alcohol-based hand rubs and appropriate use of gloves by healthcare employees and family members. Inappropriate use of gloves has been a frequent nemesis for organizations, as staff are observed going from a direct patient-care task to a non-clinical task such as answering the telephone. Employees also have a false sense of security while wearing gloves that results in less hand washing or hand antisepsis. Gloves are not 100 percent foolproof and should not be relied on as a total substitute for good hand hygiene. Miniscule perforations are not easily visible and can result in an unknown pathogenic exposure.
Clinical leaders need to revisit their education programs with on-site evaluations and observations. These should encompass clinical and nonclinical staff, such as food service and housekeeping. Patient and family education should be re-assessed to identify opportunities to improve instruction and comprehension so patients and well-intended family members avoid accidental self-contamination.
Direct patient exposure is not the only area of focus for infection control concerns. The environment of care standards also is receiving increased attention. Specifically, EC.3.2.1 requires an infection control proactive risk assessment when planning demolition, construction or renovation. The risk assessment should identify hazards and the potential for patient compromise in structural and facility changes. Based on potential hazards, clinicians should design and implement a plan to minimize them.
With a heightened emphasis on surveillance and process, surveyors are interested in data, analysis, action plans and quantifiable results. Infection control departments have traditionally done an excellent job of collecting data and data analysis including statistical process control graphs analyzing trends. Todays focus goes beyond routine surveillance, which challenges organizations to expand their thinking. Rapid cycle improvement results based on measurable success data will become part of the survey process. With the initiation of the new periodic performance review process (formerly referred to as the self-assessment process) kicking off this fall, organizations have a much shorter time frame for developing and implementing corrective action plans for areas of non-compliance. Previously, committees were formed and took months to identify an action plan and several more months to implement and measure the success indicators of the action plan. Now, the new periodic performance review process will have action plans completed within 30 days with measurable success in six months.
As evidence of JCAHOs patient safety focus on infection control, an expert panel has been convened to evaluate the current infection control standards and the survey process specific to this function. The group, which first met in February 2003, comprises 22 professionals representing multi-disciplines and professional organizations. A survey of the panel identified critical elements to address, which include:
- Staffing and personnel qualifications
- Evidence-based practice
- Employee health practices
- Data collection and analysis
- Environment of care maintenance
- Equipment and supplies
- Continuous evaluation of the infection control program
Outcomes from the expert panel affecting standard revisions are targeted for hospitals this fall, with probable implementation in 2005.
Infection control and prevention issues are part of the 2003 fixed Random Unannounced Survey agenda. Flash sterilization of instruments and cleaning processes for the endoscopes are frequently identified as problematic. Flash sterilization logs are assessed for frequency, types of items being flashed and the ability to track flashed items back to a particular patient for evaluation. Frequent flash sterilization of the same type of instruments often drive questions related to LD.1.5 and LD.1.5.2, leaderships budgeting processes and organizational planning.
Flash sterilization should be viewed as a necessity for unanticipated situations and not a routine mode of sterilization due to rapid case turn around expectations. Either a change in scheduling methodology to accommodate the sterilization process or an increase in instrument sets should be considered to minimize the use of flash sterilization. Surveyors are expecting to see a structured plan for improvement with an aggressive implementation process and a post implementation re-evaluation to verify the expected outcome.
Monitoring for the integrity of the cleaning solutions used in disinfecting the endoscopes also is a frequent area identified for improvement. Most cleaning systems for the endoscopes use solutions that require continuous testing for efficacy. This routine testing requires supporting documentation most commonly done in a log format. Lack of documentation could generate a recommendation. Managers should assign this task on a rotational basis to staff members. For example, a staff person could be assigned to the test the solution for the month of July, moving to the next staff member the following month, etc., or it could be assigned to the staff member who does the first case of the day. The bottom line is to make documentation a designated responsibility versus an assumption that someone is going to do it.
As JCAHO moves forward with its heightened awareness of infections as a possible sentinel event, health-care organizations should continue to look outside the narrow focus of isolated incidents and seek a greater scope of contributing factors related to patient safety events, including potential infection control practices. Through a broadened perspective of event analysis, managers and nurses will improve processes and initiatives that decrease adverse patient outcomes.
Diana Scott, RN, BSHA, CPHQ is director of accreditation services for VHA Inc. Scott has been supporting VHA members in their JCAHO accreditation initiatives since 1999.
JCAHO Announces 2004 Patient-Safety Goals, Universal Protocol
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announces its 2004 National Patient Safety Goals. The Goals, approved by the JCAHO Board of Commissioners in late July, continues all of the 2003 goals and adds a new goal that will focus on reducing the risk of healthcare-acquired infections.
The expert panel which developed the recommendations to the Board felt strongly that the current six National Patient Safety Goals require the continued close attention of Americas healthcare organizations, says Dennis S. OLeary, M.D., president of JCAHO. They, and we, feel just as strongly that reduction of unanticipated deaths related to nosocomial infections must become a top priority for hospital and other healthcare organization leaders.
For each of the National Patient Safety Goals, there are evidence based requirements that set forth clear expectations for healthcare organizations to address specific types of healthcare errors. The 2003 requirement to read back verbal and telephone orders in order to confirm their accuracy has been expanded for 2004 to include the read-back of critical test results that are communicated verbally.
Beginning January 1, 2004, the nearly 17,000 JCAHO-accredited healthcare organizations will be evaluated for compliance with all relevant goals and requirements. Organizations will still be able to seek prior approval by JCAHO of suitable alternatives to the requirements.
The 2004 National Patient Safety Goals and Requirements are:
- Goal 1: Improve the accuracy of patient identification. Use at least two patient identifiers (neither to be the patients room number) whenever taking blood samples or administering medications or blood products. 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.
- Goal 2: Improve the effectiveness of communication among caregivers. Implement a process for taking verbal or telephone orders or critical test results that requires a verification read-back of the complete order or test result by the person receiving the order or test result. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
- Goal 3: Improve the safety of using high-alert medications. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9 percent) from patient-care units. Standardize and limit the number of drug concentrations available in the organization.
- Goal 4: Eliminate wrong-site, wrong-patient and wrong-procedure surgery. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents, (e.g., medical records, imaging studies) are available. Implement a process to mark the surgical site, and involve the patient in the marking process.
- Goal 5: Improve the safety of using infusion pumps. Ensure free-flow protection on all general-use and PCA intravenous infusion pumps used in the organization.
- Goal 6: Improve the effectiveness of clinical alarm systems. Implement regular preventive maintenance and testing of alarm systems. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
- Goal 7: Reduce the risk of healthcare-acquired infections. Comply with current CDC hand-hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care acquired infection.
The expert panel that developed these recommendations the Sentinel Event Advisory Group includes well-known patient safety experts, as well as nurses, physicians, risk managers, pharmacists and other professionals who have hands-on experience addressing patient safety issues in healthcare settings.
In addition, the Board of Commissioners of JCAHO in late July approved a Universal Protocol for preventing wrong-site, wrong-procedure and wrong-person surgery. Compliance with the Universal Protocol by all accredited organizations that provide surgical services will be required beginning on July 1, 2004.
The Universal Protocol draws upon, and expands and integrates, a series of existing requirements under the 2003 and 2004 National Patient Safety Goals. It will be applicable to all operative and other invasive procedures.
The principal components of the Universal Protocol include:
- The pre-operative verification process
- Marking of the operative site
- Taking a time out immediately before starting the procedure
- Adaptation of the requirements to non-operating room settings, including bedside procedures.
The Universal Protocol is the consensus product of a national Summit on Wrong Site Surgery convened last spring by the Joint Commission, the American Medical Association, the American Hospital Association, the American College of Physicians, the American College of Surgeons, the American Dental Association and the American Academy of Orthopaedic Surgeons. Summit participants included leaders from other medical and surgical specialty organizations, nursing organizations and provider associations, among others. The summit participants concluded that wrong-site, wrong-procedure and wrong-person surgery can be prevented and that a Universal Protocol is needed to help accomplish this goal.
This Universal Protocol asks healthcare organizations to set a goal of zero tolerance for surgeries on the wrong site or on the wrong person, or the performance of the wrong surgical procedure, says Dennis S. OLeary, MD, president of JCAHO. These are occurrences which simply should never happen.
A three-week public comment period that concluded earlier this month generated more than 3,000 responses from surgeons, nurses and other healthcare professionals, which were overwhelmingly in support of the Universal Protocol. The comments also provided the basis for a number of refinements to the protocol.
Despite widespread acknowledgement that surgeries on the wrong site or on the wrong person, or the wrong surgical procedure should never happen, the Joint Commission continues to receive five to eight new reports of wrong-site surgery every month from organizations that provide surgical services. These reports are almost all shared with the Joint Commission on a voluntary basis.