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JCAHOs New Patient Safety Focus: Tips for Survey Preparedness
By Diana Scott, RN, BSHA,CPHQ
In October 2002, the Centers for DiseaseControl and Prevention (CDC) announced that about 2 million patients in theUnited States get nosocomial infections with approximately 90,000 resulting in asignificant untoward outcome. The Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) has been heightening the awareness that anosocomial infection resulting in death or permanent injury/loss of functionshould be treated as a sentinel event. As a result, JCAHO surveyors are nowlooking for a revision to an organizations sentinel event policy.
With this revision, healthcare organizations need to identifyhow they are going to identify and capture this data and incorporate it intotheir review process. Surveyors are looking closer at adverse event reportingprocesses during patient unit visits, leadership interviews, patient safety andmedication management interviews. Through these sessions surveyors are diggingdeeper into how decisions are being made to conduct a root cause analysis on areported adverse event. To identify if a sentinel event has occurred,organizations used to make a straightforward determination based on outcome. Nowa mini root cause analysis needs to be conducted that focuses on thecontributing factors and not solely on the event itself.
Sentinel Event alert No. 28, which was posted to JCAHOs Website in January 2003, outlines root causes and risk reduction strategiesidentified in the 10 reported sentinel events representing 53 patients. Based onthe wide media coverage of untoward events related to nosocomial infections,JCAHO is hoping for an increase in voluntary reporting that will help expand itsdatabase to identify improvement strategies. While the commission acknowledgesthe total cases reported are insufficient to determine any definitiveconclusions, surveyors are scrutinizing infection control surveillance andprocesses and looking for implementation of the CDCs recently publishedguideline on hand hygiene.
Surveyors are noting the presence of alcohol-based hand rubsand appropriate use of gloves by healthcare employees and family members. Inappropriate use of gloves has been a frequent nemesis fororganizations, as staff are observed going from a direct patient-care task to anon-clinical task such as answering the telephone. Employees also have a falsesense of security while wearing gloves that results in less hand washing or handantisepsis. Gloves are not 100 percent foolproof and should not be relied on asa total substitute for good hand hygiene. Miniscule perforations are not easily visible and can resultin an unknown pathogenic exposure.
Clinical leaders need to revisit their education programs withon-site evaluations and observations. These should encompass clinical andnonclinical staff, such as food service and housekeeping. Patient and familyeducation should be re-assessed to identify opportunities to improve instructionand comprehension so patients and well-intended family members avoid accidentalself-contamination.
Direct patient exposure is not the only area of focus forinfection control concerns. The environment of care standards also is receivingincreased attention. Specifically, EC.3.2.1 requires an infection controlproactive risk assessment when planning demolition, construction or renovation.The risk assessment should identify hazards and the potential for patientcompromise 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 quantifiableresults. Infection control departments have traditionally done an excellent jobof collecting data and data analysis including statistical process controlgraphs analyzing trends. Todays focus goes beyond routine surveillance, whichchallenges organizations to expand their thinking. Rapid cycle improvementresults based on measurable success data will become part of the survey process.With the initiation of the new periodic performance review process (formerlyreferred to as the self-assessment process) kicking off this fall, organizationshave a much shorter time frame for developing and implementing corrective actionplans for areas of non-compliance. Previously, committees were formed and tookmonths to identify an action plan and several more months to implement andmeasure the success indicators of the action plan. Now, the new periodicperformance review process will have action plans completed within 30 days withmeasurable success in six months.
As evidence of JCAHOs patient safety focus on infectioncontrol, an expert panel has been convened to evaluate the current infectioncontrol standards and the survey process specific to this function. The group,which first met in February 2003, comprises 22 professionals representingmulti-disciplines and professional organizations. A survey of the panelidentified critical elements to address, which include:
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.
The Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) announces its 2004 National Patient SafetyGoals. 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 reducingthe risk of healthcare-acquired infections.
The expert panel which developed the recommendations to theBoard felt strongly that the current six National Patient Safety Goals requirethe 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 tonosocomial infections must become a top priority for hospital and otherhealthcare organization leaders.
For each of the National Patient Safety Goals, there areevidence based requirements that set forth clear expectations for healthcareorganizations to address specific types of healthcare errors. The 2003requirement to read back verbal and telephone orders in order to confirmtheir accuracy has been expanded for 2004 to include the read-back of criticaltest results that are communicated verbally.
Beginning January 1, 2004, the nearly 17,000 JCAHO-accreditedhealthcare organizations will be evaluated for compliance with all relevantgoals and requirements. Organizations will still be able to seek prior approvalby JCAHO of suitable alternatives to the requirements.
The 2004 National Patient Safety Goals and Requirements are:
The expert panel that developed these recommendations theSentinel Event Advisory Group includes well-known patient safety experts, aswell as nurses, physicians, risk managers, pharmacists and other professionalswho have hands-on experience addressing patient safety issues in healthcaresettings.
In addition, the Board of Commissioners of JCAHO in late Julyapproved a Universal Protocol for preventing wrong-site, wrong-procedureand wrong-person surgery. Compliance with the Universal Protocol by allaccredited organizations that provide surgical services will be requiredbeginning on July 1, 2004.
The Universal Protocol draws upon, and expands and integrates,a series of existing requirements under the 2003 and 2004 National PatientSafety Goals. It will be applicable to all operative and other invasiveprocedures.
The principal components of the Universal Protocol include:
The Universal Protocol is the consensus product of a nationalSummit on Wrong Site Surgery convened last spring by the Joint Commission, theAmerican Medical Association, the American Hospital Association, the AmericanCollege of Physicians, the American College of Surgeons, the American DentalAssociation and the American Academy of Orthopaedic Surgeons. Summitparticipants included leaders from other medical and surgical specialtyorganizations, nursing organizations and provider associations, among others.The summit participants concluded that wrong-site, wrong-procedure andwrong-person surgery can be prevented and that a Universal Protocol is needed tohelp accomplish this goal.
This Universal Protocol asks healthcare organizations toset a goal of zero tolerance for surgeries on the wrong site or on the wrongperson, or the performance of the wrong surgical procedure, says Dennis S. OLeary, MD, president of JCAHO. These are occurrenceswhich simply should never happen.
A three-week public comment period that concluded earlier thismonth generated more than 3,000 responses from surgeons, nurses and otherhealthcare professionals, which were overwhelmingly in support of the UniversalProtocol. The comments also provided the basis for a number of refinements tothe protocol.
Despite widespread acknowledgement that surgeries on the wrongsite or on the wrong person, or the wrong surgical procedure should neverhappen, the Joint Commission continues to receive five to eight new reports ofwrong-site surgery every month from organizations that provide surgicalservices. These reports are almost all shared with the Joint Commission on avoluntary basis.