Assure Organizational Excellence for Our Patients Every Day
2013 National Patient Safety Goals
Goal 1 – Improve the accuracy of patient identification.
NPSG.01.01.01: Use at least two identifiers when providing care, treatment, and services.
NPSG.01.03.01: Eliminate transfusion errors related to misidentification.
Goal 2 – Improve the effectiveness of communication among caregivers.
NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.
Goal 3 – Improve the safety of using medications.
NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
NPSG.03.05.01: Reduce the likelihood of harm associated with the use of anticoagulant therapy.
NPSG. 03.06.01: Maintain and communicate accurate patient medication information.
Goal 7 – Reduce the risk of health care associated infections.
NPSG.07.01.01: Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines.
NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.
NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter PICC lines.
NPSG.07.05.01: Implement best practices for preventing surgical site infections.
NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).
Note: This NPSG is not applicable to pediatric populations.
Goal 15 – The hospital identifies safety risks inherent in its patient population.
NPSG.15.01.01: Identify patients at risk for suicide.
Universal Protocol – The organization meets the expectations of the Universal Protocol.
UP.01.01.01: Conduct a pre-procedure verification process.
UP.01.02.01: Mark the procedure site.
UP.01.03.01: A time-out is performed before the procedure
2013 National Patient Safety Goals
How do we meet them?
Goal 1 – Improve the accuracy of patient identification.
Use name and date of birth when giving medications, doing procedures or providing care to the patient.
When giving blood have two nurses identify the blood with the blood at the bedside.
Goal 2 – Improve the effectiveness of communication among caregivers.
The green notification value sticker is placed on the chart to document the action taken.
Calls to the provider need to occur within 1 hour.
Goal 3 – Improve the safety of using medications.
NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
NPSG.03.05.01: Reduce the likelihood of harm associated with the use of anticoagulant therapy.
NPSG. 03.06.01: Maintain and communicate accurate patient medication information.
Goal 7 – Reduce the risk of health care associated infections.
Wash your hands!
NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.
NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter PICC lines.
NPSG.07.05.01: Implement best practices for preventing surgical site infections.
Place Foleys using aseptic technique only when needed.
Remove Foleys per Foley Cather Removal Protocol.
Goal 15 – The hospital identifies safety risks inherent in its patient population.
Screen patients for suicide risk during initial assessment. Documentation on admission assessment.
Process Improvement Projects for 2013
· Core Measures
o Acute Myocardial Infarction (AMI) and Cardiac Care Initiatives (STEMI)
o CHF
o Pneumonia
o Surgical Care Improvement Project (SCIP)
o Stroke
· Trauma
· Cardiac Care Designation
· Readmissions
· Observations
· Fall Reduction
· Patient Satisfaction
· Line Infections in our ICU Areas
· Medication Errors
· Pressure Ulcers
· Patient Satisfaction (HCAHPS)
· Perinatal Safety
· Safety Huddles
· Bedside Reports
· Purposeful Rounding
Priority Focus Areas
Priority Focus Areas (PFAs) are defined as processes, systems or structures in a health care organization that significantly impact the quality and safety of care. They can be used to guide assessment of standards compliance in relation to the patient/resident/client experience.
The Priority Focus Process is a data-driven methodology that consistently uses pre-survey information about healthcare organizations to create priorities for reviewing standards compliance, thus lending consistency to the survey process. Pre-survey information is gleaned from data in your organization’s application for accreditation, your organization's past survey findings, our Quality Monitoring System database of complaints and non-self reported sentinel events, any ORYX core measure data, and certain external data, if available. External data consists of publicly available data that are applicable to the accreditation program(s) being surveyed, such as HCAHPS for Hospitals, Nursing Home Compare, Home Health Compare, and failed laboratory proficiency testing data from CMS.
Good Shepherd’s Priority Focus Areas Identified by the Joint Commission are as follows:
• Assessment of Care and Services
• Information Management
• Physical Environment
• Communication
Assessment and Care/Services
Assessment and Care/Services for patients/clients/residents comprise the execution of a series of processes including, as relevant: assessment; planning care, treatment, and/or services; provision of care; ongoing reassessment of care; and discharge planning, referral for continuing care, or discontinuation of services.
Assessment and Care/Services are fluid in nature to accommodate a patient’s/client's/resident's needs while in a care setting. While some elements of Assessment and Care/Services may occur only once, other aspects may be
repeated or revisited as the patient’s/clients/resident's needs or care delivery priorities change. Successful implementation of improvements in Assessment and Care/Services rely on the full support of leadership.
Sub-processes of Assessment and Care/Services include:
• Assessment
• Reassessment
• Planning care, treatment and/or services
• Provision of care, treatment and services
• Discharge planning or discontinuation of services
Information Management
Information Management is the interdisciplinary field concerning the timely and accurate creation, collection, storage, retrieval, transmission, analysis, control, dissemination, and use of data or information, both within an organization and externally, as allowed by law and regulation. In addition to written and verbal information, supporting information
technology and information services are also included in Information Management.
Sub-processes of Information Management include:
• Planning
• Procurement
• Implementation
• Collection
• Recording
• Protection
• Aggregation
• Interpretation
• Storage and retrieval
• Data integrity
• Information dissemination
Physical Environment
The Physical Environment refers to safe, accessible, functional, supportive, and effective Physical Environment for patients/clients/residents, staff members, workers, and other individuals, by managing physical design; construction and redesign; maintenance and testing; planning and improvement; and risk prevention, defined in terms of utilities,
fire protection, security, privacy, storage, and hazardous materials and waste. The Physical Environment may include the home in the case of home care and foster care.
Sub-processes of Physical Environment include:
• Physical design
• Construction and redesign
• Maintenance and testing
• Planning and improvement
• Risk prevention
Communication
Communication is the process by which information is exchanged between individuals, departments, or organizations. Effective Communication successfully permeates every aspect of a health care organization, from the provision of care to performance improvement, resulting in a marked improvement in the quality of care delivery and functioning.
Sub-processes of Communication include:
• Provider and/or staff-patient/client/resident communication
• Patient/client/resident and family education
• Staff communication and collaboration
• Information dissemination
• Multidisciplinary teamwork
The Survey
The Joint Commission (JC) Survey is anticipated to be 4 days in length. Using the patient’s medical record as a road map, surveyors will assess the care provided to patients in both inpatient and outpatient sites. A surveyor will arrive at your practice area accompanied by GSMC leadership. The surveyor will review a patient’s record with caregivers, observe care, tour the unit, interview clinicians, and, in some cases, interview patients.
Patient Interview
Who will be involved? The JC surveyor will ask the nurse caring for the patient if the patient is able to be interviewed. If yes, the JC surveyor will request permission to interview the patient and family without other members of the healthcare team present. The patient has the right to decline.
Question to the patient and family may involve the following subject matter:
• Patient and family education
• Advance directives
• Patient rights
• Participation in planning of their care
• Continuity of care
• Environment e.g. noise, cleanliness
• Pain management
• Responsiveness of staff to their needs
• Patient identification prior to treatment and procedures
• Response to their questions
• Preparation for discharge
Who will be Involved? The nurse caring for the patient and the Clinical Unit Director will participate in the record review. Because the surveyor will not know the GSMC patient record, the nurse will help locate the documentation for which he or she is looking. As the surveyor tours the unit and observes care, he or she may interview other members of the healthcare team including therapists, OAs, PTs, PAs, and physicians.
Remember!
Surveyors know the standards, but YOU know your practice and your patients and families.
Relax and take your time answering the surveyor’s questions, but be direct and to the point with your response. Be careful not to start sharing information they are not requesting.
You will not be alone, your Director and others will be there to help you.
If you don’t know the answer to a question, it’s okay to say “I don’t know but I know where to find it.”
Tell positive stories! If the surveyor asks you a question that relates to special project on your unit or in the hospital, tell about it!
Take pride in being a part of a great organization and do your very best to impress by being open, sincere, welcoming and listening.
Allow them the opportunity to teach you and thank them for sharing their knowledge.
Common Survey Questions
Health Care Associated Infections
Q What are the most common ways you prevent transmission of infections from one patient to the next?
A Hand hygiene before and after contact with the patient and the patient’s
environment (NPSG) and early identification of patients requiring isolation and timely placement on appropriate precautions.
Q How do you know if one of your patients has MRSA, VRE, C- difficile or an MDRO? (NPSG)
A I review laboratory reports; Infection Prevention or Microbiology laboratory notifies the nursing unit; physicians also inform us. I read the history and patients with a history of MRSA/VRE are flagged.
Q What precautions do you use for patients with MRSA or VRE?
(NPSG)
A Patients with known or suspected MRSA or VRE are placed on
Contact Precautions.
• They’re placed in a private room and moved out of ward settings as soon as possible.
• Gloves are worn on entry into the room; gowns are worn when there is contact with the patient, surfaces, and equipment.
• Equipment is dedicated to the patient if possible. If equipment is shared it is cleaned and disinfected with hospital-approved disinfectant
Q What precautions do you use with patients who have C-diff?
(NPSG)
A Patients with known or suspected C. diff are placed on Contact Special Precautions. This is similar to contact precautions with two primary differences. After contact with the patients, hands should be washed with soap and water. Patient rooms and equipment are cleaned daily with bleach-based disinfectant.
Q Describe the procedure for donning precaution gown and gloves.
A Perform hand hygiene, place the gown over the shoulders, tie the next strings so that the gown overlaps, then tie the waist strings so that the gown ends overlap, put on the gloves, pulling them up to cover the cuffs of the gown.
Q If a patient on precautions is leaving the unit to go to x-ray, how does the transporter know the patient is on precautions? How does radiology know? (NPSG)
A A transporter is informed by the sign on the door or by talking with the nurse. The nurse also writes the type of precautions on the Hand-Off Communication (Ticket to Ride) form which is placed on the back of the patient record.
Q What training have you received regarding infection prevention and what does it include? (NPSG)
A I’ve received training about general infection prevention practices such as hand hygiene, blood borne pathogens use of Personal Protective Equipment (PPE) and tuberculosis guidelines; and other practices to prevent healthcare-associated infections such as MRSA, VRE, C-diff, and device associated infections from central lines, urinary catheters and ventilators.
Q When did you receive this training? (NPSG)
A During orientation; it is repeated each year as part of required annual training.
Q Describe the steps that are taken to prevent infection when inserting a central line. (NPSG)
A • Perform hand hygiene prior to catheter insertion
• A qualified individual monitors the insertion for breaks in sterile technique and completes the Central Line Bundle Checklist.
• Use a standardized kit and protocol
• Educate patients and families about prevention of infection.
· Inspect dressing, tubing and scrub hubs with alcohol prior to use.
Q Describes steps that are taken to prevent surgical site infections.
(NPSG)
A • Use aseptic technique during invasive procedures; this includes use of sterile equipment, skin preparation, and managing the environment.
• Use aseptic technique during dressing changes and closely monitor wounds
• Educate patients and families about ways to prevent surgical site infections.
Q Describe a few ways you prevent urinary tract infections.
A We limit the use of urinary catheters and remove them as soon as possible. We insert using aseptic technique and equipment, clean the catheter per procedure, do not disconnect the catheter from the drainage tube unless necessary to irrigate; avoid irrigations, obtain specimens through the specimen port; avoid kinking of the tube, keep the urine bag lower than the bladder and off the floor. We have a nurse driven removal protocol.
Q How do you prevent hospital acquired pneumonia?
A We decrease or prevent aspiration, use hand hygiene and other appropriate measures to prevent cross-contamination. We also ensure that that respiratory equipment is appropriately cleaned. We administer vaccines against influenza, pneumococcal pneumonia. We also educate patients and families about infection prevention and the use of care bundles such as supporting head of bed (HOB) elevation, CHG mouth care as an example, with ventilated patients.