Joint Commission to review four patient safety goals
As reported earlier this year in Hospital Peer Review, The Joint Commission is taking a look at National Patient Safety Goal #8, medication reconciliation, with which hospitals are struggling. Now, it is taking a look at three other challenging goals; but unlike with medication reconciliation, the others still will impact accreditation decisions.
The goals are:
- the Universal Protocol, in particular the site marking requirement;
- NPSG.02.03.01, reporting of clinical tests, results, and values;
- Standard PI.04.01.01, staffing effectiveness.
In general, The Joint Commission, in response to suggestions from the field, is looking to make the goals clearer and less prescriptive.
To Jennifer Cowel, RN, MHSA, with Patton Healthcare Consulting in Glendale, AZ, it spells a nice change of atmosphere at TJC.
"I think that is based on the new leadership at The Joint Commission — Dr. [Mark] Chassin and Ann Scott Blouin. The Joint Commission has embarked on this robust process improvement. Part of the effort that they've embarked on internally makes The Joint Commission more lean, more streamlined, and more customer focused," she says.
She says The Joint Commission did outreach in December and January and listened to what it heard — that hospitals are still struggling with these measures.
"The Joint Commission got very specific this year in the '09 release of the NPSGs. A lot more detail came in; they added specificity. And in the opinion of the field and the feedback they were getting, there was too much direction, detailed direction, and there was kickback from the field." She says, for example, most agree the time out before surgery, part of the Universal Protocol, is the right thing to do. But in 2009, she says, The Joint Commission added eight elements of performance, to be used not only in operative procedures but invasive procedures done at the bedside.
"Now you're taking a good idea and you're making it so onerous that the field is kicking back on what really was a good idea and necessary for patient safety," Cowel says. "So I think The Joint Commission is doing a great thing by stepping back and saying, 'We want to keep the time out. But what parts are critical and what parts are important?'"
She thinks the more rigid 2009 guidelines made it more difficult for hospitals to comply. And some things just don't make sense. For instance, asking for a radiograph or antibiotic when a clinician is doing a lumbar puncture at the bedside.
"When The Joint Commission says we're going to ease up on the specificity and let the organization have greater control on what is included perhaps in the time outs, they're now giving power back to the professional at that bedside and the quality professional, saying 'OK, you know what we're trying to accomplish. And these are the minimum requirements and then you guys in your settings can adapt it to meet your organization and patient needs,'" Cowel says.
As reported earlier this year in Hospital Peer Review, The Joint Commission is taking a look at National Patient Safety Goal #8, medication reconciliation, with which hospitals are struggling. Now, it is taking a look at three other challenging goals; but unlike with medication reconciliation, the others still will impact accreditation decisions.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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