National Patient Safety Goals Summits and Patient Safety Solutions

1. National Patient Safety GoalsSummits andPatient Safety Solutions Peter B. Angood MD FRCS(C) FACS FCCM VP & Chief Patient Safety Officer The Joint Commission

2. Things Going Bump in the Night… • Standards • Leadership • Medical Staff • Emergency Management • Standards Improvement Initiative • Strategic Surveillance System • Performance Measures – NQF • Champions for Patient Safety

3. Standards Requirements that define performance expectationswith respect to structure, process, andoutcomes that must be substantially in place in an organization to enhance the safety and quality for patient care Performance Expectations – the moving target

4. The Joint Commission’s Sentinel Event Policy • Established in January 1996 with the following goals: • To have a positive impact in improving care • To focus attention on underlying causes and risk reduction • To increase the general knowledge about sentinel events, their causes and prevention • To maintain public confidence in the accreditation process

5. 4817 total

6. *This graph represents all RCAs reviewed and accepted in a particular calendar year. **Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.

8. Root Causes of Sentinel Events (All categories; 1995-2004) Average number of root causes cited per RCA = 3.1 Percent of 2966 events

9. Root Causes of Sentinel Events (All categories; 2006) Average number of root causes cited per RCA = 5.3 Percent of 516 events

10. The Sentinel Event Advisory Group • Assess data from the Sentinel Event Database • Advise on future topics for Sentinel Event Alert • Reach consensus on candidate NPSGs • Assess practicality and cost of implementing each of identified evidence-based NPSG recommendations • Assess comparability of alternatives to NPSG requirements that are implemented by individual organizations

11. The Joint Commission 2008National Patient Safety Goals • 2008 Goals and associated requirements approved by Board of Commissioners June 1, 2007 • Keep the focus—Limit expansion of new requirements in 2008 and beyond • High impact • Evidence-based • Cost-effective

12. Moving from 2007 to 2008 • One NEW requirement under Goal #3: • 3E—Management of anticoagulant therapy • One NEW goal: • Goal #16—Rapid response to changes in patient condition [Hospitals & critical access hospitals] • One-year phase-in period for 3E and 16A • Retire requirement 3B (see MM.2.20, EP #10) • Compliance with WHO Hand Hygiene Guidelines will be acceptable for meeting requirement 7A

13. 2008 National Patient Safety Goals • Patient identification • Communication among caregivers • Medication safety • Health care-associated infections • Medication reconciliation • Patient falls • Flu & pneumonia immunization • Surgical fires • Patient involvement • Pressure ulcers • Focused risk assessment (suicide; home fires) • Rapid response to changes in patient condition • Universal Protocol for Preventing WSS

14. Goal #3: Improve safety of using medications • Requirement #3E [AHC, HAP, CAH, LTC, OBS, OME] Reduce likelihood of patient harm associated with use of anticoagulation therapy NEW

15. Managing Anticoagulant Therapy (1-5) • Defined anticoagulant management program • Unit dose (oral) and pre-mixed parenteral preparations • Dispense warfarin based on established monitoring procedures • Use protocols for anticoagulant therapy • Baseline and current INR monitoring Continued on next slide…

16. Managing Anticoagulant Therapy (6-11) • Notify dietary service about patients on anticoagulants • Use programmable infusion pumps for continuous IV heparin • Policy for baseline & ongoing testing for management of heparin therapy • Anticoagulant education to staff & patients • Education includes … • Evaluate anticoagulant safety practices

17. Goal #16: Improve recognition and response to changes in a patient’s condition Requirement #16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to be worsening

18. Goal #16, Requirement #16A • Select a suitable method • Develop criteria for summoning help • Empower staff, patients, families • Educate requesters and responders • Measure utility and effectiveness • Measure arrest and mortality rates

19. Phase-in Milestones for 3E &16A: At 3 months—Assign responsibility At 6 months—Work plan in place At 9 months—Pilot testing under way At 12 months—Fully implemented

20. Non-Compliance Data for 2003—07

21. S. E. Alert # 6 August 1998 W.S.S. Summit I May 2003 W.S.S. Summit II February 2007 NPSGs January 2003 U.P. S. E. Alert #24 December 2001 Sentinel Event Trends:Wrong-site Surgeries Reported by Year

22. Wrong-Site Surgery Summit #2 • Results: • Tentative consensus on • Universal Protocol is sound but does not go far enough • U.P. should be more prescriptive • U.P. should address “upstream” factors • Employ technology, where possible • Emphasize applicability to anesthesia procedures and non-OR settings • Discussion of “zero tolerance” & “campaign” strategy

23. Medication Reconciliation Summit • Sept. 25, 2007 - 85 organizations invited • NPSG 8 is important but needs clarification • Accuracy & reliability of the list vs reconciliation • Next Provider issues • Minimal-Use scenarios • Inpatient & Outpatient • Focus on systems & processes • Focus on leadership and inter-professional teams • Patient engagement and education

24. 2009 National Patient Safety Goals NO NEW NPSGs ! • Patient identification • Communication among caregivers • Medication safety • Health care-associated infections • Medication reconciliation • Patient falls • Flu & pneumonia immunization • Surgical fires • Patient involvement • Pressure ulcers • Focused risk assessment (suicide; home fires) • Rapid response to changes in patient condition • Universal Protocol for Preventing WSS BUT…

25. There are a few DRAFT Requirements & IEs… • Requirement 1A; IE 7 (Patient Identification) • Requirement 1C; IEs 1-3(Patient Identification) • Requirement 7C; IEs 1-16 (Reduce HAIs - MDRO) • Requirement 7D; IEs 1-13 (Reduce HAIs - CABSI) Requirement 7E; IEs 1-7 (Reduce HAIs - SSI) • Requirements 8A-D + IEs (Med’n. Reconciliation) • Requirement 13A; IEs 3-4 (Patient Involvement) • Universal Protocol; Requirements 1A-1C

26. Surveying and Scoring theNational Patient Safety Goals • All applicable Goals & Requirements, or acceptable alternative approach(es), must be implemented • Evaluated in PPR and during all full accreditation surveys and “for-cause” surveys • Surveyors evaluate actual performance, not just intent • Emphasis is on interviews with direct caregivers and direct observation of care delivery

28. Joint Commission International Center for Patient Safety: Mission and Vision Mission • The mission of the Joint Commission International Center for Patient Safety is to continuously improve patient safety in all health care settings. Vision • To become the trusted resource for improving health care worldwide by providing pre-eminent solutions and expertise in patient safety.

29. International Advisory Structure • International Steering Committee • European Advisory Group • Middle East Advisory Group • Asia Pacific Advisory Group • Input from Latin America and Africa through WHO Focal Points • Communications Expert Panel • Medication Safety Expert Panel • Patient and Family Advisory Group

30. Definition of Solution • Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.

31. 2007 Solution topics (inaugural set) • Look-Alike, Sound-Alike Medication Names • Patient Identification • Hand-Over Communications • Wrong Site, Wrong Person, Wrong Procedure Surgery • Concentrated Electrolyte Solutions • Medication Reconciliation • Catheter and Tubing Misconnections • Single Use Devices • Hand Hygiene

33. Topics for Next Round of Solution Development • Follow-up on Critical Test Results • Patient Falls • Healthcare Associated Infections – Central Lines • Pressure Ulcers • Response to the Deteriorating Patient • Patient and Family Involvement • Apology and Disclosure • Look-alike Sound-alike Medication Packaging

34. Action on Patient Safety:High 5s Project Goals • To achieve significant, sustained, and measurable reduction in the occurrence of 5 patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative, standardized, safety operating protocols.

35. High 5s Solution Topics • Hand-over communications • Wrong Site, Wrong Procedure, Wrong Person Surgery • Medication Reconciliation • Concentrated Electrolyte Solutions • Hand Hygiene

36. For more information: Joint Commission International Center for Patient Safety www.jcipatientsafety.org The Joint Commission Resources Web Site www.jcrinc.com The Joint Commission Web Site www.jointcommission.org