The Joint Commission: National Patient Safety Goals for Medicare Based Long Term Care

The National Patient Safety Goal (NPSG) program was created in 2002 by the Joint Commission to help organizations identify and address issues with patient safety. The people who determine what the safety goals are and how they should be addressed is called the Patient Safety Advisory Group. This group is composed of medical professionals who have “hands-on experience in addressing patient safety issues in a wide variety of health care settings.”(The Joint Commission, 2015) The first group of goals set by the advisory group were published Jan. 1, 2003. Currently, there are 6 hospital patient safety goals:

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

Hospital acquired infections (HAIs) affect over 1.7 million patients each year, causing almost 100,000 deaths annually in the United States alone (Johnson, 2010). According to the World Health Organization, HAIs are the most frequent adverse event in the healthcare industry. Fortunately, most of these infections can be prevented with one single intervention, proper hand hygiene (“The Evidence,” n.d.). Four out of five pathogens that cause illness are spread by direct contact. Proper hand hygiene eliminates these pathogens and helps to prevent cross-contamination and HAIs (Linton, 2015; “Hand Hygiene,” n.d.). Reduction of cross-contamination and HAIs improves patient outcomes, increases employee wellness, and lowers health care costs. Adherence to proper hand hygiene is the single most important safety measure in the health care setting. However, for many years compliance to proper hand hygiene in the healthcare industry has been dismally low. New and inventive measures must be implemented to increase compliance to proper hand hygiene and lower the rate of hospital-acquired infections.

The National Patient Safety Goals were first developed in 2002 by the Joint Commission. The goals are established to help guide medical organizations to focus on which areas of patient safety need improving (Hudson 2016). The first set of goals were released and put in motion in 2003, prior to 2003 there were no policies or goals for an organization to set their sights on (Hudson 2016 page 2). A panel of experts advises the Joint Commission on the development of new goals or the updating of old ones. The panel is called the Patient Safety Advisory Group and is made up of nurses, risk managers, clinical engineers, and physicians (Hudson 2016). The National Patient Safety Goals have specific goals geared toward the type of medical organizations such as a critical access hospital, home care, behavioral health, and long term care services to name a few (Hudson 2016 page 2). The National Patient Safety Goals help protect patients and make sure providers are practicing safely across the board.

Article by Clancy (2009) explained central lines were a result of an estimated 250,000 blood stream infections and accounted for 30,000 to 62,000 patient deaths, then adding that each infection cost upwards of $36,000 and cumulatively add up to at least $9 billion in preventable costs annually. The article also explains how the mindset has changed from the cost of having a central line in place and expecting complications to lowering infection rates by an intentional interventional process/s. The article speaks of 5 basic steps to reduce CLABSI, hand washing, insertion techniques, skin cleansing, avoidance of certain sites and earlier removal of the CVC. Studies showed that these guidelines were only followed 62% of the time. The system was changed to ascertain that all the clinicians were in compliance. This prompted 5 interventions, education, a CVC insertion cart with all necessary equipment, physicians having to validate central line necessity, a concise checklist for bedside clinicians and the empower of nurses to stop procedures if guidelines were not followed. These low cost interventions from 11.3/1000 in catheter days in 1998 to zero in the fourth quarter of 2002.

One of the ways to combat the incidence of Central Line Associated Bloodstream Infection (CLABSI) is by following the proper steps in Central Line Dressing changes. The topic you picked is an important one, both for patients and our overall health care system as well. If nurses will learn, and follow the proper manner in the way Central Venous Lines should be changed it can have a positive outcome for patients. CLABSI can be fatal to the patient, this can devastate the patient's family as well. “Although a 46% decrease in CLABSIs has occurred in hospitals across the U.S. from 2008-2013, an estimated 30,100 central line-associated bloodstream infections (CLABSI) still occur in intensive care units and wards of U.S. acute care facilities each

The Joint Commission has instituted a number of goals nationally; the aim is to improve patient’s safety. The goals selected look at areas that are of concern in the healthcare industry particularly how it affect patients safety and make recommendations how to reduce if not eradicated these. The Joint Commission is the governing body that accredited hospitals and other health care organizations. The two hospitals that this paper will be comparing, using the goals and criteria recommended by the Joint commission, is Holy Cross Hospital located at 1500 Forest Glen Road, Silver Spring, MD and Shady Grove Hospital situated at, 9901 Medical Center Drive, Rockville, MD.

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

The Joint Commission also addresses safety issues through the publication and distribution of the Sentinel Event which identifies a severe breach in safety and addresses ways on how to improve processes and to prevent harm in the future. It also publishes the National Patient Safety Goals which address healthcare safety and ways to solve problems that focus on issues such as identifying patients correctly, improving communication among staff, and administering medications safely, just to name a few. “A majority of Joint Commission standards are directly related to safety, addressing such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security. The standards also include requirements for preventing accidental harm; responding to patient safety events; and the organization’s responsibility to tell patients about the outcomes of their care” (TJC,

Back in 2003, the Joint Commission created a National Patient Safety Goal due to 23 occurrences of death or injury to a patient where alarms had been applied incorrectly or the alarms had been muted (Sendelbach & Funk, 2013). By 2004, Joint Commission had removed it from their National Patient Safety Goal list and made it a requirement for Joint Commission accreditations (Sendelbach & Funk, 2013). In 2013, it was brought to the attention of the Joint Commission regarding many alarm-related events, including multiple deaths, permanent loss of function, and prolonged hospital stays due to health care worker’s decreased response times to alarms (Horkan, 2014; Joint Commission, 2013). The Joint Commission reinstated a National Patient Safety Goal in 2013 and had requirements for all hospitals that had to be met by July 1, 2014 (Joint Commission, 2013). These goals included being able to make alarm safety a priority and develop a plan to decrease the amount of alarms. This plan could include preventing unnecessary patient monitoring, clarifying who is allowed to monitor and silence alarms, setting the cardiac monitors to have multiple tones, and having a brief delay in the alarm to see if the patient can self-resolve. The second phase of the Joint Commission’s plan was to be implemented by January 2016, to where the hospital must have followed through with their designated plan (Joint Commission, 2013).

The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

This paragraph explains ways to prevent infections contracted from hospitals. The number one way to lower the spread of infections contracted through a hospital is correct sanitation customs. Occupational Safety and Health Administration (OSHA), a federal government agency has come up with guidelines in order to safeguard against the expansion of infections and diseases for patients and the workers (Hedman, 2010). It is mandatory for administrators of hospitals to write a disclosure policy to protect the workers from infections like Hepatitis B and other infections and bad bacteria. Minimizing infections that the workers have can aid in stopping the spread of

Healthcare associated infections have an impact on patients - how? Can be prevented greatly with compliance to hand hygiene protocols (REF).

Research shows that Surgical site infections are preventable. According to the CDC, hand hygiene is the simplest approach to preventing the spread of infections and needs to be incorporated into the culture of the organization. Ensuring the use of infection control prevention is an important component of nursing care. Infection control prevention policies must be communicated undoubtedly to all employees. Staffers who do not comply must be re-educated to ensure that all are complying. Speaking up and pointing out that a nurse forgot to wash his or her hands, or notifying the surgical team that surgical instruments were not adequately cleaned may seem like small issues; but at the same time, not acknowledging a break in a sterile technique could mean the difference between life and death for a patient. One hospital that was struggling with high levels of infection related to surgical procedures, implemented a pre-procedure huddle as a team. This innovate way decreased the spread of infection and was a great way to improve the quality of care for patients. As mandated by the Joint commission, infection prevention personnel should provide multidisciplinary education on SSI prevention, to all team members, including