Exactly where are you now with overall NPSG compliance?
Exactly where are you now with overall NPSG compliance?
'Use the time wisely' before new goals are surveyable
With the 2009 National Patient Safety Goals (NPSGs) just announced, it's an ideal time to perform a self-assessment for all of the existing goals, including the requirements for improving recognition and response to changes in a patient's condition and improving safety of anticoagulation medications, which are being phased in right now, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC.
Swain recommends using a "quick and easy" matrix to track current compliance. "You need to determine your progress to date, as well as get your staff ready for the next onslaught," she says. "It's a moving target with data collection."
One of the first steps is to embed the new elements of performance into the existing NPSGs your facility is tracking. Swain recommends using one of the popular examples from the public domain, such as The Joint Commission's own web site (www.jointcommission.org).
"This shows what has changed, with very little labor on the facility side," says Swain.
When this task is finished, the organization can see that there are no new NPSG goals, but there are significant expansions in goal numbers 1 (patient identification activity), 7 (infection control efforts), and 8 (medication reconciliation).
"However, rewording in many other goals will cause tightening of patient education, documentation, and additional angst for the Universal Protocol," says Swain.
Next, use the strategies that your organization already has developed for your anticoagulation and rapid response team work plans. At Presbyterian, a matrix was created that color coded each of the quarter performance expectations, as described by The Joint Commission.
"Create the same type of matrix for the new goals. The quarterly matrix that is required to keep a facility on track needs to be replicated for the new infection control goals," says Swain. "Those goals will go through the implementation phase in 2009 and be surveyable in 2010. So, use the time between now and actual survey of the new items wisely."
Kathleen Catalano, RN, JD, director of healthcare transformation support for Perot Systems Corp., agrees that your first step should be to make a list of all changes and additions to the NPSGs, and the data that are currently being tracked.
"A task force, or some other committee familiar with the work already performed on NPSGs at the facility, should be convened. Based on the organization's practices, a determination should be made as to how the collection of data will be altered," Catalano says.
If the required data have changed or are no longer applicable, the organization should shift its energies to other NPSG requirements. "In many instances, organizations will be adding to what is being collected, not deleting," says Catalano.
Next, look throughout the organization and determine exactly what is being collected and by whom. "Is everyone doing the same thing? This may not be the case," says Catalano. "Many times, even though there's been a directive on what data to collect and how to do the data collection, it is not followed. Try getting everyone on the same page."
At University of Pittsburgh Medical Center, each facility in the 20-hospital system has "adopted" a goal and acts as the system resource and content expert for that goal, says Kathy Hale, director of patient safety. "The information is shared among patient safety officers at a monthly forum."
This past year, Cincinnati-based Catholic Healthcare Partners implemented TeamSTEPPS in many of its facilities, Patient Safety WalkRounds in all, and launched a professional behavior initiative. "All of these actions are intended to improve the care and safety of our patients and compliance with national standards and NPSGs," says Jana B. Deen, patient safety officer. "Each of our facilities has teams committed to constant readiness for The Joint Commission and compliance with NPSGs."
NPSG compliance is monitored at the local level at individual sites. "We provide resources and support system initiatives that promote safety. For example, our professional behavior initiative was intended to improve compliance with the Universal Protocol," says Deen. "And as a system, we have endorsed SBAR to improve communications."
'Share the wealth' throughout facility
Swain recommends "keeping a campaign going" to alert staff at all levels about the NPSG changes. Be sure every meeting, from the unit level to the quality council and the medical staff, keeps staff up to date on what is being done. "None of the National Patient Safety Goals are conducted in a silo. Share the wealth as information on changes and improvements is known," says Swain.
[For more information, contact:
Kathleen Catalano, RN, JD, Director of Healthcare Transformation, Perot Systems, 2300 W. Plano Parkway, Plano, TX 75075. Phone: (972) 577-6213. E-mail: [email protected].
Jana B. Deen, Patient Safety Officer, Catholic Healthcare Partners, 615 Elsinore Place, Cincinnati, OH 45202. Phone: (513) 639-2750. Fax: (513) 639-2762. E-mail [email protected].
Kathy Hale, Director of Patient Safety, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213-2582. Phone: (412) 647-3052. E-mail: [email protected].
Paula Swain, MSN, CPHQ, FNAHQ, Director of Clinical and Regulatory Review, Presbyterian Healthcare, 200 Hawthorne Lane, Charlotte, NC 28204. Phone: (704) 384-8856. E-mail: [email protected].]
With the 2009 National Patient Safety Goals (NPSGs) just announced, it's an ideal time to perform a self-assessment for all of the existing goals, including the requirements for improving recognition and response to changes in a patient's condition and improving safety of anticoagulation medications, which are being phased in right now, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC.Subscribe Now for Access
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