Copyright, The Joint Commission National Patient Safety Goals

Similar documents
Patient Safety. Annual Continuing Education Modules. Contents

APPROVED: 2010 National Patient Safety Goals

2016 Hospital National Patient Safety Goals

National Quality Forum Safe Practices for Better Healthcare

National Quality Forum (NQF) Endorsed Set of 34 Safe Practices*

Facts about The Joint Commission

Patient Safety Overview

Quality Outcomes & Patient Safety

The Physician s Guide to The Joint Commission s Hospital Standards and Accreditation Process

National Patient Safety Goals Effective January 1, 2015

Improving Safety: Developing Safety Metrics and Improving Error Reporting. Petra Khoury, Pharm D Adnan Tahir, MD

Accreditation History

The Joint Commission s Patient Safety Initiatives

DISTRIBUTION: This Patient Safety Plan shall be distributed hospital-wide and online.

National Patient Safety Goals Effective January 1, 2016

Errors in the Operating Room. Patrick E. Voight RN BSN MSA CNOR President Association of perioperative Registered Nurses (AORN)

Patient Safety Plan. Effective Date: March 12, 2009 for

Reducing Medical Errors for CNAs

Standards and National Patient Safety Goals: What s new for Critical Access Hospitals in 2012

Spotlight on Success: Implementing Nurse-Driven Protocols to Reduce CAUTIs

State HAI Template Utah. 1. Develop or Enhance HAI program infrastructure

NURSE DRIVEN FOLEY CATHETER PROTOCOL

Title: An Organized Strategic Focus to Achieve National Patient Safety Goals (NSPGs) Augmented by an Electronic Medical Record (EMR)

National Patient Safety Goals Effective January 1, 2015

VUMC Guidelines for Management of Indwelling Urinary Catheters. UC Access/ Maintenance

REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012

Catheter-Associated Urinary Tract Infection (CAUTI) Prevention. Basics of Infection Prevention 2 Day Mini-Course 2013

healthcare associated infection 1.2

New Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan 2010

NEVER EVENT LISTS ENDORSED BY NATIONAL QUALITY FORUM & MEDICARE

Hospital Information. Facility Name: Primary HEN Contact: Quality Lead: Infection Preventionist: HEN 2.0 Survey Questions

Changing Clinical Behaviors to Lower Costs and Reduce Catheter-Associated Urinary Tract Infections (CAUTI)

NQF. Safe Practices for Better Healthcare 2010 Update SAFE PRACTICES A CONSENSUS REPORT NATIONAL QUALITY FORUM

National Patient Safety Goals Effective January 1, 2015

Quality Report User Guide

We are pleased to present the publication of the first edition of the Health Authorty - Abu Dhabi Health Care Standards for Hospitals.

An Infusion of Quality and Safety STAT!

Joint Commission International Accreditation Standards for Ambulatory Care

Improving Hospital Performance

4/5/2013. Dee Webber RN BSN Staff Nurse EMMC CCU. Health care-associated infections are one of the most common complications of hospital care.

CAUTI-The Challenge Continues IHA-Coalition for Care April 23, 2014 Presented by Linda Doerflein, BS, RN, CPHRM Director of Quality/Risk HealthSouth

A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page

Information Management and Continuity of Care Safe Practices (8-13)

National Healthcare Safety Network (NHSN) Introduction & Enrollment

The Vermont Healthcare Associated Infection Prevention Plan

We are pleased to present the publication of the first edition of the Health Authorty - Abu Dhabi Health Care Standards for Ambulatory Care.

AHRQ Patient Safety Tools and Resources

Medication Management (Safe Practices 14-18)

Catheter Associated Urinary Tract Infection (CAUTI) Prevention. System CAUTI Prevention Team

Patient Safety: Applying Industrial Quality Models in Healthcare Settings Tempora mutantur, nos et mutamur in illis

Accreditation Handbook for Ambulatory Care. What you need to know about obtaining accreditation

Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure

Relevant Quality Measures for Critical Access Hospitals

Joint Commission International Standards for Clinical Care Program Certification

National Provider Call: Hospital Value-Based Purchasing (VBP) Program

Nursing Continuing Education Series

2/15/2015 HEALTHCARE ACCREDITATION: WHAT IT MEANS TO YOU HEALTHCARE ACCREDITATION WHAT IT MEANS TO YOU

Complication Prevention

MN HAI Prevention Plan 1

Common Outcomes/Competencies for the CCN Nursing Web Page

To decrease and/or prevent the incidence of catheter associated infections and other complications associated with IUC.

Nursing Quality: Measurement and Improvement

AGENCY-SPECIFIC PLAN FOR THE NATIONAL QUALITY STRATEGY

NDNQI. NDNQI:Transforming Data into Quality Care Rainbow Boulevard, M/S University of Kansas Medical Center

Crucial Complications: Preventing Harm and Promoting Health

Hospital Inpatient Quality Reporting (IQR) Program

Yale New Haven Health System Center for Healthcare Solutions

N ATIONAL Q UALITY F ORUM. Safe Practices for Better Healthcare 2006 Update A CONSENSUS REPORT

Hospital Engagement Networks: Connecting Hospitals to Improve Care

APPENDIX CONFLICT OF INTEREST CODE OF THE COUNTY OF SANTA CLARA EXHIBIT A LIST OF DESIGNATED POSITIONS FOR

Overview of the Hospital Value-Based Purchasing (VBP) Fiscal Year (FY) 2017

Introduction. The History of CMS/JCAHO Measure Alignment

The Joint Commission. Survey Activity Guide For Health Care Organizations

Appendix II - Outpatient settings worksheets

National Action Plan to Prevent Health Care-Associated Infections: ROAD MAP TO ELIMINATION

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT INFECTIONS. (CAUTIs)

Common Mistakes Medical Facilities Make

Value-Based Purchasing An Opportunity for Clinical Nurse Leaders

Quality A ssurance Assurance in Healthcare State I nstitute Institute of Health & F amily Family Welfare, Jaipur

PHYSICIAN. JOB DESCRIPTION Employees in this job function as professional physicians in a general or specialized area of medicine.

Guideline for Preventing Catheter- Associated Urinary Tract Infections

associated Urinary Tract Infection Case Definitions

Value Based Purchasing (VBP) Awareness Brief. FY 2018 Value Based Purchasing Program Domain Weighting

Patient Care Technician (Bridge Program)

Clinical Reasoning Case Study: I. Data Collection Chief complaint/history of Present Illness:

Arizona Department of Health Services Healthcare-Associated Infection Plan Progress Report June 2010

Improving Patient Safety with Team Training

INFORMATION NOTE. Hospital accreditation schemes in selected places

Staff should not feel that the Quality Management staff are policing them. These thoughts

Health Science Career Field Allied Health and Nursing Pathway (JM)

PATIENT SAFETY SENTINEL EVENT REPORTING FORM (DRAFT) January FACILITY INFORMATION

Patient Care Services Quality Report Evaluation of 2013 Outcomes August 2014

REPORT TO THE GENERAL ASSEMBLY AN ACT CREATING A PROGRAM FOR QUALITY IN HEALTH CARE JUNE 30, Jewel Mullen, MD, MPH, MPA, Commissioner

Incorporating Best Practices Into Undergraduate Critical Care Nursing Education

The Leapfrog Hospital Survey Scoring Algorithms. Scoring Details for Sections 2 9 of the 2016 Leapfrog Hospital Survey

Appendix E: Comparison of Human Resources Standards for HCSS Certification and Hospital Accreditation(AXE)

Safety FIRST: Infection Prevention Tips

Prescription For Pennsylvania

Written Statement. for the. Senate Finance Committee of The United States

A CAREER IN CARING. Healthcare Career Opportunities in B.C.

Transcription:

2015 National Patient Safety Goals

Background The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety The first set of NPSGs was effective January 1, 2003 The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs 2015 National Patient Safety Goals - Pg. 2

Patient Safety Advisory Group Panel of widely recognized patient safety experts Nurses, physicians, pharmacists, risk managers, clinical engineers, other professionals Hands-on experience in addressing patient safety issues in wide variety of health care settings Advises The Joint Commission how to address emerging patient safety issues NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, Center for Transforming Healthcare projects 2015 National Patient Safety Goals - Pg. 3

2015 NPSGs No new Goals for 2015 NPSG.15.02.01 on home oxygen safety modified for home care Minor language changes for NPSG.03.04.01 (AHC, HAP, CAH, OBS) 2015 National Patient Safety Goals - Pg. 4

Patient Identification Goal 1: Improve the accuracy of patient identification. 2015 National Patient Safety Goals - Pg. 5

Patient Identification NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 6

Patient Identification NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 7

Improve Communication Goal 2: Improve the effectiveness of communication among caregivers. 2015 National Patient Safety Goals - Pg. 8

Improve Communication NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. Applies to: Critical Access Hospital, Hospital, Laboratory 2015 National Patient Safety Goals - Pg. 9

Medication Safety Goal 3: Improve the safety of using medications. 2015 National Patient Safety Goals - Pg. 10

Medication Safety NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office Based Surgery 2015 National Patient Safety Goals - Pg. 11

Medication Safety NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Applies to: Ambulatory, Critical Access Hospital, Hospital, Nursing Care Center 2015 National Patient Safety Goals - Pg. 12

Medication Safety NPSG.03.06.01: Maintain and communicate accurate patient medication information. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Nursing Care Center, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 13

Clinical Alarm Safety Goal 6: Reduce the harm associated with clinical alarm systems. 2015 National Patient Safety Goals - Pg. 14

Clinical Alarm Safety NPSG.06.01.01: Improve the safety of clinical alarm systems. Applies to: Critical Access Hospital, Hospital 2015 National Patient Safety Goals - Pg. 15

Health Care-Associated Infections Goal 7: Reduce the risk of health care-associated infections. 2015 National Patient Safety Goals - Pg. 16

Health Care-Associated Infections NPSG.07.01.01: Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 17

Health Care-Associated Infections NPSG.07.03.01: Implement evidencebased practices to prevent health careassociated infections due to multidrugresistant organisms in acute care hospitals. Applies to: Critical Access Hospital, Hospital 2015 National Patient Safety Goals - Pg. 18

Health Care-Associated Infections NPSG.07.04.01: Implement evidencebased practices to prevent central lineassociated bloodstream infections. Applies to: Critical Access Hospital, Hospital, Nursing Care Center 2015 National Patient Safety Goals - Pg. 19

Health Care-Associated Infections NPSG.07.05.01: Implement evidencebased practices for preventing surgical site infections. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 20

Health Care-Associated Infections NPSG.07.06.01: Implement evidencebased practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Applies to: Critical Access Hospital, Hospital (Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children.) 2015 National Patient Safety Goals - Pg. 21

Reduce Falls Goal 9: Reduce the risk of patient harm resulting from falls. 2015 National Patient Safety Goals - Pg. 22

Reduce Falls NPSG.09.02.01: Reduce the risk of falls. Applies to: Home Care, Nursing Care Center 2015 National Patient Safety Goals - Pg. 23

Pressure Ulcers Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers). 2015 National Patient Safety Goals - Pg. 24

Pressure Ulcers NPSG.14.01.01: Assess and periodically reassess each resident s risk for developing a pressure ulcer and take action to address any identified risks. Applies to: Nursing Care Center 2015 National Patient Safety Goals - Pg. 25

Risk Assessment Goal 15: The organization identifies safety risks inherent in its patient population. 2015 National Patient Safety Goals - Pg. 26

Risk Assessment NPSG.15.01.01: Identify patients at risk for suicide. Applies to: Behavioral Health Care, Hospital (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.) 2015 National Patient Safety Goals - Pg. 27

Risk Assessment NPSG.15.02.01: Identify risks associated with home oxygen therapy, such as home fires. Applies to: Home Care 2015 National Patient Safety Goals - Pg. 28

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery UP.01.01.01: Conduct a preprocedure verification process. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 29

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery UP.01.02.01: Mark the procedure site. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 30

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery UP.01.03.01: A time-out is performed before the procedure. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery 2015 National Patient Safety Goals - Pg. 31

For more information The National Patient Safety Goals for each program and more information are available on The Joint Commission website at www.jointcommission.org Questions can be sent to the Standards Interpretation Group at 630-792-5900 or via the Standards Online Question Form 2015 National Patient Safety Goals - Pg. 32