2009 National Patient Safety Goals

1. 2009 National Patient Safety Goals Presented by Patricia J. Moss, JD Corporate Counsel / Patient Safety Officer (PSO) Athens-Limestone Hospital

2. Why National Patient Safety Goals? • The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. • The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. • The Requirements focus on system-wide solutions, wherever possible.

3. 2009 NationalPatient Safety Goals • Approved by The Joint Commission’s Board of Commissioners in May 2008 • The Goals and Requirements are program-specific • Include improvements emanating from the Standards Improvement Initiative, including: • New numbering system for sorting in new electronic manuals • Minor language changes for consistency

4. Patient Identification Goal 1:Improve the accuracy of patient identification • NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services [was Goal 1A].Applies to:Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, & Office-Based Surgery • NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques. [was Goal 1B]~ EPs Mirror the Universal Protocol ~Applies to: Home Care, Lab, Long Term Care • NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification. Applies to:Ambulatory, Critical Access Hospital, Hospital,Office-Based Surgery Revised for 2009

5. Improve Communication Goal 2: Improve the effectiveness of communication among caregivers • NPSG.02.01.01: For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result [was Goal 2A].Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital,Lab, Long Term Care, & Office-Based Surgery • NPSG.02.02.01: There is a standardized list of abbreviations, acronyms, symbols, and dose designations that areNOT to be used throughout the organization [was Goal 2B].Applies to:Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

6. Improve Communication Goal 2: Improve the effectiveness of communication among caregivers • NPSG.02.03.01: The organization measures, assesses and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, and critical results and values by the responsible licensed caregiver [was Goal 2C]. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, &Office-Based Surgery • NPSG.02.05.01: The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions [was Goal 2E]. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, & Office-Based Surgery

7. Medication Safety Goal 3:Improve the safety of using medications • NPSG.03.03.01: The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications [was Goal 3C]. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery

8. Medication Safety Goal 3:Improve the safety of using medications • NPSG.03.04.01: Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field [was Goal 3D] . Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery • NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy [was Goal 3E].Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery Clarified and Revised for 2009

9. Health Care Associated Infections Goal 7: Reduce the risk of health care associated infections • NPSG.07.01.01: Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines [was Goal 7A]. • NPSG.07.02.01: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care associated infection [was Goal 7B]. • NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery New for 2009 - Addition of 3 Requirements

10. Health Care Associated Infections Goal 7: Reduce the risk of health care associated infections • NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. • NPSG.07.05.01: Implement best practices for preventing surgical site infections. Applies to:Ambulatory, Critical Access Hospital, Home Care, Hospital, & Long Term Care New for 2009

11. Reconcile Medications Goal 8:Accurately and completely reconcile medications across the continuum of care • NPSG.08.01.01: A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of the organization [was Goal 8A].Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery • NPSG.08.03.01: When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family.Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery Completely Revised for 2009

12. Reconcile Medications Goal 8:Accurately and completely reconcile medications across the continuum of care • NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery New for 2009

13. Reduce Falls Goal 9:Reduce the risk of patient harm resulting from falls • NPSG.09.02.01: The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program. [was Goal 9B] Applies to: Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, & Long Term Care

14. Influenza & Pneumococcal Disease Goal 10:Reduce the risk of influenza and pneumococcal disease in institutionalized older adults -Not Applicable • NPSG.10.01.01: The organization develops and implements protocols for administration of the flu vaccine. [was Goal 10A] • NPSG.10.02.01: The organization develops and implements protocols for administration of the pneumococcus vaccine. [was Goal 10B] • NPSG.10.03.01: The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. [was Goal 10C] Applies to: Disease-Specific Care, Long Term Care -Not Hospitals

15. Surgical Fires Goal 11: Reduce the risk of surgical fires – Not Applicable • NPSG.11.01.01: The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. [was Goal 11A] Applies to: Ambulatory Care, Office-Based Surgery – Not Hospitals

16. Patient Involvement Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy – • NPSG.13.01.01: Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so [was Goal 13A].Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, & Office-Based Surgery New for 2009 - Addition of 2 elements of performance

17. Pressure Ulcers Goal 14: Prevent health care associated pressure ulcers (decubitus ulcers) – Not Applicable • NPSG.14.01.01: Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. [was Goal 14A] Applies to: Long Term Care - Not Hospitals

18. Risk Assessment Goal 15: The organization identifies safety risks inherent in its patient population • NPSG.15.01.01: The organization identifies patients at risk for suicide [was Goal 15A]. Applies to: Behavioral Health Care, Hospital (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals) • NPSG.15.02.01: The organization identifies risks associated with home oxygen therapy such as home fires [was Goal 15B]. Applies to: Home Care

19. Changes in Patient Condition Goal 16:Improve recognition and response to changes in a patient’s condition • NPSG.16.01.01: The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening [was Goal 16A]. Applies to: Critical Access Hospital, Hospital Clarified for 2009

20. Universal Protocol The organization meets the expectations of the Universal Protocol. • UP.01.01.01: Conduct a pre-procedure verification process. • UP.01.02.01: Mark the procedure site. • UP.01.03.01: A time-out is performed immediately prior to starting procedures. Applies to: Ambulatory, Critical Access Hospital, Disease-Specific Care, Hospital, and Office-Based Surgery Revised for 2009

21. Athens-Limestone Hospital The Patient Safety & Medical Error Reduction Team (PSMERT)“Our Patients, Our Partners – One Team, One Goal” The Patient Safety & Medical Error Reduction Team (PSMERT) meets monthly to pro-actively address potential concerns regarding the safety of our patients as they relates to MedicalErrors.

22. Patient Safety Initiatives PSMERT Oversees Include: • Failure Mode & Effects Analysis (FMEA)– A “process” is reviewed for potential failure modes annually and the Performance Improvement Team for that area of clinical care is assigned oversight of the adopted process improvement to assure compliance. • A Root Cause Analysis (RCA) is conducted during Sentinel Event Team meetings, and as needed, to determine the cause(s) of medical errors that have occurred. This is conducted in a non-punitive environment, designed to learn from mistakes and prevent their recurrence. • Implementation of the National Patient Safety Goals and general patient safety training is provided to each clinical employee annually. • 4. Our policy for Disclosure of Unanticipated Outcomes outlines the procedure for discussing medical errors with patients and their families. The physician is always informed first and explains what happened to the patient, according to policy.

23. Please take out your Patient Safety Quiz Directions: Please circle the letter next to the best response for each question… 1.  Athens Limestone Hospital’s accrediting organization is… A.      The Joint Commission (TJC). B.      The Alabama Hospital Association (AlaHA). C.      The American Hospital Association (AHA). D.      The Center for Medicare & Medicaid Services (CMS).

24. Patient Safety Quiz  2.A Sentinel Event is best defined as… A. Any patient event that is out of the ordinary.      B. Any unexpected occurrence resulting in a dissatisfied patient. C. Any event resulting in unanticipated patient death or major permanent loss of function. D. Any unexpected occurrence involving a visitor.

25. Patient Safety Quiz • 3.When a suspected Sentinel Event has • occurred, the first thing I must do is… • Call 911 • Notify my supervisor • Clock out and go home • Take appropriate action to care for the patient

26. Patient Safety Quiz • 4.How often does the Patient Safety & • Medical Error Reduction Team meet? • As needed • Annually • Monthly • Weekly

27. Patient Safety Quiz 5. What is ALH policy for addressing Unanticipated Outcomes? A. Deny that anything unusual has occurred. B. Invoke the Fifth Amendment and refuse to comment. C. Fully disclose unanticipated outcomes to patients and their families according to the guidelines set out in our “Disclosure of Unanticipated Outcomes” policy. D. Call 1-800-LAWYERS for advice.

28. Patient Safety Quiz 6. How may concerns for Patient Safety be reported at ALH? A. Call the compliance Hotline at 1- 800-442-0959 to report anonymously. B. Report concerns directly to my Patient Safety Officer. C. Contact TJC or CMS directly if not satisfied by ALH resolution of concerns. D. All responses are correct.

29. Patient Safety Quiz 7. Athens Limestone Hospital Patient Safety compliance initiatives include which of the following? A. Monthly meetings of the Patient Safety & Medical Error Reduction Team (PSMERT). B. Adherence to TJC’s National Patient Safety Goals. C. A proactive approach to preventing medical errors before they happen through Performance Improvement tools such as Failure Mode & Effects Analysis (FMEA) of complicated processes, Root Cause Analysis of medical errors, and continuing education. D. All responses are correct.

30. Patient Safety Quiz • The Joint Commission’s Patient Safety Goals for 2009 include which initiatives? • A. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. • B. Utilize a standardized approach to “hand-off” communications. • C. Identify safety risks inherent in our patient populations, such as suicide and falls. • D. All responses are correct

31. Patient Safety Quiz 9. Provisions for the Universal Protocol include which of the following practices? A. A pre-procedure verification process. B. Surgical site marking by the physician. C. Time Out immediately before starting a procedure, involving the patient in the process. D. All responses are correct.

32. Patient Safety Quiz 10. From where does The Joint Commission derive the National Patient Safety Goals? A. Common Sense B. State Law C. Federal Law D. Sentinel Event Alerts

33. Athens-Limestone Hospital The Patient Safety & Medical Error Reduction Team (PSMERT) “Our Patients, Our Partners – One Team, One Goal”