Updates on activities for 2009
Over the next year, the current National Patient Safety Goals will undergo an extensive review process; as a result, there will be no new NPSGs developed for 2010. The Joint Commission and the Patient Safety Advisory Group (PSAG, formerly the Sentinel Event Advisory Group), which helps develop the NPSGs, have heard from the field and determined that now is the time to look at current NPSGs and review the process for development of NPSGs. Some of The Joint Commission’s most visible and effective requirements, the NPSGs highlight serious patient safety issues that need to be addressed by health care organizations. Compliance with the NPSGs is a critical and demanding part of the accreditation process. NPSGs have evolved over time, becoming more specific and detailed in some cases, and therefore require more time and resources to implement. The field is struggling to meet some of the current NPSGs.
The success of the Standards Improvement Initiative (SII) demonstrated a way to thoroughly review the current NPSGs. The SII process will be used to clarify language, ensure that NPSGs are program-specific, delete NPSGs that are redundant or non-essential in specific programs, and consolidate similar NPSGs. The SII process also incorporates feedback from health care organizations and other stakeholders nationwide. The review process includes a baseline survey, review of potential changes by the PSAG and the Standards and Survey Procedures (SSP) Committee, and final approval by the Board of Commissioners. Revisions to the NPSGs based on SII recommendations will be effective in 2010. The Joint Commission will continue to work with the PSAG and the SSP throughout 2009 to review and refine the process for future NPSG development.
Development of the Goals
The Joint Commission established its National Patient Safety Goals program in 2002 and the first set of Goals was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety. The development and annual updating of the NPSGs is overseen by an expert panel of widely recognized patient safety experts, as well as nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Each year, the Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group) works with Joint Commission staff to undertake a systematic review of the literature and available databases to identify potential new NPSGs. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other parties of interest, the advisory group determines the highest priority NPSGs and makes its recommendations to The Joint Commission. In order to maintain the focus of accredited organizations on the most critical patient safety issues, the Patient Safety Advisory Group may, as part of its annual review, recommend the retirement of selected NPSGs.
The Patient Safety Advisory Group is charged with reviewing draft patient safety suggested actions for potential publication in The Joint Commission’s Sentinel Event Alert patient safety advisory. The Group also advises The Joint Commission as to the evidence for and face validity of these suggestions, as well as their practicality and cost of implementation. The Advisory Group’s recommendations for annual NPSGs are forwarded to The Joint Commission’s Standards and Survey Procedures Committee (SSP) and Board of Commissioners for approval prior to the year in which they are to be implemented. All Joint Commission accredited health care organizations and the Disease-Specific Care certified programs are surveyed for implementation of applicable NPSGs—or acceptable alternatives—as appropriate to the services the organization or program provides.
Submitting alternative approaches
An alternative approach to a NPSG must be accepted by The Joint Commission based on the Patient Safety Advisory Group’s review and recommendation that it is at least as effective as the published NPSG in achieving the NPSG. Organizations that wish to submit alternative approaches to the NPSGs can do so by filling out a “Request for Review of an Alternative Approach to a NPSG Requirement” form. The form and instructions for submitting it are available online. Members of the Patient Safety Advisory Group review and advise The Joint Commission on the acceptability of the alternative. If not accepted, the organization will be provided with the rationale and will need either to revise the alternative until it is approved, or to implement the NPSG as issued by The Joint Commission. Surveyors will accept organizations’ use of approved alternatives and will evaluate the implementation of those alternatives and other relevant NPSGs.
The National Patient Safety Goals for each program and more information are available on The Joint Commission Website.
Questions can be sent to the Standards Interpretation Group at (630) 792-5900 or via the Standards Online Question Submission Form.
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