Updates on activities for 2009
During 2009, the National Patient Safety Goals underwent an extensive review process. As a result, The Joint Commission has revised the 2010 National Patient Safety Goals. The changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific and detailed over time. The revisions include clarifying and streamlining certain elements of performance, as well as deleting some requirements and moving others to the standards. For the remainder of 2009, during the on-site survey, surveyors will not evaluate compliance with the requirements that have been deleted. Other changes will be effective January 1, 2010. The changes to the NPSGs reflect The Joint Commission’s continuing efforts to focus the NPSGs on those topics that are of highest priority to patient safety and quality care. Decreasing the number of NPSGs allows organizations to focus their efforts on the most important issues. Moving a requirement to the standards means that it is no longer necessary to “spotlight” the issue in the NPSGs. The improvements are similar to the Standards Improvement Initiative (SII), which the standards have undergone, and the goal of the improvements is to clarify language and ensure relevancy to the settings in which they apply.
The NPSG 8 on medication reconciliation is not included in these changes as additional work is being done to evaluate and refine the medication reconciliation expectations for accredited organizations. Early this year, The Joint Commission took action to reduce the burden of the NPSG on medication reconciliation for organizations. Effective January 1, 2009, NPSG 8 continues to be evaluated during the on-site survey, but survey findings are not factored into the organization’s accreditation decision and Requirements for Improvement (RFIs) are not generated. The Joint Commission is conducting research on this NPSG, including literature reviews, focus groups, and interviews with experts. A revised version of the NPSG is expected to be available for field review in early 2010, and for Standards and Survey Procedures Committee approval in the spring of 2010. In addition, based on the recent decision to limit Disease-Specific Care certification to programs in Joint Commission accredited organizations only, the parent organizations of DSC programs will be responsible for making sure that the DSC program meets applicable NPSGs. The DSC program will no longer have its own set of NPSGs.
While no new NPSGs have been developed for 2010, on January 1, 2010, organizations will be expected to have fully implemented the requirements related to health care-associated infections (which were established with the 2009 NPSGs). Currently, The Joint Commission is reviewing the role of NPSGs and how they are developed. See the 2010 NPSGs on The Joint Commission Web site.
Development of the Goals
In 2002, The Joint Commission established its National Patient Safety Goals program and the first set of NPSGs 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 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 and Board of Commissioners for approval prior to the year in which they are to be implemented. All Joint Commission accredited health care organizations are surveyed for implementation of applicable NPSGs—or acceptable alternatives—as appropriate to the services the organization 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. 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 Web site. Questions can be sent to the Standards Interpretation Group at (630) 792-5900 or via the Standards Online Question Submission Form.