Analysis of current version of implementation expectations



JCAHO 2007 National Patient Safety Goals … Hospital Version

Analysis of implementation expectations

Revised July 7, 2006

When JCAHO released the 2007 implementation expectations for the National Patient Safety Goals (NPSGs) there were a surprising number of changes to existing requirements. Some of these changes were intended by JCAHO and will remain. We believe other changes were unintentional and should be corrected by the end of the year.

In this analysis: ( means we see no substantial change; ( means this change may make compliance easier; ( means this change may make compliance more difficult.

JCAHO requirements in this analysis are paraphrased. The official wording of the 2007 performance expectations is posted on the JCAHO web site () and published in July’s “Perspectives.”

General Format Changes … Relaxed scoring, clearer expectations

The format of the national patient safety goals will become the same as other standards in the manual:

← Each sub-goal (e.g.2A, 3B, 8A) becomes its own standard.

Implications:

Currently a problem of any kind with a NPSG (e.g. medication reconciliation) leads to only one RFI. In the future, there could be a separate RFI for each sub-goal. This could mean an increase in the overall RFI count.

← Each sub-goal will have elements of performance, just like other standards in the manual.

← We have been told that the same rules apply to NPSG elements of performance as apply to the elements of performance for other standards.

Implications:

Some problem prone goals will not be as strictly scored. One observation for a Category C EP is still full compliance. 2 observations constitute partial compliance. It takes 3 or more observations to trigger non-compliance. Also, a hospital can clarify or clear a Category “C” by sampling: 90% is full compliance; 80% is partial compliance, which is sometimes good enough.

Caution: JCAHO still has plenty of time to change its mind in case leadership decides 80% should not be good enough.

1A: Use of 2 identifiers … Scoring relaxed; “treatments” overlooked (for now)

EP.1 (Category C) requires the in practice use of two patient identifiers for the administration of medications or blood products and for specimen collection.

Implications:

← The EP does not require the use of 2 identifiers for treatments. We believe this is an unintentional change from the current requirement which will be corrected before the end of the year. Stay tuned!

← Full Category C rules apply. Partial compliance is good enough because there are 3 or more EPs.

EP.2 (Category A) Room numbers may not be used as one of the 2 required patient identifiers.

Implications:

← No change.

EP.3 (Category C) Specimen containers must be labeled in the presence of the patient.

Implications:

← Although JCAHO argues otherwise, in our opinion this is a new requirement for hospitals. This requirement was part of the laboratory goals in 2006, but will be included in the 2007 hospital goals.

← Full Category C rules apply. Partial compliance is good enough because there are 3 or more EPs

2A: Read Back … Relaxed scoring; an avoidable trap

EP.1 (Category C) The receiver of a telephone or verbal order or test result must transcribe the information onto a piece of paper or directly into a computer.

Implications:

← This is no change from the current expectation.

← Full Category C rules apply. Partial compliance is good enough because there are 3 or more EPs

EP.2 (Category C) The receiver must read the transcribed order or test result back to the transmitter.

Implications:

← This is no change from the current expectation.

← Full Category C rules apply. Partial compliance is good enough because there are 3 or more EPs

EP.3 (Category C) There must be a confirmation from the transmitter that the information is correct.

Implications:

← This is a change from the actual goal, but this expectation for confirmation was in the FAQs published February of 2006. We do not see this as a substantive change.

← Full Category C rules apply. Partial compliance is good enough because there are 3 or more EPs

Please avoid the documentation trap: There is and never has been a requirement that you document the order and result read back process. We suggest you NOT require that staff members document the read back process for the following reasons:

a. There is no correlation between the documentation of the read back process and the actual execution of the read back process. Some staff members document the read back but do not do it correctly (if at all), while others read verbal transactions perfectly, yet neglect to check the box.

b. Successful implementation of this goal requires concurrent observations and ongoing, real-time feedback.

c. JCAHO does not require that you monitor rates of this goal. (Some require documentation so they can collect compliance rates.)

d. If you require documentation of read back, JCAHO will expect compliance with your policy. And even though scoring has been relaxed, there is no reason to stand in the way of this particular bullet.

2B: Prohibited Abbreviations … Relaxed scoring; unclear wording

EP.1 (Category A) The organization is required to develop a list of abbreviations, acronyms, symbols, and dose designations that may not be used.

Implications:

← This is no change from the current expectation.

EP.2 (Category A) The list of unapproved abbreviations must include U, u, IU, Q.D. QD, q.d., qd, Q.O.D., QOD, q.o.d, qod, trailing zero (X.0 mg), lack of leading zero (.X mg), MS, MSO4, and MgSO4.

Implications:

← This is no change from the current expectation.

← IMPORTANT: You are not required to add to this list. We strongly suggest that you not include additional items. If you included them in the past, take them off. (You can discourage the use of certain abbreviations without prohibiting them.)

EP.3 (Category C) Prohibited abbreviations are not used in all handwritten orders and medication-related documentation (free-text entries into a computer are considered hand-written).

Implications:

← Category C rules apply. In 2007 you will only need 80% compliance to clarify or clear this issue. (Today you need 90% or better.) [Remember: this may change before the end of the year, so stay tuned.]

← TIP: some hospitals use the medication reconciliation form to eliminate some abbreviations. For example, the pre-print “use ____ daily” so the physician can indicate once, twice, X3, etc.

EP.4 (Category A) Pre-printed forms do not include any prohibited abbreviations.

Implications:

← We think JCAHO means any “medication-related entries on pre-printed forms”, but they don’t actually say that. If that is what they mean, there is no change. If they mean to apply this requirement to all entries on all forms, there may an increase organizational vulnerability. (Since this is a category A EP, it only takes one unapproved abbreviation out of a million pre-printed form entries to trigger an RFI.)

2C: Critical Tests and Critical Values … some things clearer; one thing unintentionally left out

EP.1 (Category A) The organization defines critical tests and critical results/values

Implications:

← This is no change from the current expectation. To help with your definition:

⇨ A critical test is a STAT test

⇨ A critical result/value is a panic value for any test or study. The list of panic values is shorter than the list of values considered critical by the laboratory. Also, don’t forget imaging, cardiology and pulmonary function testing.

← Although these are not new requirements, they have not been as clearly stated in the past. We expect surveyors to learn from this new language and do a better job of applying current expectations.

Figure 1: JCAHO requires that you define (a) acceptable time frames for critical tests and (b) acceptable time frames for physician notification of critical values or results from any test. This illustration imagines the laboratory testing process. Slightly different steps are usually involved in other testing modalities, such as imaging, cardiology or pulmonary function testing. The interval for critical (STAT) testing [A] is from order to reporting. Because the time it takes to do the test and access to testing equipment varies, so will acceptable targets for performance. The interval for critical values / results [B] is from availability of the result to notification of the provider. We recommend that this be a single target rather than to vary by test. However, it is essential that you hone down the list so that only the truly critical values are subject to this target (for example 1 hour or 30 minutes). Note that some intervals not commonly collected (e.g. order to intake and report to provider) must be accurately collected to comply with this goal.

EP.2 (Category A) The organization defines the acceptable length of time between the ordering of critical tests (e.g. STAT tests) and reporting the test results and values

Implications:

← This is no change from the current expectation. Remember, you need to define the acceptable length of time from Order to Reporting. Provider (responsible licensed care giver) notification is not part of this interval. Different tests will have different acceptable time frames.

← Remember to narrow the list of STAT testing to those that are truly critical. You may decide to have both “STAT” testing (for critical tests) and “NOW” testing for others. You want to avoid “STAT creep,” the phenomenon that over time all testing tends to become STAT. In short: don’t set yourself up.

EP.3 (Category A) The organization defines the acceptable length of time between the availability of critical results/values (i.e. “panic” values) and receipt by the responsible licensed care giver (physician).

Implications:

← This is no change. This element of performance requires that you establish an acceptable time (30 minutes? 1 hour?) from the availability of a panic value to notification of the responsible provider. We recommend that the time frame you set is the same for all panic values and critical test results.

EPs.4, 5 and 6 (Category A) The organization must now collect and analyze date and, if necessary, take actions to improve the timeliness of panic value reporting (result availability to provider.

Implications:

← This is no change. It is interesting that the standards to not currently require the analysis and improvement of STAT testing turn-around times, but we think this was an oversight. The current FAQ seems to require it (although the wording is less than ideal) and JCAHO may change the working of EP.4 to include “critical tests”. Bottom line: we recommend that you have data for both critical values and critical tests.

2E: Standard Content for Handoffs … clear expectations; relaxed scoring

EP.1, EP.2, EP.3 and EP.5 (Category C) The handoff process is (1) interactive, (2) includes up-to-date information, (3) includes a way of verifying important information such as read back or repeat back, and (5) has limited interruptions.

Implications:

← Full Category C rules apply. Partial compliance is good enough for one of these EPs.

EP.4 (Category A) The handoff process includes an opportunity for the receiver to review relevant patient historical data, which may include previous care, treatment and services.

Implications:

← No change.

3B: Limited Concentrations … evolving and unclear expectations

EP.1. (Category A) Drug concentrations are standardized throughout the organization.

Implications:

← Since no one is sure that this means, it leaves a lot up to the judgment of the individual surveyor and whoever picks up the telephone at the Standards Interpretation Group. This is not a change for this unfortunately unclear expectation, which sanctions broad “second guessing.”

← According to the February, 2006 FAQ, surveyor are currently instructed to only review internally-compounded IV / parenteral infusions of “high alert” medications, including concentrated electrolytes, cardioactive drugs, pressors, and antihypertensives. Nevertheless, we frequently see this requirement used to critique the number of concentrations of commercially manufactured medications such as epinephrine in crash carts.

EP.2. (Category A) When more than one concentration is necessary, the number of concentrations is limited to the minimum required to meet patient care needs.

Implications:

← Who decides how many concentrations are required?

← The Greeley Company Recommendation: Standard MM.7.10 / 1 requires the hospital to list what it thinks are high alert / high risk medications. Use this list to your advantage.

(a) Include which concentrations of high alert / high risk mediations are used within the hospital.

(b) Whenever more than one concentration is listed, indicate why additional concentrations are clinically indicated (physician preference is not an acceptable reason).

(c) Either discontinue using the Rule of Six in the NICU now or get a written request for exception approved by JCAHO. We have no reason to believe the Rule of Six will be allowed past 2008.

3C: Look Alike / Sound Alike … something forgotten

EP.1. (Category A) A list of 10 look-alike, sound-alike pairs must be selected.

Implications:

← Whoops: the Joint Commission forgot to specify that your list must be selected from the lists published on the JCAHO web site. We expect this oversight to be corrected before the end of the year. Please continue to use JCAHO’s lists to select your 10 pairs.

EP.2. (Category A) Review your list of look-alike/sound-alike drugs at least annually.

Implications:

← No change. We recommend that the review be documented in the minutes of the Pharmacy and Therapeutics Committee (or equivalent).

EP.3. (Category A) Actions must be taken to prevent errors involving the interchange of these drugs.

Implications:

← No change. A single deviation from your actions related to your pairs can result in a valid RFI. (Note that there are a lot of invalid RFIs issued for this NGSG.)

← Some surveyors like to impose the actions they would take if they ran your hospital. For example, the surveyor may not think storing different types of insulin on the same shelf or in the same tub is a good idea. However, you get to choose which medications are on your list (you many not have chosen insulin) and you get to choose what measures are taken related to those medications (you may think storing the vials together is OK).

← You are expected to base your actions on JCAHO’s recommended actions (found on JCAHO’s web site) and recommendations from other organization (such as the Institute for Safe Medical Practices). But, in the end, you get to choose which actions you will and will not take. We suggest that you document the consideration of any JCAHO and ISMP recommendations during the annual review required in EP.2.

← REMEMBER that your actions should be hospital-wide. For example: you will be at risk if you choose to separate certain look-alike, sound-alike pairs but only implement separate storage in the pharmacy.

3D: Labeling Secondary Containers … still a little unclear

The new implementation expectations do not specify the settings in which this goal applies. However, we are told that the language will be clarified and that the intent is that the requirement pertain to the peri-procedural setting (pre-, intra- and post procedure areas): it applies to surgery and other high risk procedures whether they’re done in a special procedure room or at the bedside. It does not apply to medication administration that is not associated with a high risk procedure. Stay tuned for definitive word from JCAHO.

However, remember that MM.4.30 addresses the requirement for labeling of secondary containers in the non-high risk setting. Although the goal only addresses procedural settings, your processes should consider the use of all secondary containers.

EP.1, EP.2 and EP.3. (Category A) Medications and solutions are labeled when transferred from the original package with drug name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.

Implications:

← No change.

← This labeling need not occur then the person transferring the mediation will immediately administer the medication (FAQ, Feb, 2006)

EP.4. (Category C) When the person preparing the medication is not the person administering the medication, a verbal and visual verification process occurs.

Implications:

← No change in the expectation.

← Full Category C rules apply.

EP.5 and EP.6. (Category A) Only one medication is labeled at a time and medications or solutions found unlabeled are immediately discarded.

Implications:

← No change.

EP.7. (Category C) Original containers remain available until the conclusion of the procedure.

Implications:

← No change in the expectation.

← Since this is now scored as a “C”, 80-90% performance reflects overall compliance with the standard (NPSG).

EP.8. (Category A) All labeled containers on the sterile field are discarded at the conclusion of the procedure.

Implications:

← No change.

← Although the wording is unclear, we’ve been informed that there is no intentional change. If a reusable container (e.g. stainless steel basin) is used, then only the contents and the label need be discarded; the container itself may be reprocessed.

EP.9. (Category C) All medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting personnel at shift change or break relief.

Implications:

← No change in the expectation.

← Since this is now scored as a “C”, 80-90% performance reflects overall compliance with the standard (NPSG).

7A: Hand Hygiene … stricter scoring?

EP.1. (Category C) The hospital must comply with category 1A, 1B and 1C hand hygiene guidelines of the Centers for Disease Control and Prevention (CDC).

Implications:

← No change.

← This goal may be scored harder than in the past. Because there is only one element of performance, 2 observations is partial compliance and enough to trigger an RFI (compared to 3 observations allowed by the current FAQ). 90% compliance would continue to be required to clear the issue, again because there is only one EP.

7B: Infection Related Sentinel Events … relaxed scoring?

EP.1. (Category C) A root cause analysis is done for unanticipated deaths or major permanent loss of function that are associated with health care-associated infections

Implications:

← No change in requirement.

← A single observation is no longer enough to trigger an RFI: there must be 2 observations for partial compliance or 3 or more for non-compliance. However, either will result in an RFI because there are only 2 elements of performance. It also takes 90% compliance to clear or clarify the RFI.

← This is a strange construct for this requirement: the expectation that a root cause analysis be performed is a C but the scope of the analysis is an A. This logic may drive a change before the end of the year.

EP.2. (Category A) Any root cause analysis addresses the management of the patient before and after the identification of infection.

Implications:

← Clarified wording, but the requirement is essentially the same.

8A: Reconciliation of Medications throughout the Patient’s Stay … relaxed scoring

EP.1. (Category C) The organization, with the patient’s involvement, creates a complete list of the patient’s current medications at admission/entry.

EP.2. (Category C) The medications ordered for the patient while under the care of the organization are compared to those on the list and any discrepancies (e.g., omissions, duplications, potential interactions) are resolved.

Implications:

← No change in requirements assuming the FAQs published in February, 2006 still pertain.

← A single observation is no longer enough to trigger an RFI: there must be 2 observations for partial compliance or 3 or more for non-compliance. However, either will result in an RFI because there are only 2 elements of performance. It also takes 90% compliance to clear or clarify the RFI.

8B: Reconciliation of Medications at Discharge … relaxed scoring; unclear expectation

← A single observation under either EP is no longer enough to trigger an RFI: there must be 2 observations for partial compliance or 3 or more for non-compliance. There may be partial compliance at one EP as long as neither of the other 2 EPs is at partial or non-compliance.

← There are no changes in expectations.

EP.1. (Category C) The patient’s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside the organization.

Implications:

← No change in requirements assuming the FAQs published in February, 2006 still pertain. .

EP.2. (Category C) The next provider of service should check over the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed.

Implications:

← This has changed from a general principle to a scored element of performance. It is unclear that the hospital has any control whatsoever on the next provider, and therefore how it can implement the requirement.

EP.3. (Category C) The complete list of medications is also provided to the patient on discharge from the facility.

Implications:

← No change.

9B: Falls Program … relaxed scoring; new and unclear expectations

EP.1 and EP.3 (Category A) There is a fall reduction program includes interventions to reduce the patient’s fall risk factors

Implications:

← No change.

EP.2. (Category C) Patients are evaluated for fall risk as appropriate to the patient population.

Implications:

← No change. The February, 2006 FAQs and the wording of the EP would allow the individual assessment of some patient populations.

← Intentionally or not, JCAHO has not included the requirement for periodic environmental assessment for fall risk (2006 FAQs).

← Full “Category C” scoring rules apply.

EP.4. (Category C) Staff receive education and training in the fall reduction program.

Implications:

← New requirement.

← Full “Category C” scoring rules apply.

EP.5. (Category C) The patient and their family are educated on the fall reduction program and on strategies to reduce their (or their family members) fall risk.

Implications:

← No change.

← Poorly worded requirement that unintentionally includes ALL patients and ALL family members. We trust that the currently unwritten “as appropriate” becomes part of the element of performance.

EP.6. (Category A) The effectiveness of the fall program is evaluated. Outcome indicators such as decreases in the number and severity of falls “could be used.”

Implications:

← No change. Note that the use of indicators is not required, but suggested.

13A: Reporting Safety Concerns … new but not difficult

EP.1. (Category C) Patients and families are educated on methods available to report concerns related to care, treatment, services and patient safety issues.

Implications:

← New.

← We recommend that you consider using a patient safety brochure that includes reporting concerns of any kind, including concerns over their safety, to any care giver. If they do not get satisfaction or do not want to report the issue to their care given, then give them a easy to use complaint or concern line. This brochure can also cover the hospital’s grievance procedure (see APR 8 below).

← “Category C” scoring rules apply, but since there is only one element of performance, partial compliance (2 observations or 80% performance) will result in an RFI

APR 8: Complaining to JCAHO … a new twist on an old requirement

Published in the June 2006 Perspectives, the additions to APR 8 are a logical extension of (but are separate from) NPSG 13A. This expectation was in the “rationale” before, but was not actually a requirement until June, when it was moved to the elements of performance. (Remember, rationale statements are not enforceable requirements.)

EP.1. (Category A) The public must be encouraged to contact management if there are any concerns about patient care and safety that are not addressed. If the concerns cannot be resolved using the organization’s process, the hospital must encourage the individual to contact JCAHO.

Implications:

← The part about encouraging a dissatisfied complainant to contact the JCAHO is new.

← Presumably, a single instance where this Category A requirement is missed could result in an RFI

← There is a natural synergy between this and the Medicare patients rights standards related to grievances.

15A: Assessing Suicide Risk … new but not difficult; poorly worded

This requirement only applies to behavioral health care hospitals or units and other settings within general acute care hospitals were patients may be seen for emotional or behavioral disorders (for example, the emergency department).

EP.1. (Category C) Patients being treated for emotional or behavioral complaints or disorders are assessed for risk for suicide, including any specifics that may increase suicidal risk.

Implications:

← New.

← Full Category C rules apply.

← Most units already have such elements of assessment in place. This should not be anything new.

EP.2. (Category C) Steps are taken to reduce any risk of suicide (when assessed) by making sure the patient is in the most appropriate setting and receives appropriate care

Implications:

← New.

← The requirement itself is very poorly worded. We assume our paraphrasing catches the intent, but surveyors and the standards interpretation group could draw different (and widely varying) interpretations.

← Full Category C rules apply.

EP.3. (Category C) The organization provides crisis hotline information to patients and families in the event of a crisis.

Implications:

← New.

← The requirement itself is very poorly worded. We have been told that JCAHO means that, upon discharge, patients who were assessed to be at risk for suicide are given recourses for crisis intervention.

← We have been informed that the hospital does not have to provide a crisis hotline directly, but may give the patient and family community resources.

← Full Category C rules apply.

Universal Protocol 1A: Pre-procedural Verification … relaxed scoring

EP.1. (Category C) Verification of the correct person, procedure, and site should occur during the following (as applicable): (a) at the time the surgery/procedure is scheduled; (b) at the time of admission or entry into the facility; (c) anytime the responsibility for care of the patient is transferred to another caregiver; (d) if possible, with the patient involved, awake and aware; and (e) before the patient leaves the preoperative area or enters the procedure/surgical room.

Implications:

← Limited Category C rules apply. Partial compliance will lead to an RFI because there are only two elements of performance. The EP is in full compliance if no more than one deviation is observed per bullet (a through e).

← We’ve never met anyone with a good method of verifying person, procedure and site at the time of scheduling.

← There is no change in the wording, but it has proven unclear.

EP.2. (Category C) Before the start of the procedure (a) relevant documentation, including the history and physical examination, is reviewed; (b) images are labeled and displayed; and (c) special equipment and any required implants are reviewed.

Implications:

← Limited Category C rules apply. Partial compliance will lead to an RFI because there are only two elements of performance.

← No change in requirement.

Universal Protocol 1B: Site marking … relaxed scoring

The following are Category C requirements:

EP.1 The mark should be on the operative site unless clinical reasons indicate otherwise.

EP.3 The mark must be visible after the patient is prepped and draped.

EP.5 Sites should be marked in cases involving laterality, multiple structures, or multiple levels. For spine surgery: both a skin mark of the general spinal region and intraoperative radiographic techniques are required.

EP.6 The person performing the procedure should mark the site.

EP.7 The marking should take place with the patient awake, alert and aware, when possible.

Implications:

← Full Category C rules apply. Because there are 7 elements of performance, two of the above may be at partial compliance (2 observed deviations or 80% compliance to clarify or clear).

← No change in requirement.

The following are Category A requirements:

EP.2 The mark must be unambiguous.

EP.4 The method of marking and type of mark should be consistent throughout the organization

Implications:

← No change in requirement.

Universal Protocol 1C: Time Out … slightly relaxed scoring

EP.1 (Category A). The time out must occur in the location where the procedure will be done, just before starting the procedure

Implications:

← No change in requirement.

EP.2 (Category C) The process must involve the entire operative team, use active communication, and must address (a) the identify of the patient, (b) side and site, (c) procedure to be done, (d) patient position, (e) availability of correct implants and special equipment

Implications:

← Full Category C rules apply.

← No change in requirement.

EP.3 (Category A) The time out should be documented. The documentation should be brief and may be a check list or may be any other type of documentation determined by the organization.

Implications:

← No change in requirement.

EP.4 (Category A) There should be a process for reconciling differences in staff response.

Implications:

← No change in requirement.

← Be sure to address how differences are reconciled in a brief policy.

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Consulting tel 888/749-3054 fax 781/639-0085 | Seminars tel 800/801-6661 fax 800/738-1553

200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 |

Consulting tel 888/749-3054 fax 781/639-0085 | Seminars tel 800/801-6661 fax 800/738-1553

JCAHO requirements are paraphrased. Please refer to the JCAHO web site for the exact wording of the requirements and for official interpretations.

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