1. National Patient Safety Goals Summits and Patient Safety Solutions Peter B. Angood MD FRCS(C) FACS FCCM VP & Chief Patient Safety Officer The Joint Commission

2. © Copyright, The Joint Commission Things Going Bump in the Night… Standards  Leadership  Medical Staff  Emergency Management Standards Improvement Initiative Strategic Surveillance System Performance Measures – NQF Champions for Patient Safety

3. © Copyright, The Joint Commission Standards Requirements that define performance expectations with respect to structure, process, and outcomes that must be substantially in place in an organization to enhance the safety and quality for patient care Performance Expectations – the moving target

4. © Copyright, The Joint Commission The Joint Commission’s Sentinel Event Policy Established in January 1996 with the following goals:  To have a positive impact in improving care  To focus attention on underlying causes and risk reduction  To increase the general knowledge about sentinel events, their causes and prevention  To maintain public confidence in the accreditation process

5. Type of Sentinel Event#% Wrong-site surgery 62513.0% Suicide 59612.4% Op/post-op complication 56811.8% Medication error 4469.3% Delay in treatment 3607.5% Patient fall 2815.8% Assault/rape/homicide 1773.7% Patient death/injury in restraints 1763.7% Perinatal death/loss of function 1433.0% Unintended retention of foreign body ** 1412.9% Transfusion error 1132.3% Infection-related event 1002.1% Medical equipment-related 821.7% Anesthesia-related event 811.7% Patient elopement 761.6% Fire 721.5% Maternal death 701.5% Ventilator death/injury 501.0% Abduction 280.6% Utility systems-related event 240.5% Infant discharge to wrong family 70.1% Other less frequent types 60112.5% 4817 total

6. *This graph represents all RCAs reviewed and accepted in a particular calendar year. **Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007. *This graph represents all RCAs reviewed and accepted in a particular calendar year. **Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.

7. Sentinel Event Setting#% General hospital325067.5% Psychiatric hospital52010.8% Psych unit in general hospital2395.0% Behavioral health facility2214.6% Emergency department2064.3% Long term care facility1453.0% Ambulatory care1262.6% Home care881.8% Office-based surgery110.2% Clinical laboratory90.2% Health care network20.0% Sentinel Event Outcomes#% Patient death347870% Loss of Function4659% Other100220% Total patients impacted4945100%

8. © Copyright, The Joint Commission Root Causes of Sentinel Events (All categories; 1995-2004) Percent of 2966 events Average number of root causes cited per RCA = 3.1

9. © Copyright, The Joint Commission Root Causes of Sentinel Events (All categories; 2006) Percent of 516 events Average number of root causes cited per RCA = 5.3

10. © Copyright, The Joint Commission The Sentinel Event Advisory Group Assess data from the Sentinel Event Database Advise on future topics for Sentinel Event Alert Reach consensus on candidate NPSGs Assess practicality and cost of implementing each of identified evidence-based NPSG recommendations Assess comparability of alternatives to NPSG requirements that are implemented by individual organizations

11. © Copyright, The Joint Commission The Joint Commission 2008 National Patient Safety Goals 2008 Goals and associated requirements approved by Board of Commissioners June 1, 2007 Keep the focus—Limit expansion of new requirements in 2008 and beyond  High impact  Evidence-based  Cost-effective

12. © Copyright, The Joint Commission Moving from 2007 to 2008 One NEW requirement under Goal #3:  3E—Management of anticoagulant therapy One NEW goal:  Goal #16—Rapid response to changes in patient condition [Hospitals & critical access hospitals] One-year phase-in period for 3E and 16A Retire requirement 3B (see MM.2.20, EP #10) Compliance with WHO Hand Hygiene Guidelines will be acceptable for meeting requirement 7A

13. © Copyright, The Joint Commission 2008 National Patient Safety Goals 1.Patient identification 2.Communication among caregivers 3.Medication safety 7.Health care-associated infections 8.Medication reconciliation 9.Patient falls 10.Flu & pneumonia immunization 11.Surgical fires 13.Patient involvement 14.Pressure ulcers 15.Focused risk assessment (suicide; home fires) 16.Rapid response to changes in patient condition  Universal Protocol for Preventing WSS

14. © Copyright, The Joint Commission Goal #3: Improve safety of using medications Requirement #3E [AHC, HAP, CAH, LTC, OBS, OME] Reduce likelihood of patient harm associated with use of anticoagulation therapy NEW

15. © Copyright, The Joint Commission Managing Anticoagulant Therapy (1-5) 1.Defined anticoagulant management program 2.Unit dose (oral) and pre-mixed parenteral preparations 3.Dispense warfarin based on established monitoring procedures 4.Use protocols for anticoagulant therapy 5.Baseline and current INR monitoring Continued on next slide…

16. © Copyright, The Joint Commission Managing Anticoagulant Therapy (6-11) 6.Notify dietary service about patients on anticoagulants 7.Use programmable infusion pumps for continuous IV heparin 8.Policy for baseline & ongoing testing for management of heparin therapy 9.Anticoagulant education to staff & patients 10.Education includes … 11.Evaluate anticoagulant safety practices

17. © Copyright, The Joint Commission Requirement #16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to be worsening Goal #16: Improve recognition and response to changes in a patient’s condition

18. © Copyright, The Joint Commission 1.Select a suitable method 2.Develop criteria for summoning help 3.Empower staff, patients, families 4.Educate requesters and responders 5.Measure utility and effectiveness 6.Measure arrest and mortality rates Goal #16, Requirement #16A

19. © Copyright, The Joint Commission At 3 months—Assign responsibility At 6 months—Work plan in place At 9 months—Pilot testing under way At 12 months—Fully implemented Phase-in Milestones for 3E &16A:

20. Year NPSGFull surveys 1ATwo patient identifiers 1B"Time-out" before surgery (U.P.) 2ARead back verbal orders 2B"Do not use" abbreviations 2CReporting critical test results 2EHand-off communication 3AConcentrated electrolytes 3BStandardize drug concentrations 3CLook-alike/sound-alike drugs 3DLabel meds and solutions 4APre-op verification process (U.P.) 4BSurgical site marking (U.P.) 5AFree-flow protection on pumps 6AAlarm maintenance & testing 6BAlarm settings & audibility 7ACDC hand hygiene guidelines 7BHC-associated infection & RCA 8AMedication list & reconciliation 8BTransfer/discharge reconciliation 9AFall risk assessment 9BFall prevention program 13APatient involvement 15ASuicide risk assessment Hospitals 20032004200520062007 124915281,5731429958 3.8%4.1%4.7%8.1%2.9% 8.9%8.0%17.3%25.8%21.6% 7.4%8.2%12.3%15.7%4.4% 23.5%24.8%38.6%36.9%28.3% 9.5%26.9%35.4% 6.1%2.1% 3.0%1.9%1.4% 0.6%0.9%1.5%1.7%0.4% 2.4%7.4%4.5% 8.9%18.0% 1.5%5.4%4.5%2.9%1.0% 6.2%4.6%3.3%6.6%5.0% 0.3%0.1% 1.4%0.1% 2.1%1.7% 1.2%3.6%8.8%8.9% 0.1%0.0%0.1%0.0% 0.1%33.9%19.1% 0.3%27.5%11.4% 4.5% 6.5%5.7% 0.6% 2.2% Non-Compliance Data for 2003—07

21. © Copyright, The Joint Commission Sentinel Event Trends: Wrong-site Surgeries Reported by Year S. E. Alert # 6 August 1998 W.S.S. Summit I May 2003 S. E. Alert #24 December 2001 NPSGs January 2003 U.P.W.S.S. Summit II February 2007

22. © Copyright, The Joint Commission Wrong-Site Surgery Summit #2 Results:  Tentative consensus on -Universal Protocol is sound but does not go far enough -U.P. should be more prescriptive -U.P. should address “upstream” factors -Employ technology, where possible -Emphasize applicability to anesthesia procedures and non-OR settings  Discussion of “zero tolerance” & “campaign” strategy

23. © Copyright, The Joint Commission Medication Reconciliation Summit Sept. 25, 2007 - 85 organizations invited NPSG 8 is important but needs clarification Accuracy & reliability of the list vs reconciliation Next Provider issues Minimal-Use scenarios Inpatient & Outpatient Focus on systems & processes Focus on leadership and inter-professional teams Patient engagement and education

24. © Copyright, The Joint Commission 2009 National Patient Safety Goals 1.Patient identification 2.Communication among caregivers 3.Medication safety 7.Health care-associated infections 8.Medication reconciliation 9.Patient falls 10.Flu & pneumonia immunization 11.Surgical fires 13.Patient involvement 14.Pressure ulcers 15.Focused risk assessment (suicide; home fires) 16.Rapid response to changes in patient condition  Universal Protocol for Preventing WSS NO NEW NPSGs ! BUT…

25. © Copyright, The Joint Commission There are a few DRAFT Requirements & IEs… Requirement 1A; IE 7 (Patient Identification) Requirement 1C; IEs 1-3(Patient Identification) Requirement 7C; IEs 1-16 (Reduce HAIs - MDRO) Requirement 7D; IEs 1-13 (Reduce HAIs - CABSI) Requirement 7E; IEs 1-7 (Reduce HAIs - SSI) Requirements 8A-D + IEs (Med’n. Reconciliation) Requirement 13A; IEs 3-4 (Patient Involvement) Universal Protocol; Requirements 1A-1C

26. © Copyright, The Joint Commission Surveying and Scoring the National Patient Safety Goals All applicable Goals & Requirements, or acceptable alternative approach(es), must be implemented Evaluated in PPR and during all full accreditation surveys and “for-cause” surveys Surveyors evaluate actual performance, not just intent  Emphasis is on interviews with direct caregivers and direct observation of care delivery

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28. Joint Commission International Center for Patient Safety: Mission and Vision Mission The mission of the Joint Commission International Center for Patient Safety is to continuously improve patient safety in all health care settings. Vision To become the trusted resource for improving health care worldwide by providing pre-eminent solutions and expertise in patient safety.

29. © Copyright, The Joint Commission International Advisory Structure International Steering Committee European Advisory Group Middle East Advisory Group Asia Pacific Advisory Group Input from Latin America and Africa through WHO Focal Points Communications Expert Panel Medication Safety Expert Panel Patient and Family Advisory Group

30. © Copyright, The Joint Commission Definition of Solution Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.

31. © Copyright, The Joint Commission 2007 Solution topics (inaugural set) Look-Alike, Sound-Alike Medication Names Patient Identification Hand-Over Communications Wrong Site, Wrong Person, Wrong Procedure Surgery Concentrated Electrolyte Solutions Medication Reconciliation Catheter and Tubing Misconnections Single Use Devices Hand Hygiene

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33. Topics for Next Round of Solution Development Follow-up on Critical Test Results Patient Falls Healthcare Associated Infections – Central Lines Pressure Ulcers Response to the Deteriorating Patient Patient and Family Involvement Apology and Disclosure Look-alike Sound-alike Medication Packaging

34. © Copyright, The Joint Commission Action on Patient Safety: High 5s Project Goals To achieve significant, sustained, and measurable reduction in the occurrence of 5 patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative, standardized, safety operating protocols.

35. © Copyright, The Joint Commission High 5s Solution Topics Hand-over communications Wrong Site, Wrong Procedure, Wrong Person Surgery Medication Reconciliation Concentrated Electrolyte Solutions Hand Hygiene

36. © Copyright, The Joint Commission For more information: Joint Commission International Center for Patient Safety www.jcipatientsafety.org The Joint Commission Resources Web Site www.jcrinc.com The Joint Commission Web Site www.jointcommission.org