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NPSG compliance problems hospitals face now; where do you stack up?
Hospitals struggling with all NPSGs
The Joint Commission has put a one-year moratorium on its National Patient Safety Goals (NPSGs), as it reviews current goals with input from the field. One goal in particular, Goal 8 regarding medication reconciliation, will no longer be scored as part of the accreditation decision until a more refined goal is set forth in 2010.
So in what areas do the experts Hospital Peer Review spoke with still see hospitals struggling to comply? "I think they're struggling with many of the National Patient Safety Goals, but medication reconciliation was a particular hardship," says Grena Porto, RN, ARM, CPHRM, principal of QRS Healthcare Consulting Inc. in Hockessin, DE, who has worked with The Joint Commission's patient safety advisory group. "The universal protocol also continues to pose challenges for hospitals."
In 2003, when the NPSGs first were rolled out, they were pretty straightforward, she says. As they have progressed, though, they've "become more complicated, because all the 'low-hanging fruit' is gone. What is left is the hard stuff, like medication reconciliation," she says.
It is becoming more and more difficult to create a "one-size-fits-all goal," Porto says. For example, initially only KCI was cited as a concentrated electrolyte that had to be removed from patient care units. Later, all concentrated electrolytes were included in this. Then it was found that some units actually needed exceptions to this rule. Even the requirement for surgical-site marking — an apparent "no brainer" — presents a number of challenges to compliance and exceptions to the rule, Porto says. So, as the NPSGs have grown and the years have passed, she says, the NPSGs themselves are more complicated, and hospitals are struggling more and more.
The following are only some of the areas experts see hospitals struggling to comply:
• Medication reconciliation.
The No. 1 NPSG the experts cited as troublesome for hospitals was Goal 8 (accurately and completely reconcile medications across the continuum of care), and in a nod to this, The Joint Commission itself has taken this goal out of play in the accreditation decision and in generating any requirements for improvement. In compliance data posted on The Joint Commission's web site, compliance with the medication reconciliation goal has gone from 100% in 2005 to 81% in 2007 and 78% so far in compiled survey data from 2008.
"Hallelujah!" says Porto, of The Joint Commission's decision on the med reconciliation goal. It has been awhile in coming, she adds.
"[E]verywhere I go, they're struggling with it," and from her perspective, the compliance issue gets to the very core of the health care industry as it is now: fragmented. "It's because we don't have a real health system. Instead, we have a patchwork of providers, and none of the components speak to one another or even use the same language."
This, she says, is compounded, or perhaps caused, by two things: the fact there is no universal health record and the way the health care culture has cast the patient, in a very passive, nonproactive role. She thinks patients must be much more active in their own health care. "Even then it's a stretch," she says, "because the system is so fragmented.
"For medication reconciliation to work, the patient has to own the list. Because they're the only common denominator between all the health care settings and providers that the patient travels through," Porto says. "I think that's an example of a goal that people are really struggling with and that has failed as a goal just because there is not an infrastructure for it."
Unfortunately, neither patients nor health care in general are yet set up to see the patient as the active participant, Porto says. "When you look at what percentage of patients have all of their updated information, even ask for it or care about it or display any interest in it, it's a real minority."
Does she carry a list of medications for herself? No, she says, laughing. She compares this to the push for advance directives. Health care has been pushing people for 20 years to have advance directives in order, but still only a small minority of patients have them, she says.
Following a theoretical patient through the hospital, she says, the first problem with med reconciliation occurs upon admission when the patient is asked what medications he or she is on. Often, they might not know the name or dose of the drug. For instance, Porto says, they might just say, "I take a heart pill."
So, she says, you start off with an incomplete list. Often, it's the emergency department that bears the brunt of this. A patient comes in, doesn't know his or her medications, but the ED is required to treat the patient upon presentation.
Then the ED patient is admitted to a floor, and the admitting nurse, an already overburdened employee, Porto says, must get the patient's medications from a primary care physician. Then the physician has to deal with HIPAA issues and not being able to give the medications over the phone. Also, the patient could be seeing other providers in addition to his or her PCP, so even the PCP might not have a complete list of the patient's medications.
"The system of multiple, unaffiliated providers who don't communicate means that there's really no way for anyone other than the patient to know what a patient is taking. And then there's the whole issue of patients not being complete or truthful — either intentionally or unintentionally they leave stuff out. Now you're relying on the memory of the patient, and that's not always so good. It's kind of a huge big mess no matter how you slice it," Porto says.
There's a lot of work involved with med reconciliation, and it's a cumbersome process, says Kathleen Catalano, RN, JD, director of healthcare transformation support for Perot Systems Corp. in Plano, TX. She suggests hospitals "literally need to walk through the whole process and look at the handoffs, just like we do with everything to see where the problems are."
Getting all the information together is a tough job, she says, and who's responsible for keeping the medication sheet up to date: the nurse, the pharmacist?
• Handoff communication.
Inherent in the medication reconciliation problem is the problem of active handoff communication.
"The big struggle" with medication reconciliation "is really the transfer between the units and then if [the patient is transferred out] to another level of care and then transferred back in," says Darla Farrell, RN, BS, FACHE, CPHQ, who consults with hospitals on Joint Commission-related compliance and mock surveys and works in the compliance department of Kindred Healthcare.
She says hospitals using electronic medical records are having an easier time with med reconciliation, adding, "I think it's the level of sophistication of the technology that the hospital has. Because I'm finding that hospitals that have a higher level of sophistication in their IT departments are finding it much easier to accomplish."
But Catalano says many hospitals are not making handoff communication documentation regarding the patient's care and medications part of the medical record. "It doesn't say it has to be documented. But I don't know how you prove you've done something if you don't have it documented," she says.
• "Time-out" before surgery.
"The whole pre-op time-out, surgical site marking... There is still pretty significant non-compliance with that," says Porto. And according to compliance data on The Joint Commission's web site, compliance was at 91% in 2003 and 78% in 2007.
The actual requirements are "eminently doable" and "pretty straightforward;" the challenge is simply a behavioral one, she says. One area she hears discussion about is cases of multiple procedures by multiple surgeons. For instance, if the patient is first going to be operated on by an orthopedist and then later a plastic surgeon, "how do you do the time out? You're supposed to have all of those people there at the same time, and that gets difficult from a logistics perspective."
• Two patient identifiers.
The problem with the goal on patient identifiers is not identifying the identifiers, but rather the fact that the identifiers are not checked every time. Ode Keil, MS, MBA, president of Ode Keil Consulting Group, which specializes in preparing organizations for Joint Commission accreditation, says when the bedside nurse visits Joe Smith to give him his medication, he or she often may not check the wristband or follow the mechanics of the NPSG.
"I think there's some reasonableness to the argument that the guy has been there for three days; he hasn't changed," Keil says. "But [the nurse] is supposed to check the medication administration record, the physician orders, to make sure it's the right med, the right dose, the right time, the right method of administration."
• Hand hygiene.
Another area in which Keil sees a lot of noncompliance is hand hygiene. "Hospitals are struggling to balance out the desire of infection control to put some sort of hand-cleaning compound every inch or two along the corridor walls according to fire safety code in terms of the amount you can put in a given area. I hear that a lot in terms of compliance," he says.
The real struggle is not logistics, but behavior. "It doesn't matter how many cans or bottles of the hand sanitizer you put out; if people don't push the pump or squirt the little ball of foam into their hands, it isn't good for anything," he says.
• Anticoagulation therapy.
Farrell says she sees hospitals struggling with anticoagulant therapy. Where exactly are they falling short? Education of the patient and family members and updating the plan of care as the patient's needs change, she says.
• Reporting critical test results.
Compliance numbers shared by The Joint Commission on this goal have slipped from 90% in 2005 to 64% in 2007. Farrell says the challenge for many facilities she sees is the identification of the critical test. Hospitals "have the values and they're reporting their time limits," she says, "but they have not identified the critical test." She says she has seen this in "at least 75% to 80%" of the policies she reviews.
The real deal? When it comes to NPSGs, Keil says, hospitals are having problems with all of them.