Patient Safety Curriculum Module 10: The National Landscape ...

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NPSG Background• The National Patient Safety Goals (NPSGs) were established in 2002(became effective January 1, 2003) to address specific areas ofconcern in regard to patient safety• The Joint Commission’s (TJC) mission is to “continuously improve thesafety and quality of care delivered to the public through the provisionof healthcare accreditation.”• The NPSGs have related specific requirements for improving thesafety of patient care in healthcare organizations.• TJC requires accredited healthcare organizations implement NPSGsas appropriate to the services provided by the organization. Allaccredited health care organizations such as Hospitals, AssistedLiving, Home Care, Behavioral Health Care, Disease-Specific Care,Ambulatory, Laboratory, etc., are surveyed to evaluate theimplementation of these goals as they relate to the services of theorganization.36NPSF Professional Learning Series
2011 Hospital NPSGs• There are six NPSGs for accredited hospital organizationsand a Universal Protocol.• 2011 revisions:• The Joint Commission revised four Elements of Performance (EPs) withinthe Goals.• The revised EPs are effective immediately.• NPSG #8 on medication reconciliation is not included in the changes;additional work is being done to evaluate and refine the medicationreconciliation expectations for accredited organizations.• Goal 14: The goal of preventing healthcare-associated pressure ulcers(decubitus ulcers) has now become a STANDARD!!• Goal 9: The goal of reducing patient harm resulting from falls has nowbecome a STANDARD!!37NPSF Professional Learning Series
Page 1 and 2: NPSF Professional Learning Series p
Page 3 and 4: Goals of this module• Upon comple
Page 5 and 6: “End result system of hospitalsta
Page 7 and 8: Patient Safety in the Popular Press
Page 9 and 10: The Cost Landscape• Per capita he
Page 11 and 12: Mounting Pressures for Transparency
Page 17 and 18: Regulatory Landscape17NPSF Professi
Page 19 and 20: Example of One Year of PotentialReg
Page 21 and 22: The Joint CommissionDPHCMSThe Regul
Page 23 and 24: Potential CMS CoP Findings• Condi
Page 25 and 26: Influences on the Joint CommissionS
Page 27 and 28: Customized Survey Process• Priori
Page 29 and 30: “Tracing” the Patient: Across S
Page 31 and 32: “Tracing” the Patient - Priorit
Page 33 and 34: Sample: Unannounced SurveySchedule
Page 35: National Patient Safety Goals(NPSGs
Page 39 and 40: Goal 8: Reconcile Medications• Ac
Page 41 and 42: Managing Regulatory Visits41NPSF Pr
Page 43 and 44: The Regulatory Survey CycleMonitorc
Page 45 and 46: Survey Preparations• Develop a re
Page 47 and 48: Opening Meetings• Getting off on
Page 49 and 50: Command Central (Bull Pen)• Large
Page 51 and 52: Exit Conference• At the exit conf
Page 53 and 54: Attributes of a Well ManagedRegulat
Page 55 and 56: Regulatory ReadinessPreparing for t
Page 57 and 58: Quality and Safety FrameworkQuality
Page 59 and 60: Culture: Communications Plan forSur
Page 61: Final Thoughts• B Teams with A Sy

Patient Safety Curriculum Module 10: The National Landscape ...

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