Joint Commission 2021 Hospital National Patient Safety Goals

Laura A. Dixon

Laura A. Dixon

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role,...
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Laura A. Dixon

This webinar will cover the Joint Commission 2021 National Patient Safety Goals (NPSGs) for Acute and Critical Access Hospitals. It will discuss other resources to help hospitals comply with the National Patient Safety Goals.

This webinar will summarize the specific changes over the past few years. It will include medication reconciliation standards and why CMS has now added this requirement to one of their three hospital worksheets and in a proposed regulation. Discussion includes the medication labeling goal and how it relates to standards in the medication management chapter.

The webinar will include goals related to anticoagulation, central line-associated infections, surgical site infections, and surgical site infections along with related tool kits. The CMS revised blood transfusion standards will be discussed and contrasted with the one in the NPSG. The approach marks an effort to move away from prescriptive requirements and to reflect evidenced-based standards.

Find out why the infection control standards and the NPSGs on infection control issues are especially important to hospitals and healthcare facilities including that some hospitals can be financially penalized under the CMS Hospital-Acquired Condition (HAC) Reduction Program. As part of the Patient Protection and Affordable Care Act, hospitals that rank in the quartile of hospitals with the highest total HAC scores will have their CMS payments reduced by 1%.

Hospitals should also be familiar with the final CMS hospital worksheet on infection control, and the proposed changes, along with a memo on safe injection practices and infection control breaches. Success Stories by hospitals on how they complied with the NPSGs will also be discussed.

Some of the most recent revisions occurred in late 2020 and are effective January 2021. Those changes include: 

  • Patient identifiers, especially in new-borns
  • Improving communication between caregivers
  • Medication safety
  • Reducing the harm with anticoagulant therapy
  • Patient harm associated with clinical alarm systems
  • Reducing the risk of healthcare-associated infections
  • Identification of safety risk inherent in its patient population

The changes to NPSG 15 are important and address the requirement for the hospital to identify safety risks inherent in its patient population and to identify patients at risk for suicide. Ligature risk is identified as one of the four areas of focus identified by the Joint Commission.

The 2019 changes will be discussed including using distinct methods of identification for newborns under 01.01.01. This goal is to improve the naming conversation of new-borns after delivery to prevent medical errors due to conventional, non-distinct naming methods to prevent wrong tests, wrong procedures, and administering the wrong breastmilk to the infant.

The July 2019 change under NPSG 03.05.01 regarding reducing the likelihood of harm associated with the use of anticoagulants. Recently, there has been a number of new oral anticoagulants on the market such as Apixaban (Eliquis), Dabigatran (Pradaxa), Rivaroxaban (Xarelto), and Idarucizumab (Praxbind) to name a few. Anticoagulants are frequently prescribed in atrial fibrillation, VTEs, and low-risk pulmonary embolism. Changes include the use of approved protocols and evidence-based guidelines, monitoring, and education.

January 1, 2018, changes were to Goal 7 on healthcare-associated infections (HAIs). These reflect updates in the Compendium of Strategies to Prevent HAI in acute care hospitals. NPSG.07.03.01 has been revised to include carbapenem-resistant Enterobacteriaceae (CRE) and education requirements. There has also been a modification to NPSG.07.04.01 on preventing central line-associated bloodstream infections like those changes made to multi-drug resistance organisms (MDROs). This addresses the correct time frame for education. There has been a revision to specify the use of chlorohexidine for antiseptic skin preparation.

The 2017 changes on the catheter-associated urinary tract infections include mandatory education in orientation and periodically. Indwelling catheter care would have to be added to the person’s job responsibilities such as their job description. Patients would have to be educated on preventing a UTI and an evidenced-based policy would have to be drafted with specific requirements for what must be in the policy. This webinar by industry expert Laura A. Dixon, BS, JD, RN is a must-attend program to learn about the changes to Hospital National Patient Safety Goals

Webinar Objectives

  • Describe the NPSG related to reducing healthcare-associated infections
  • Recall the changes to NPSG 15 on reducing the risk of suicide
  • Discuss the infection control goals and the CDC/WHO guidelines on hand hygiene
  • Recall that TJC standards on patient identification
  • Recall the current five medication reconciliation standards and that CMS is looking at this issue in their revised worksheets

Webinar Agenda

  • Goal 1 Improve the accuracy of patient identification
    • Use of 2 identifiers, labelling blood samples, and distinct methods for new-born identification
    • Rationale: reliably identify the patient and match service or treatment to that patient
  • Goal 2 Improve the effectiveness of communication among caregivers
    • Reporting critical results of tests and diagnostic procedures on a timely basis
  • Goal 3 Improve the safety of using medications
    • Labeling of medications – including in the perioperative setting
    • Anticoagulants
    • Medication reconciliation
    • Maintain and communicate accurate patient medication information
  • Goal 6 Alarm Safety
  • Goal 7 Reduce the risk of healthcare-associated infections  
    • Compliance with CDC and/or WHO guidelines re Hand Hygiene
  • Goal 15 Identification of safety risks
    • Reduce the risk for patient suicide
  • Universal Protocol changes to prevent wrong-site surgery

Who Should Attend

This program is designed for anyone involved in implementing and following the Joint Commission National Patient Safety Goals including Joint Commission Coordinator, Quality Improvement staff, chief nursing officer (CNO), patient safety officer, nurse educator, all nurses with direct patient care, pharmacist, pharmacy staff, patient safety officer, infection preventionist, OR nurse manager, chief medical officer (CMO), nurse managers, nursing supervisors, nurse managers, nursing directors, policy and procedure team, compliance officers, risk managers, hospital legal counsel, and medication team members.

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