<p> Joint Commission (JC) 2008 National Patient Safety Goals Hospital Version Analysis of implementation expectations When JC released the 2008 implementation expectations for the National Patient Safety Goals (NPSGs) there were minimal changes to the existing requirements. Two goals were added: 3E to address management of anticoagulation therapy and Goal 16 regarding early recognition and response to changes in a patient’s condition. With this release, JC has corrected the verbiage they inadvertently omitted when reformatting the 2007 NPSGs in July of 2006. A large volume of Frequently Asked Questions (FAQs) were posted on JC’s website in February of 2007 following a January 2007 update. </p><p>In this analysis, the following symbols will be used to guide the reader: </p><p>No Wording, scoring and implementation are Changesunchanged</p><p>2007 Underlined revisions, effective 7-1-07, were included Revision in 2007 Frequently Asked Questions</p><p>Reworde New wording changes for 2008 NPSGs d</p><p>A New 2008 NPSGs</p><p>Issues we have found to be problematic for our clients Hot Button</p><p>200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 Tips that may aide a facility in achieving compliance </p><p>JC requirements in this analysis are paraphrased. The official wording of the 2008 performance expectations is posted on the JC web site and published in a special issue of the July 2007 “Perspectives.”</p><p>(http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_ hap_npsgs.htm)</p><p>2007 Revision 1A: Use of 2 identifiers … EP.1 (Category C) When administering medications EP.2 (Category A) When collecting blood samples and other specimens EP.3 (Category C) When providing other treatments or procedures EP.4 (Category A) Room numbers may not be used as one of the 2 required patient identifiers. EP.5 (Category A) Specimen containers must be labeled in the presence of the patient.</p><p>Implications: . There are five scoreable elements of performance within this goal primarily due to wording changes . Element of performance (EP) 3 is not new; it was inadvertently left out in a previous JC printing . EP 5 was changed from a category C to an A allowing no room for error . When delivering special diets or snacks, the use of two patient identifiers is expected . The use of two identifiers applies to orders for care, computerized physician order entry, and reporting of critical test results and critical value results</p><p>2</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. TIP: Ensure the selected two patient identifiers are included on the dietary slips that accompany patient dietary trays and snacks. Personnel delivering these items could use this slip to verify the two patient identifiers against the patient’s identification band. </p><p>2007 Revision 2A: Read Back … EP.1 (Category C) The receiver of a telephone or verbal order or test result must write down the information onto a piece of paper or directly into a computer. EP.2 (Category C) The receiver must read back the written order or test result to the transmitter. EP.3 (Category C) There receiver of the information receives confirmation from the transmitter that the information is correct. Avoid this documentation trap: There is and never has been a requirement that you document the read back process. We suggest you NOT require that </p><p>Hot staff members document the read back process for the following reasons: Button 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. If you require documentation of read back, JC will expect compliance with your policy. </p><p>3</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. No Changes 2B: Prohibited Abbreviations … EP.1 (Category A) The organization is required to develop a list of abbreviations, acronyms, symbols, and dose designations that may not be used. 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. </p><p>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 Hot Button off. (You can discourage the use of certain abbreviations without prohibiting them.)</p><p>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). 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.</p><p>EP.4 (Category A) Pre-printed forms do not include any prohibited abbreviations. Implications: . This requirement applies to all entries on all forms and may increase organizational vulnerability . This is a category A element of performance; it only takes one unapproved abbreviation out of a million pre-printed form entries to trigger an RFI</p><p>TIP: For computerized forms, use the “find and replace” feature as a mechanism to convert prohibited abbreviations to acceptable verbiage. </p><p>4</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. 2C: Critical Tests and Critical Values …some things are clearer</p><p>Reworde EP.1 (Category A) The organization defines critical tests and critical d results/and values Implications: . No change from the current expectation. To help with your definition:  A critical test is a test which will always require rapid communication of the results, even if normal. Some organizations include all of STAT tests into this category.  A critical result/value is a panic value for any test or study determined to be vital to the patient’s subsequent treatment decisions. Besides the lab, don’t forget imaging, cardiology and pulmonary function testing. . Although these are not new requirements, we continue to see Hot Button organizations struggle with their definitions of critical tests and non- laboratory critical results/and values as they apply to this goal.</p><p>Reworde d EP.2 (Category A) The organization defines the acceptable length of time between the ordering of critical tests and reporting the critical tests and critical results/and values Implications: . Not a change from the current expectation but more clearly stated with the expectation that the results of critical tests are also be reported whether the results are normal or abnormal 2C: Critical Tests and Critical Values (continued)</p><p>. Organizations need to define the acceptable length of time from the ordering of a critical test to reporting the results of a critical test. Different critical tests will have different acceptable time frames based on factors that only your organization can identify. </p><p>5</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. Reworde d EP.3 (Category A) The organization defines the acceptable length of time between the availability of critical tests and critical results/and values and receipt by the responsible licensed care giver (physician). Implications: . Not a change. This element of performance requires that you establish an acceptable time (30 minutes? 1 hour?) from the availability of a critical result/and value to notification of the responsible provider. . We recommend that the time frame be the same for all critical test results and not vary from setting or type of test.</p><p>EP.4 (Category A) The organization must collect and analyze data on Reworde the timeliness of reporting critical tests and critical results/and values. d Implication: . Not a change. By rewording the EP, although it remains less than ideal, it is clearer that EP 4 also includes critical tests and not just critical test values. </p><p>EPs 5 and 6 (Category A) The organization analyzes the data and, if necessary, take actions to improve the timeliness of reporting critical tests and critical results/and values and receipt by the responsible Hot Button licensed care giver. Implication: . This has been a requirement since the goal was established. We still see hospitals who have not implemented data collection for critical test turnaround time based on the reason that physician orders are not time. As an alternative, utilize the best “guesstimate” by using RN order sign off, entry into computer system, time physician made rounds, etc. You must begin some where. </p><p>6</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. No Changes 2E: Standard Content for Handoffs </p><p>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. 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. Implication: . Newly added FAQs released in 2007 reinforces the need to include physicians in the handoff process. A standardized process needs to be communicated and understood by all physicians who hand off care. TIP: When conducting internal tracers, ask physicians in group practices what the hand off process is; also applicable to emergency department physicians, on-call physicians, etc. </p><p>3B: Limited Concentrations … gone…..included in MM.2.20 Implication: . Removed as a NPSG, still required and scored under the standard MM.2.20. </p><p>2007 3C: Look Alike / Sound Alike … Revision EP.1 (Category A) A list of 10 look-alike, sound-alike pairs must be selected from the table on JC’s website EP.2 (Category A) Review your list of look-alike/sound-alike drugs at least annually. EP.3 (Category A) Actions must be taken to prevent errors involving the interchange of these drugs. Implication: . We often find that the process of selecting the medications and the actions to prevent errors has been well defined but staff involved in </p><p>Hot 7 Button JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. medication management cannot always articulate the names or the drugs or the corresponding actions. This is a red flag and is indicative of a paper-process versus a well implemented medication safety intervention. TIP: The list on the JC’s website was updated in August 2006. If you have not performed your annual review since that date, your organization-specific list may be outdated. See the following website: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ </p><p>2007 3D: Labeling Secondary Containers….. Revision settings clarified </p><p>8</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. In the 2007 FAQ update, the implementation expectations specified the settings in which this goal applies were added to the rationale statement. The requirement pertains to the peri-procedural setting (pre, intra and post procedure areas) and other procedural settings where high-risk procedures are performed such as patient care units, interventional radiology, endoscopy, cardiac catheterization, etc. </p><p>Implications: . This goal must be implemented in all locations where high-risk procedures are performed </p><p>. We often find that the operating staff are able to speak to these requirements but staff in patient care areas such as an ICU where bedside procedures are performed are not always informed and complying with all the expectations. </p><p>. Taping the medication vial to the syringe is NOT acceptable as labeling method.</p><p>. Power injectors used for administration of contrast media must be labeled if not administered immediately.</p><p>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 Hot Button when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.</p><p>Implications: . This goal applies even if only one medication or solution has been transferred to a secondary container and is not immediately administered or utilized.</p><p>. Pre-labeled syringes are not acceptable. If your organization has purchased such supplies from ill-informed vendors, immediately pursue a change in this practice 9</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. 3D: Labeling Secondary Containers….. settings clarified (continued)</p><p>EP.4 (Category C) When the person preparing the medication is not the person administering the medication, a verbal and visual verification process occurs.</p><p>EP.5 and EP.6 (Category A) Only one medication is labeled at a time and medications or solutions found unlabeled are immediately discarded.</p><p>2007 EP.7 (Category C) Original containers remain available for reference in Revision the perioperative/procedural area until the conclusion of the procedure.</p><p>EP.8 (Category A) All labeled containers on the sterile field are discarded at the conclusion of the procedure.</p><p>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.</p><p>TIP: Visit procedural areas outside of the operating room and observe the table set-up. While in the location, also observe for the components of universal protocol particularly the time out. </p><p>10</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. 3E: Reduce the harm associated with anticoagulation therapy A high risk and complex treatment which commonly leads to adverse drug events; a standardized practice can reduce the risks and occurrence of adverse drug events. This goal has a one-year phase-in period with defined expectations. Implications: . We all learned when medication reconciliation was a new goal that the one-year to prepare and implement flies by and organizations found they could not meet the due date . Begin now and use the lessons learned within your organization to guide your implementation to meet the four time lines . Goal applies to organizations that provide anticoagulant therapy using heparin (unfractionated), low molecular weight heparin (LMWH), warfarin and other anticoagulants . Organizations may be ahead of the game and already have some form of a practice guideline, protocols, etc. implemented. Ensure all expectations (EP 1 – 11 effective January 1, 2009) are included in your organization’s program. If not, use the timelines as a means of bringing the program into compliance. </p><p>EP.1 (Category A) As of April 1, 2008, leadership has assigned oversight and coordination of the development, testing and implementation</p><p>TIP: Ensure this assignment is captured in written format: meeting minutes, memo, printed e-mail, etc. so there is no confusion of who is accountable for seeing this project through to completion.</p><p>EP.2 (Category A) By July 1, 2008, an implementation work plan is in place that identifies adequate resources, assigned accountabilities and a time line for full implementation by January 1, 2009. EP.3 (Category A) As of October 1, 2008, pilot testing of the process in at least one clinical unit is under way</p><p>11</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. Implication: . Begin the pilot as soon as possible because you will only have three months to correct and refine any issues identified during the pilot. 3E: Reduce the harm associated with anticoagulation therapy (continued)</p><p>EP.4 (Category A) By January 1, 2009, the process is fully implemented across the organization</p><p>Beginning, January 1, 2009, the following elements of performance will apply: EP.1 (Category A) A defined anticoagulant management program is implemented EP.2 (Category A) Only unit dose products and pre-mixed infusions are used by the organization, when available EP.3 (Category C) When pharmacy services are provided, warfarin is dispensed for each patient in accordance with established monitoring procedures EP.4 (Category C) Approved protocols are used for the initiation and maintenance Implication: . EP 3 and 4 have a measure of success; consider collecting data during the pilot process to determine compliance to program expectations</p><p>EP.5 (Category A) A baseline INR is available for all patients being started on warfarin; for all patients already receiving warfarin, a current INR is available and being used to monitor/adjust therapy EP.6 (Category C) Dietary is notified of all patients receiving warfarin and responds appropriately as defined in food/drug interaction program EP.7 (Category A) Programmable infusion pumps are used when administering heparin IV and continuously</p><p>12</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. EP.8 (Category C) A policy exists that addresses baseline and ongoing lab tests required for heparin and low molecular weight heparin therapies EP.9 (Category C) Education is provided to prescribers, staff, patients and families EP.10 (Category C) Patient/family education includes, follow up monitoring, compliance issues, dietary restrictions and potential for adverse drug reactions or interactions EP.11 (Category A) Anticoagulation safety practices are evaluated Implications: . Select data collection indications that mirror the requirements in the above EPs . Include process steps and analyze any variations to determine appropriate interventions</p><p>7A: Hand Hygiene … added World Health Organization’s guidelines as an option</p><p>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: . There are minor differences between the two sets of guidelines . WHO references hand hygiene before handling or preparing food . WHO- when an alcohol based product is used, do not use an antimicrobial soap concomitantly . Artificial fingernails not recommended for use in high-risk patient care by CDC; WHO prohibits in all direct patient care</p><p>No Changes 7B: Infection Related Sentinel Events 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</p><p>13</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. EP.2. (Category A) Any root cause analysis addresses the management of the patient before and after the identification of infection.</p><p>14</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. 8A: Reconciliation of Medications throughout the Patient’s Stay EP.1. (Category C) The organization, with the patient’s involvement, creates a complete list of the patient’s current medications at admission/entry. Implication: . The only required documentation is the list itself! </p><p>2007 EP.2. (Category C) The medications ordered for or administered or Revision dispensed to 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.</p><p>8B: Reconciliation of Medications at Discharge 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.</p><p>EP.2. (Category C) The next provider of service checks the medication Reworde reconciliation list again to make sure it is accurate and in concert with d any new medications to be ordered/prescribed.</p><p>EP.3. (Category C) The complete list of medications is also provided to the patient on discharge from the facility.</p><p>15</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. No 9B: Falls Program Changes EP.1 and EP.3 (Category A) There is a fall reduction program includes interventions to reduce the patient’s fall risk factors EP.2. (Category C) Patients are evaluated for fall risk as appropriate to the patient population. EP.4. (Category C) Staff receive education and training in the fall reduction program. 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. 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.</p><p>13A: Encouraging Reporting Safety Concerns EP.1. (Category C) Patients and families are educated on methods available to report concerns related to care, treatment, services and 2007 patient safety issues. Revision EP.2. (Category C) Organization encourages patients to report concerns Implication: . The use of a patient safety brochure that includes reporting concerns of any kind, including concerns over their safety, to any care giver is recommended as a method to “encourage” reporting. Tip: Tent cards with information on how to report a safety concern could be placed in patient rooms following terminal cleaning by environmental service </p><p>16</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. No 15A: Assessing Suicide Risk Changes Implications: . This requirement only applies to behavioral health care hospitals and patients being treated for emotional or behavioral disorders in a general hospital (for example, the emergency department). . “Treated for” was clarified in the 2007 FAQ as a primary diagnosis or primary complaint of an emotional or behavioral disorder EP.1. (Category C) Risk assessment identifies specific factors that may increase suicidal risk. EP.2. (Category C) Immediate safety needs and most appropriate setting for treatment are addressed EP.3. (Category C) The organization provides crisis hotline information to patients and families in the event of a crisis.</p><p>Tip: A two-stage process of screening followed by a comprehensive assessment, if appropriate, is an acceptable approach. </p><p>16A: Response to a Change in Patient’s Condition Implications: . Organization defines a method for patient care staff to request additional assistance from specially trained individuals when it appears a patient’s condition is deteriorating . A one-year phase in period is defined EP.1. (Category A) As of April 1, 2008, leadership has assigned oversight and coordination of the development, testing and implementation EP.2 (Category A) By July 1, 2008, an implementation work plan is in place that identifies adequate resources, assigned accountabilities and a time line for full implementation by January 1, 2009.</p><p>17</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. EP.3 (Category A) As of October 1, 2008, pilot testing of the process in at least one clinical unit is under way EP.4 (Category A) By January 1, 2009, the process is fully implemented across the organization 16A: Response to a Change in Patient’s Condition (continued)</p><p>Beginning, January 1, 2009, the following elements of performance will apply: Implication: . If your organization has already implemented a similar program, often referred to as a Rapid Response Team, evaluate it against the requirements below.</p><p>EP.1. (Category A) An early recognition and response method is selected by the organization EP.2. (Category A) Criteria is developed for calling for assistance for a change in patient’s condition or perception of change by staff, patients and families EP.3. (Category A) Staff, patients and families are empowered to request additional assistance when they have a concern about the patient’s condition</p><p>Implication: . Think across the organization……nothing in the goal limits the scope to only inpatients</p><p>EP.4. (Category C) Formal education is provided to people who may request and who may respond EP.5. (Category A) The utility and effectiveness of the interventions are measured EP.6. (Category A) Organization measures cardiopulmonary arrest, respiratory arrest and mortality rates before and after implementation of an early intervention plan</p><p>18</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. Implications: . Already have a program in place that meets the above elements of performance? Great! You are a step ahead of plan. . Do you have data as required in EP.6? Be prepared to show “before and after” data for your program. </p><p>19</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. Universal Protocol 1A: Pre-procedural Verification … continues to be problematic </p><p>2007 EP.1. (Category A) Verification of the correct person, procedure, and Revision 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. Implication: . Changed to a Category A; you’re either doing it or you’re not. No wiggle room! 2007 EP.2. (Category A) Before the start of the procedure (a) relevant Revision 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. Implication: . Same as EP.1</p><p>Universal Protocol 1B: Site marking … </p><p>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.</p><p>Hot EP.6 The person performing the procedure should mark the site. Button Implications:</p><p>20</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. . Organizations that consistently have another member of the team other than the person performing the procedure mark the site will be at risk for being considered non-compliant. . It is Joint Commission’s position that this practice should be by exception and not routine EP.7 The marking should take place with the patient awake, alert and aware, when possible.</p><p>Universal Protocol 1B: Site marking (continued)</p><p>Implication: . 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). 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</p><p>Universal Protocol 1C: Time Out …….. observation Hot Button may identify a lax practice </p><p>EP.1 (Category C). The time out must occur in the location where the procedure will be done, just before starting the procedure EP.2 (Category A) 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</p><p>Implications: . Active communication means that each team member will acknowledge their agreement with (a) through (e) . Side conversations are to be halted</p><p>21</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. . An observer must be able to identify who called the time out and hear all of the requirements stated with responses from all persons in the room</p><p>EP.3 (Category C) 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. EP.4 (Category A) There should be a process for reconciling differences in staff response.</p><p>NOTE: Top Standards Compliance Issues for Full-Year 2006 Related to NPSGs (as reported by Joint Commission in the August issue of Perspectives) Goal 2……….58% non-compliance Goal 3……….17% non-compliance Goal 8……….46% non-compliance UP1………….30% non-compliance</p><p>22</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations. Pat Pejakovich – Senior Consultant</p><p>23</p><p>JCAHO requirements are paraphrased. Please 200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com refer to the JCAHO web site for the exact Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-1553 wording of the requirements and for official interpretations.</p>