By Staff | September 23, 2009

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Tags: accreditation | Ambulatory Care Accreditation | The Joint Commission

The Joint Commission has announced its 2010 National Patient Safety Goals for its Ambulatory Care Accreditation Program. Although no new goals have been developed for 2010, accredited organizations are expected to have fully implemented requirements related to healthcare-associated infections (NPSG 07.05.01 for ambulatory organizations), which were established in the 2009 NPSGs.

The 2010 NPSGs are fewer in number than in years past due to increased compliance by accredited organizations for certain goals and similar concepts in accreditation standards. The NPSGs are designed as a high-level spotlight of critical areas in patient safety. As compliance improves, goals are moved out of the NPSGs but remain part of accreditation standards, according to Michael Kulczycki, executive director for the Ambulatory Care Accreditation Program. Nearly one-fourth of the 2009 NPSGs were eliminated from the 2010 NPSGs, and another 30 percent were moved to standards. 

Several clarifications were made in the 2010 NPSGs regarding the Universal Protocol. The 2010 NPSGs require the licensed independent practitioner responsible for the procedure to mark the site. However, in limited circumstances, site marking may be delegated to an individual in a medical residency program who is being supervised by the licensed independent practitioner performing the procedure and who is familiar with the patient and will be present when the procedure is performed. A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure, such as an advanced practice registered nurse or physician assistant, who is familiar with the patient and will be present when the procedure is performed may also be used in limited situations.

When time-outs must occur has also been clarified. They should take place before the incision is made or the procedure is started. Organizations may choose to conduct the time out before the provision of anesthesia. Additionally, organizations need only to document that the Universal Protocol has occurred in patient charts; documenting each step of the Universal Protocol is not necessary. There were also changes to the pre-procedure verification. References to the location (pre-procedure area) and timing of the verification will be removed. The term "checklist" will be replaced by a reference to a standardized list to be used in the verification process. The term "checklist" implied the need to document each step for each patient. A note will be added clarifying that documentation of the use of the standardized list on a per patient basis is not required, according to The Joint Comission.

The 2010 ambulatory care NPSGs are (overarching goals are in italics):

Improve the accuracy of patient identification.

•    Use at least two patient identifiers when providing care, treatment or services. 
•    Eliminate transfusion errors related to patient misidentification.

Improve the safety of using medications.

•    Label all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.
•    Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Reduce the risk of health care-associated infections.

•    Comply with current World Health Organization hand hygiene guidelines or Centers for Disease Control and Prevention hand hygiene guidelines.
•    Implement evidence-based practices for preventing surgical site infections.

Accurately and completely reconcile medications across the continuum of care.*

•    A process exists for comparing the patient's current medications with those ordered for the patient while under the care of the organization.*
•    When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the organization's care directly to his or her home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, or the original referring provider, or a known next provider of service.*  
•    When a patient leaves the organization's care, a complete and reconciled list of the patient's medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family.*
•    In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.

The organization meets the expectations of the Universal Protocol.

•         Conduct a pre-procedure verification process.
•         Mark the procedure site.
•         A time out is performed before the procedure.


* Denotes that compliance with the requirement is evaluated during on-site surveys, but is not factored into survey findings.. 

View the 2010 ambulatory care National Patient Safety Goals (pdf).