Joint Commission 2021 Hospital National Patient Safety Goals

April 07, 2021
90 Mins
Laura A. Dixon
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Joint Commission 2021 Hospital National Patient Safety Goals

This program 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 program 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 labelling goal and how it relates to standards in the medication management chapter.

The program will include goals related to anticoagulation, central line-associated infections, surgery 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 area of focus identified by the Joint Commission.

The 2019 changes will be discussed including using distinct methods of identification for new-borns 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 03.05.01regarding 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 use of approved protocols and evidenced based guidelines, monitoring and education.

The January 1, 2018 changes were to Goal 7 on health care-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 blood stream 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
    • Labelling of medications – including in the peri-operative 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.

Laura A. Dixon

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining...
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