Increased documentation added to 2009 NPSGs

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Med rec, patient involvement, UP among revised goals

With the release of the 2009 National Patient Safety Goals (NPSG) came some cumbersome documentation requirements. The Joint Commission has modified several of its NPSGs to include more language about documentation, including:

  • Goal #8, concerning medication reconciliation
  • Goal #13, concerning patient involvement
  • The Universal Protocol

During the July 18 HCPro audioconference “2009 National Patient Safety Goals: Expert Analysis and Advice for Compliance,” Bud Pate, REHS, vice president of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Kurt Patton, former Joint Commission executive director of accreditation services and principal of Patton Healthcare Consulting, LLC, in Glendale, AZ, discussed these requirements and the rest of the 2009 NPSGs.

Medication reconciliation

NPSG.08.01.01 was modified to include the need to document that the completed list of home medications was created upon a patient’s admission. Any discrepancies with this list are handled while the patient is still in the hospital, and this reconciliation is documented. Patton said these documentation requirements were added to show conscious decision-making during the reconciliation process. For example, the caregiver acknowledges that he or she saw a patient’s medication list and states why a medication might have been taken off that list during the hospital stay.

“You might want to reconsider using your list of medications as an order sheet,” said Patton about NPSG.08. 01.01, concerning the gathering of a patient’s medication list. If the medication list is used as the order sheet, any decisions about changing medications or increasing dosages can be documented there, he said.

NPSG.08.02.01 requires that hospitals document the discussion concerning a patient’s medication reconciliation when that patient is being transferred. Patton and Pate said the discussion does not have to be an actual conversation but can be written communication; there just has to be documentation showing that the communication occurred.

New to the medication reconciliation goal is 08.03.01, about providing the patient and his or her family with a list of the patient’s medications and ensuring that they understand the updated medication list. This interaction must be documented.

A simple solution Patton recommended for complying with this new element of performance is to have the doctor and patient sign off that this list was provided to the patient upon discharge. If a facility is using an electronic medical record (EMR), documenting in the EMR that the patient was given his or her list of medications and understood them is sufficient. Patton also recommended adding language to the medication form about patients throwing away old medication lists. This reminder is also part of NPSG.08.03.01.

Patient involvement

NPSG.13.01.01, concerning involving patients in their own care, has many added documentation requirements along with new requirements about patient education. All patients must now be educated about hand and respiratory hygiene and contact precautions employed at the facility. Additionally, surgical patients must be educated about the methods the hospital will use to prevent adverse events during surgery. This education, along with patient and family comprehension of the education, must be documented.

“Brochures and posters used to be it,” Patton said. However, that might no longer be considered a sufficient means of educating patients to comprehension. Whether a facility uses a poster, brochure, or other method to distribute this information, give patients an assessment to ensure that they understand the education that’s been delivered and use that as documentation, Patton said.

Universal Protocol

The Joint Commission (formerly JCAHO) added many new documentation requirements to the Universal Protocol, although Pate said he’s not convinced the changes will reduce the number of wrong-site procedures.

“The Joint Commission found as many, if not more, wrong-site surgeries after implementation of the Universal Protocol,” Pate said. With this new edition of the Universal Protocol, which was updated based on feedback from the Wrong Site Surgery Summit in 2007, The Joint Commission made the requirements much tighter with more documentation.

UP.01.01.01 requires the use of a checklist during the preprocedural verification process. This does not have to be documented and could take place on a whiteboard. However, Pate recommended not to require each element of the checklist to be signed off if the checklist is part of a patient’s record. Instead, have a place for the person completing the checklist to sign off and document that the whole checklist was completed.

Last, UP.01.03.01 requires you to document the entire contents of the Universal Protocol along with the timeout. The timeout has been modified to include the need to confirm a consent form, any images present and that they’re properly displayed, any antibiotics to be used during the procedure, any necessary irrigation fluids, and any precautions based on patient history and medications.

In other news from The Joint Commission

In July, The Joint Commission released information about the 2009 standards in its Standards Improvement Initiative (SII) and a new Sentinel Event Alert.

Joint Commission unveils 2009 standards

The Joint Commission (formerly JCAHO) has released its revised standards, rationales, and elements of performance for 2009. These standards, set to take effect January 1, 2009, are available through the accreditor’s Web site and reflect the results of the SII, a program intended to clarify and consolidate existing standards, remove redundancy, and ensure that the standards are, on the whole, program-specific. The SII also includes a renumbering of all standards to allow for ease of organization, as well as to simplify adding new standards in the future. The Joint Commission says it has placed the standards online to help organizations get used to the new format.

To help organizations compare and contrast the new standards with previous versions, The Joint Commission has also included a history-tracking report on the Web site. The Joint Commission will offer single-user access to electronic editions of the standards. Visit to find out more about the SII.

New Sentinel Event Alert targets disruptive behavior

The Joint Commission’s most recent Sentinel Event Alert targets disruptive behavior by healthcare providers. Disruptive behavior was considered as a possible National Patient Safety Goal for 2008 but was not selected.

In the alert, The Joint Commission states that rudeness, unpleasant language, hostile attitudes, and other bad behaviors not only create an unpleasant environment, but are detrimental to patient safety and quality care.

This alert ties in to new standards to take effect January 1, 2009, which will require healthcare organizations to create a code of conduct defining acceptable and unacceptable actions, as well as crafting a process for dealing with poor behavior.

The Sentinel Event Alert provides 11 steps to curbing disruptive behavior, including:

Providing education and training for healthcare providers about professional behavior and appropriate interactions with coworkers

Creating accountability for maintaining appropriate behavior

Establishing a zero tolerance policy for disruptive behaviors and a means for enforcing this policy

Crafting nonconfrontational methods for reporting and addressing inappropriate behavior

Visit for more information.