Question

The Joint Commission National Patient Safety Goals (NPSGs) address patient safety issues within health care organizations. First, review the current NSPGs at http://www.jointcommission.org/standards_information/npsgs.aspx. Next, determine three patient safety issues that are being addressed by your health care organization (or health care organizations in general). Lastly, identify the actions the organization is taking, or identify three action-item issues to be addressed by health care organizations in general. What actions should the health care organization take regarding each of these NPSGs, and why? What goals do they need to achieve? Support your responses with a minimum of two peer-reviewed references.

Answer 1

There has been a movement toward making all healthcare providers and patients aware of patient safety issues and errors within the healthcare field. The IOM has addressed the issues of errors in their report To Err Is Human: Building a Safer Health System. Despite many improvements to decrease errors, there are still errors occurring. The Joint Commission has implemented National Patient Safety Goals to further address such errors (Mollon & Fields, 2009). Three errors in which my organization is currently focusing on are identifying patients correctly, improving staff communication and medication safety.

We are required to use two patient identifiers upon admission and before any procedure or distribution of medication and when discussing any patient information with another provider. This is done to ensure we have the correct patient with the correct chart and information. There are policies outlining the admission process and medication administration processes that requires two identifiers. Another policy was written that addresses staff communication in regards to communicating abnormal results. There are yearly competencies regarding all three safety issues that staff must read about and complete a quiz. The way we practice is constantly changing so yearly compliance programs like the formentioned reinforces the requirements and importance of compliance. Some may complain stating it takes a lot of time and therefore, money that is being wasted on information that all staff members already know but in the end, it is beneficial to the staff to get these reminders. These types of reinforcement activities provide a movement toward safer patient care which benefits the organization as a whole (Mollon & Fields, 2009). We must continue to move forward with innovations to improve patient outcomes while striving to maintain a team atmosphere. In order to improve our communication we must understand that errors are often created when there is a failure of part of a member of the team to work together(Daly & Mort, 2014). It is important to always remember risk management is an on-going process and there are always ways to improve patient care and safety.

The Occupational Safety and Health Administration (OSHA), the Centers for Medicaid and Medicare Services (CMS), and The Joint Commission (TJC) require that health care organizations maintain risk management programs to address infection control. Detail three measures that your health care organization (or any health care organization) needs to address in the delivery of safe health care services. (Example: Placing hand washing devices at all of the public entrances of the health care facility). Support your response with a minimum of two peer-reviewed references.

The organization I work for has a fairly good infection control program. However, there will always be areas to improve in. Recently, I have noticed that some patients are having IV lines kept in them for 72 hours that were placed in an ambulance. An IV that was placed in the field may have been done under quick and stressful circumstances which would increase the risk of infection for the patient. IV’s should be removed as soon as possible and replaced by a IV therapist team member once the patient is stable in the hospital setting. In an adult, as long as the IV is not showing signs of infection or infiltration this line should be used for 72-96 hours (Fang, 2012).

It is cold and flu season once again. We have been having an increase in the number of patients being seen for coughs and colds. There are signs in the welcome center that encourage patients to wear a mask. When people are sick they do not always pay attention to the signs around them though. A cough can propel germs up to 2 meters when a person is unmasked (Tang & Settles, 2009). The organization I work for could improve their infection control policy by requiring staff at the welcome center to provide a mask to any patient that is checking in to be seen for a cough or cold. This is the best way to prevent an outbreak or infection in a fellow patient that has a decreased immune system.

Lastly, it would be in the best interest of my organization to get rid of play areas for children within the hospital. Although children playing together have a positive impact on a child’s development of social skills, the hospital is not the best place to work on these milestones. The current cleaning routine does not eliminate bacteria and poses a risk for transmission of infection even after being washed (Moore, 2008).

All of these changes sound simple but it takes time to create policies and procedures that guide all members of the organization. Staff members cannot be expected to know this information and maintain compliance without the guidance of written policies and procedures.

The Patient Protection and Affordable Care Act (PPACA) of 2010 (section titled “Subtitle D”) identifies requirements relating to provider compliance with fraud, waste, and abuse laws. Identify three measures that your health care organization ((or health care organizations in general) has initiated, or could initiate, to comply with these measures. Support your analysis with a minimum of two peer-reviewed articles.

Medicaid and Medicare fraud and abuse has become a problem over the years. In 2007, $1 billion in improper payments was found (“CMS Strengthens Efforts to Fight Medicare Waste, Fraud and Abuse,” 2009). This has caused the DOJ to pay close attention to these two issues. New statuettes relating to health care fraud and abuse and penalties for violations have been created to decrease the incidences. It is required that organizations serving Medicaid and Medicare patients commit to a program of compliance with the federal laws and reduce their potential for liabilities (Bradshaw, 1997).

My place of employment adheres to the program by not partaking in “kickbacks” with other companies that we refer our patients to. All of our patients are given options within our city as well as options available to them in larger nearby cities.

Confidentiality is a hot topic where I work. We have yearly competencies regarding HIPAA compliance. There was a recent HIPAA breech discovered when a patient was given an AVS with an extra paper that contained another patient’s name. We are currently in the process of discussing the situation with a compliance expert to find the root cause of the breech. Everyone is encouraged to provide ideas as to how we can improve our system so this does not happen again. I am trying to find out more information regarding the requirements for AVS use. I thought I had read one time that it is no longer a required measure. If this is the case, my suggestion would be to print out what the patient would like rather than printing everything with all private information on it. I have started asking my patients what they do with this AVS after they leave and most admit they end up throwing it away. If it isn’t a requirement to print it out we could be saving ourselves money as well as protecting patients from confidentiality breeches. I am betting that a lot of the patients don’t shred the papers before throwing it away at their home.

Reference:

Bradshaw, K. M. (1997). Fraud & abuse: DOJ and Medicare and Medicaid model compliance programs. Journal Of Law, Medicine & Ethics, 25(2/3), 218. Retrieved from http://eds.b.ebscohost.com.lopes.idm.oclc.org/eds/detail/detail?sid=6afdfdd3-a3b1-4ece-afe6-efebc8c69cba%40sessionmgr102&vid=7&hid=119&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=106078053&db=ccm

CMS Strengthens Efforts to Fight Medicare Waste, Fraud and Abuse. (2009). O&P Business News, 18(5), 63-64. Retrieved from http://eds.b.ebscohost.com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?sid=6afdfdd3-a3b1-4ece-afe6-efebc8c69cba%40sessionmgr102&vid=11&hid=119