National Patient Safety Goals (NPSG)

JOINT COMMISSION STANDARDS AND PROCESSES

Health care providers may volunteer to be accredited by an external body. The Centers of Medicare and Medicaid provide an updated list of approved accrediting organizations. For this discussion, we are focusing on the acute care hospital. Below are fourteen of the categories in The Joint Commission Standards Manual and accreditation process topics.

Topic

National Patient Safety Goals (NPSG)

For your assigned topic, access The Joint Commission Standards Manual and The Joint Commission’s publication The Source. To access this information follow the steps below:

From the homepage of the Ashford University library, click on Find Articles & More in the purple bar near the top of the page. Next, take the following steps:

Click on Databases by Subject

Click on Health & Medicine

Click on Joint Commission E-dition for the Standards Manual. Review the standard assigned to you.

Next, go back to Health & Medicine in the AU Library. Then click on Joint Commission: The Source link located just below the Joint Commission E-dition link. Do not access The Source via the Joint Commission E-dition link or it will ask you to pay a fee.

To select two articles, do one of the following:

Select two journal articles from The Source that were published within the past 5-8 years pertaining to your assigned topic. Please use The Source tip sheet? for guidance to find what you need through The Source.

Select two journal articles from either Google Scholar or the Ashford Library Databases.

Once you have chosen two articles related to your assigned Standard, identify, and summarize the two articles chosen. In addition, your response should reflect the TJC Standard, how it is utilized, and why it is important in health care. Include any best practice mentioned, and discuss at least one new concept that you learned from the articles.

Sample Answer for National Patient Safety Goals (NPSG) Included After Question

Find what you need in Joint Commission: The Source Begin by using the keyword search line to enter keywords related to your topic. Then click the Search button. 3 Click on the download icon to download the issue you want to browse 1 2 Click on any of these volumes of The Source found under the Available Periodicals heading 4 Sept 2017 To find relevant content, either browse through the issue, or use the keyboard shortcut CTRL +F and type in a keyword. Use the Next button or arrow to advance to the next location the words appears in the issue. 12/14/2019 Print Glossary A3 A single sheet outline that summarizes a lean improvement project. accreditation The process through which an organization is recognized for its compliance with the accrediting agency’s standards. administrative data Data collected to document for insurers and government payers the care that was provided. adoption Accepting change at an individual level, such as when one employee decides to adopt a new process. analytic tools Used to help identify and organize the plan of action in process improvement. analyze Third of five process steps in Six Sigma; in this step, the root causes of defects or problems are examined. balancing measures Measures intended to identify an unintended consequence or harm that results from a change in care delivery. best practice A method or technique that has consistently produced results superior to those achieved with other means. Black Belts Dedicated Six Sigma specialists. categorical data Data that describes qualities of an individual in discrete groups, which are frequently mutually exclusive. Center for Medicare & Medicaid Services (CMS) An agency responsible for administering the Medicare program, Medicaid program, State Children’s Health Insurance Program (SCHIP), and various healthcare standards. clinical data Medical data generated in the course of caring for individual patients; examples include vital signs, symptoms, and laboratory test results. clinical measures Measures that are related to clinical performance. communication channels How information about the innovation is spread. consumer satisfaction The degree to which care services meet consumers’ expectations. continuous data Data that are on a continuous scale, such as blood pressure or serum glucose levels. continuous PDSA Several back-to-back PDSA cycles to move from the present situation to the ideal future situation. continuous quality improvement (CQI) The process-based, data-driven approach to improving the quality of a product or service. continuous quality management An approach to improving and maintaining the quality of care that focuses on constantly assessing causes of quality defects and implementing interventions in improvement. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 1/8 12/14/2019 Print control Last of five process steps in Six Sigma; in this step, actions are taken to sustain improvements over time. cost effective Demonstrating that a substantial improvement can be achieved relative to the associated cost or with little cost. cost saving Demonstrating that money can be saved over the long term. creating flow The process of ensuring that each step involved in creating a product or service is as efficient as possible. critical-to-quality (CTQ) characteristics Key measurable characteristics of a process or product that are essential for customer satisfaction; also known as customer-oriented metrics. customer-oriented metrics Key measurable characteristics of a process or product that are essential for customer satisfaction; also known as critical-to-quality (CTQ) characteristics. dashboard A visual display of data for the purpose of monitoring current conditions and detecting when processes may be going awry. define First of five process steps in Six Sigma; in this step, the problem or defect that needs improvement is identified. Department of Health and Human Services (HHS) An agency established to administer health-related services, particularly to communities that are unable to seek services themselves. department of insurance A unit of the state government that manages the activities of insurance companies conducting business in their state. diffusion The spread of change across a group of people, or the collective decision among a group of employees to adopt a change. direct observation A data collection technique that involves watching individuals perform a task, such as washing their hands. DMAIC Acronym referring to the five process steps in Six Sigma (Define, Measure, Analyze, Improve, and Control). DMAICR Acronym referring to an updated version of Six Sigma process steps, which includes an additional sixth step known as Reporting. effective care Care whereby services are provided based on scientific knowledge. efficient care Care that ensures high quality while limiting waste and managing costs. Electronic Health Record (EHR) Incentive Program A voluntary program that provides Medicare and Medicaid incentive payments to eligible healthcare providers for implementing certified EHR technology in delivering their services and improving their quality of care. Electronic Prescribing (eRx) Incentive Program An incentive program to encourage electronic prescription. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 2/8 12/14/2019 Print equitable care Care that is equally accessible to all social and ethnic groups with equal quality of care delivery. existing quality measures Data that are already routinely generated in the process of patient care. Examples include administrative claims data or clinical data (i.e., laboratory testing results). experiential data Information, typically qualitative, that individuals provide to describe how they perceive or experience a phenomenon, such as a clinic visit. external data Information that describes the environment outside of the healthcare organization. external quality improvement Improvement conducted across healthcare organizations. financial data Information regarding the cost or charges for patient care. financial metrics Measurements of financial impact. fishbone diagram (cause-and-effect diagram) A visual technique for identifying contributory factors to lapses in care delivery. five Ss Term that conveys the importance of a neat, clean, and organized work environment. focus group A forum typically of a small group of individuals who provide qualitative information regarding experiences or perceptions. gemba Direct observation of work where it actually occurs. Hawthorne effect A term describing the phenomenon that merely observing a behavior (such as hand washing) may improve performance if those being observed become aware of which behaviors are being monitored. Health Insurance Portability and Accountability Act (HIPAA) 1996 Act of Congress that protects people covered by healthcare plans and sets standards for the use and storage of private medical data. health maintenance organizations (HMOs) State-licensed health plans that require each member to have a PCP who acts as a “gatekeeper” for the care delivered to the HMO members. health policies Authoritative decisions that come from the government in order to improve a certain outcome or control healthcare players’ actions. healthcare reform Health policy creation or changes made by the government that affect the healthcare delivery system. horizontal integration strategies Ways an organization finds to own and operate a larger amount of a single component of the care spectrum. For example, an entity may own and operate a network of hospitals, focusing only on delivery of inpatient care. hospital safety score Score resulting from a survey conducted by the Leapfrog Group as its initiative to enhance the safety of hospital care. improve Fourth of five process steps in Six Sigma; in this step, modifications are made for improvement to occur. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 3/8 12/14/2019 Print innovation The change; the new idea/practice/object. interdisciplinary team A group of healthcare providers of different backgrounds working together toward a common goal for a patient or a process. internal quality improvement Improvement conducted within a healthcare organization. inter-rater reliability An assessment tool that does not change when employed by different individuals, assuming that the measured process or phenomenon does not change. intra-rater reliability Refers to the same results achieved by the same researcher when measuring and re-measuring a process. jidoka Rapid identification and correction of mistakes in a manufacturing process to prevent defects. judicial decisions A final decision made by the courts in cases in which laws and other regulations are unclear and clarification or interpretation is needed. just-in-time Describes the concept of making “only what is needed, when it is needed, and in the amount needed.” Kaizen To improve. Kaizen event Assembly of a small team of individuals to work together on a project to improve a process or service. laws Policies that are formulated and approved by legislators that are codified in the statutory language of specific pieces of enacted legislation. lean theory One type of process improvement methodology that was derived from Toyota manufacturing; also referred to as simply lean. measure Second of five process steps in Six Sigma; in this step, data is collected on the existing process and outcomes of interest. measurement The process of quantifying or otherwise describing a phenomenon; it refers to describing (usually quantitatively) healthcare delivery and outcomes. measurement strategy A plan that describes the information needs of a project and how those needs will be met during the project’s execution. Medicare Shared Savings Program A program that rewards ACOs when they incur lower costs while meeting quality standards and satisfying patients and their health plans. metric Measureable factors that provide useful information about the performance of a process. National Patient Safety Goals (NPSG) A series of specific actions recommended by a panel of national experts to prevent medical errors, such as patient misidentification, miscommunication among caregivers, and surgery on the wrong body part. National Quality Forum (NQF) A non-profit organization that enhances healthcare transformation by reviewing, endorsing, and recommending use of standardized healthcare performance measures. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 4/8 12/14/2019 Print National Quality Improvement Goals (NQIG) Desirable goals for effectively treating patients with specifically identified conditions, such as children’s asthma, heart attack, heart failure, pneumonia, pregnancy and related conditions, and surgical care improvement. NCQA accreditation standards Measures that are required by NCQA during its accreditation process. new quality measures Data that are not currently collected in the process of care delivery but instead require additional effort to specifically identify and record outcomes or processes of care. operational decisions and guidelines Documents of practical application, which have less authority than rules and much less than healthcare laws. outcome A measure of clinical results that are delivered by healthcare organizations. May include health states, such as mortality and hospital infection rates; laboratory test results; or patient-reported outcomes, such as functional status and satisfaction scores. outcome metrics Relating to the change in or final state of health of a patient as a result of a healthcare intervention. Pareto analysis A type of analytic tool using lines and graphs to visually demonstrate the relative frequency of root causes for a defect or problem. Pareto principle Refers to the phenomenon that in quality improvement projects, 80% of necessary information is often identified through a small proportion (20%) of the available measures. parsimony Use of the fewest resources or measures necessary to achieve a given aim for a quality improvement project. patient-centered care Care that focuses on patient self-empowerment, accountability, and demographics. Physician Quality Reporting System (PQRS) A pay-for-reporting program that gives eligible professionals incentives and payment adjustments if they report quality measures data of the services delivered to Medicare and Medicaid patients. point of service plan (POS) A health insurance plan that typically does not have a specific network of providers, but will provide coverage for any provider that a patient chooses to see for healthcare. poka-yoke Error proofing. preferred provider organizations (PPOs) PPOs offer patients a list of member providers who agree on a predetermined list of charges. prevention Measures how well physicians, in conjunction with patients’ health plans, provide screenings, immunizations, and other preventive services. process A measure of a series of actions taken by healthcare professionals to deliver their services. process flow diagram A type of analytic that maps the general flow of a process. process improvement methodologies A systematic approach to process improvement. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 5/8 12/14/2019 Print process mapping Activities of structural analysis, including drawing out the steps or the flow of a process. process metrics Measurements relating to the activities of delivering healthcare or the interactions between patients and providers. project hoppers Senior management involved in Six Sigma project selection. prospective An approach in which data collection is initiated prior to when an outcome, such as a patient safety event, occurs. proxies Indirect estimates of patients’ health states. pull Allowing the customer’s need for the final product or service to guide how much of that product or service is to be generated or offered. qualitative data Data describing characteristics or experiences of patients. qualitative methods Research methods that focus on the significance of observations made in a study rather than on the raw numbers themselves. quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. quality assurance The reactive method of ensuring quality, which is primarily focused on identifying outliers in the process and removing them to create a uniform standard. quality improvement (QI) A process using quantitative and qualitative methods to improve the effectiveness, efficiency, and safety of, as well as human resources’ performance in, healthcare delivery. quality management The establishment of policies and standards in the healthcare facility to improve health outcomes of medical services provided and continuously aim to achieve better performance. quality measures Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high quality healthcare or that relate to quality goals for healthcare. quantitative data Numerical data, such as weight, time elapsed, or many laboratory test values. quantitative methods Research methods that depend on comparing quantities. record review (chart audit) A data collection process whereby medical records are examined in order to extract information regarding care of individual patients. reliability How stable a measure is when the item being measured does not change. reporting The sixth step in DMAICR; in this step, communication and internal reporting about improvements take place. responsiveness How a measure changes with an underlying change in the item being measured. retrospective An approach in which one looks backward in time. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 6/8 12/14/2019 Print risk adjustment A statistical procedure that seeks to balance differences in patient characteristics (i.e., age or health conditions) when comparing outcomes between healthcare facilities or providers. root cause analysis A problem-solving method that identifies the root causes of errors or problems. rules and regulations More detailed interpretations of healthcare laws, which are made in the executive branch of government by the organizations and agencies responsible for implementing laws and policies. safe care Care that focuses on minimizing the risk of injury. sample size The number of observations (i.e., patients) used to measure a phenomenon. sampling A process to increase the efficiency of measurement by observing only a portion of all cases to measure a phenomenon. satisfaction with physicians Measures how well doctors communicate, rating primary-care doctors, rating specialists, and rating care provided. satisfaction with services Measures how easily and quickly patients receive care. Six Sigma A type of process improvement methodology. social system The group or related units that are involved in communication, adoption, and diffusion. standard work Common process in creating a product or delivering a service and uniform way of approaching a task. statistical process control charts A type of analytic tool used to visually track quality over time. structure A measure of the capacity to provide high quality healthcare in an organization; includes physical plant, medical supplies and materials, and employees, as well as organizational arrangements, policies, and protocols. structure metrics Measures that relate to the characteristics of the setting where care occurs (e.g., resources and facilities). survey A series of queries designed to gather data, often provided in written or electronic format. The Joint Commission (TJC) A non-profit organization that serves as a regulatory agency for quality assurance. time The rate of adoption or the speed with which adoption of an innovation occurs. time lag The time between when an event is measured and when the information becomes available to inform a constituency. timely care Care that focuses on reducing waiting times and being more attentive to patient needs. Toyota Production System (TPS) Formal description of core concepts that were integral to the way Toyota conducted daily activities. tracer methodology A methodology that allows Joint Commission surveyors to evaluate the organization’s systems of providing care and services by using a patient’s record as a roadmap, moving https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 7/8 12/14/2019 Print through areas that individual experienced. treatment (clinical quality measures) Measures how well a doctor or doctor’s office does in providing treatment for certain common conditions. validity Whether an indicator actually measures what it purports to measure. value Quality from the customer’s perspective; what the customer is willing to pay for. value stream Detailed map of all the steps or activities that are required to create a product or service. variation Fluctuation in an existing process or the tendency to revert back to the old system. vertical integration strategies Ways an organization finds to own and operate all of the services necessary for the care of a patient’s condition. For example, a health system may own primary care clinics, specialist clinics, surgical centers, and an inpatient care facility. visual controls A way to relay information about decisions related to efficiency or safety. visual displays Usually used to help communicate information about quality measures. waste Anything that does not add value from the customer’s perspective. https://content.ashford.edu/print/AUHCA375.14.1?sections=glossary&content=content&clientToken=6b7dd2ed-2134-9a34-c1f3-554689cebbab&np=gl… 8/8

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