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REGULATORY READINESS
"promoting excellence every day"
Collaborative Governance Magnet Recognition Regulatory Readiness Innovation Units

QUICK LINKS: Joint Commission Lab Survey | Pocket Guides | Tuesday Take Aways | National Patient Safety Goals


The Joint Commission logo

The Joint Commission Announces New 2014 National Patient Safety Goal

In June 2013, The Joint Commission (TJC) approved new National Patient Safety Goal 6.01.01. Improve the safety of clinical alarm systems. This goal will be implemented in tow phases.

  • In Phase 1, which begins January 2014, hospitals are required to establish clinical alarms as an organizational priority and to identify the most important alarms to manage based on the clinical needs of our patients.
  • In Phase 2, which begins in January 2016, hospitals will be expected to develop and implement specific components of policies and procedures and to ensure staff are educated about alarm system management.
Click here for more details

DPH logo

DPH INFECTION CONTROL SURVEY:
The Department of Public Health (DPH) will conduct an Infection Control Survey anytime during 2014.
Resources to help you prepare Click here

Regulatory Readiness Resource Guide for RNs

 

Excellence Every Day Regulatory Readiness Resource Guides:

Operations Associates
Patient Care Associates
Patient Care Services Licensed Staff
Unit Service Associates (English) | Spanish | Creole

     

 

 

The Joint Commission logo

"Joint Commission Readiness" presentation (2/8/12)

QUICK LINKS for JOINT COMMISSION READINESS:
NPSG Resources | Resource Guides | Links | Goal: 1 | 2 | 3 | 6 | 7 |15 | Universal Protocol | Additional Resources


National Patient Safety Goals (NPSGs)


GOAL 1: Use at least two patient identifiers when providing care, treatment, and services

Overview
FAQs
Quiz
10-Minute Mini-Tracer

Tuesday Take Away: Documentation of Blood Transfusion (5/22/2013)

Tuesday Take Away: Accurate Labeling of Lab Specimens

Selected MGH Policies and Procedures Related to NPS Goal 1 (in Trove; internal access only):

Clinical Policy and Procedure Manual

Identity Verification
Specimen Rejection

Blood Transfusion

Nursing Procedure Manual

01. General Procedures - Blood Sampling: venipuncture
Transfusion Therapy Overview

EMAPPS: Electronic Medication Administration Process for Patient Safety

Medication: Administration Non eMAR Units

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GOAL 2: Improve the effectiveness of communication among caregivers

Overview

MGH Clinical Laboratory Callback List
FAQs
Quiz
Tuesday Take Away: Response to Critical Values (6/25/13)
MGH Lab Handbook

Selected MGH Policies and Procedures Related to NPS Goal 2 (in Trove; internal access only):

Clinical Policy and Procedure Manual

Critical Values Results

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GOAL 3: Improve the safety of using medications

Goal 3 has 3 standards related to safe medication management: labeling of medications, anticoagulation therapy, and medication reconciliation.

NPSG.03.04.01:
Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Overview
FAQs
Quiz

Related MGH Policy-Labeling in the OR:

Mixture of Medications on the Sterile Field (internal access only)

NPSG.03.05.01:
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Overview
FAQs

Related MGH Policy-Anticoagulation:

Adult Venous Thromboembolism for Medical Patients (Trove-internal access only)
MGH Anticoagulation Guidelines (MESAC-internal access only)

NPSG.03.06.01:
Maintain and communicate accurate patient medic
ation information.

Overview
FAQs
Quiz

Med Reconciliation

Medication Reconciliation (Clinical Policy and Procedure Manual) (Trove-internal access only)
Medication List Documentation and Management for Ambulatory Patients (Trove-internal access only)

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GOAL 6: Reduce the harm associated with clinical alarm systems.

NPSG.06.01.01
Improve the safety of clinical alarm systems.
FAQs
Quiz

Joint Commission Sentinel Event Alert
Biomed Website
Healthstream Courses:

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GOAL 7:

Goal 7 has five standards related to preventing healthcare-associated infections.

FOR STAFF: Infection Control: Dos and Don'ts

PATIENT EDUCATION MATERIALS:

NPSG.07.01.01:
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
Overview

NPSG.07.03.01:
Implement evidence-based practices to prevent health-care associated infections due to multi-drug resistant organisms in acute care hospitals.
Overview

NPSG.07.04.01:
Implement evidence-based practices to prevent central line-associated bloodstream infections
Overview

NPSG.07.05.01:
Implement evidence-based practices to prevent surgical site infections

NPSG.07.06.01:
Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). *
Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is no consensus that these practices apply to children.
Overview

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GOAL 15:

NPSG 15.01.01 Identify patients at risk for suicide.

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Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

UP.01.01.01: Conduct a preprocedure verification process. Overview

UP.01.02.01: Mark the procedure site. Overview

UP.01.03.01: A time-out is performed before the procedure. Overview

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ADDITIONAL RESOURCES

IN-HOUSE

Glossary of Terms

Blum Patient and Family
Learning Center

Maxwell V. Blum Cancer Resource Room

Regulatory Readiness

Magnet @ MGH

MGH "Excellence Every Day" site

MGH Center for Quality & Safety

PCS Office of Quality & Safety

Treadwell Library

   

EXTERNAL

Agency for Healthcare Research
and Quality (AHRQ)

American Hospital Association

American Nurses
Credentialing Center (ANCC)

Centers for Disease Control
and Prevention (CDC)



Institute for Healthcare Improvement (IHI)

Institute of Medicine (IOM)

Joint Commission

National Committee for
Quality Assurance (NCQA)

National Database of Nursing Quality Indicators (NDNQI)

National Patient Safety Foundation

 

 

If you have questions or suggestions related to the Regulatory Readiness portal, please contact Georgia Peirce at (617) 724-9865 or via email at gwpeirce@partners.org.

updated 1/6/14

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