National patient safety goals: A healthcare system's approach to improvement

Background: In 2003, the Joint Commission began publishing annual National Patient Safety Goals (NPSG) in response to its review of sentinel events and the increased national focus on patient safety and patient safety errors. Despite significant effort on the part of healthcare institutions, many hospitals continue to struggle with implementing systems that support all of the NPSGs. In 2008, the NewYork-Presbyterian Healthcare System (NYPHS) conducted a survey to assess 2008 NPSG compliance, identify opportunities for quality improvement focus as well as identify best practice examples for dissemination system-wide.

Methods: Using a structured interview process and standardized survey instrument, data were collected from key quality and patient safety leaders at each NYPHS site. Survey responses were aggregated and analyzed.

Results: Twenty hospitals, all Joint Commission accredited, 45% teaching hospitals, were surveyed. Variation in approach to implementation of the NPSGs was observed. Goals with the least established monitoring processes include patient active involvement in their care and safety risk which were monitored by 60% and 50% of surveyed institutions respectively. Medication reconciliation (70%), hand hygiene compliance (45%), reporting of critical test results (15%), read back verbal orders (15%), and do not use abbreviations (10%) were the NPSGs reported as most challenging to implement and demonstrate success.

Discussion: From our results, common success factors across all sites and all of the 2008 NPSG's include leadership involvement, multi-disciplinary team approach to the goal, continued education, monitoring and feedback with the use of information technology. Survey results have been used at the system level to develop an Internal Action Plan which include: identifying best practice hospitals for each NPSG; developing a System-wide curriculum of best practice presentations to leaders, including CEO's and Board members as well as clinical and administrative leadership of individual System sites; providing feedback on NPSG attainment using an existing structure of clinical specialty councils, CEO, CNO, CMO, CQO, Infection Control, Respiratory and Pharmacy Forums, as well as electronic media, an intranet site, and the NewYork-Presbyterian journal, “System Quality Review”. Impact of these interventions will be assessed by a follow-up survey to be conducted in Spring 2009. Future work will continue to focus on organizational variables that contribute to successful implementation of Quality Improvement initiatives.