Joint Commission Releases 2011 NPSGs

July 15th, 2011


By , BSN, RN

Ask any nurse what her number-one job is, and the answer is simple: patient safety. With that in mind, the Joint Commission just released its National Patient Safety Goals (NPSGs) for 2011 and an additional goal for 2012. The NPSGs exist to help accredited healthcare organizations address specific areas of concern in regards to patient safety.

The goals highlight problem areas in health care and promote specific improvements for that area. Using evidence collected form health care institutions and expert-recommended solutions, The Joint Commission demands that facilities put plans into play that help providers deliver safe, high quality health care, integrating system-wide solutions wherever possible.

2011 Goals

For 2011, The Joint Commission is not implementing any new NPSGs; however, four elements of performance (EPs) were revised to remove very specific requirements and allow for the use of new, accepted clinical practices. When the EPs in existing NPSGs were developed, they reflected the best evidence-based knowledge at the time, but medical research is continuously discovering new treatments or changes to existing practices. NPSGs are specific to different types of facilities, for example, while general rules apply to everyone, and there might be some that apply only to a hospital or ambulatory surgery center that do not apply to home health care agencies or mental health facilities. Listed below are the 2011 guidelines:


  • Identify Patients Correctly — This goal is number one on the list for every health care provider.
  • Improve Staff Communication — This seems like a given –if you have better communication, there is less room for mistakes. Document everything that is completed.
  • Use Medicines Safely — These guidelines are applied to every health care provider who work with medications.
    1. Record and pass along correct information about a client’s medicines.
    2. Find out what medicines the client is taking. Compare those medicines to new medicines prescribed.
    3. Make sure the client knows which medicines to take when they are at home.
    4. Tell the client it is important to bring their up-to-date list of medicines every time they visit a doctor.
  • Prevent Infections — Number one under this topic is using the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
  • Identify Patient Safety Risks — Finding out which patients are most likely to try to commit suicide applies in behavioral health care facilities and hospitals.
  • Prevent mistakes In Surgery — By far the most publicized occurrences when they happen, preventing surgical mistakes is an ongoing, never-ending process. Steps include:
    1. Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
    2. Mark the correct place on the patient’s body where the surgery is to be done.
    3. Pause before the surgery to make sure that a mistake is not being made.
  • Prevent Patients From Falling — This NPSG is focused towards Home Care providers. Part of home health is assessing the patient's home for safety issues, like throw rugs not properly secured and unlit rooms and hallways.
  • Prevent Bed Sores — This goal is listed specifically for Long Term Care facilities but applies to anywhere patients are bedridden for long periods of time.

2012 Goals

The Joint Commission has approved one new NPSG for 2012 that focuses on catheter-associated urinary tract infection (CAUTI) for the hospital and critical access hospital accreditation programs. CAUTI is the most frequent type of health care-associated infection and represents as much as 80% of health care associated infections in hospitals.

Goal Development

The Patient Safety Advisory Group is a panel of experts who counsel The Joint Commission. This panel includes nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings.

After receiving input from the Advisory Group and collecting information from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders the Joint Commission makes a list of what are the highest priority safety issues for the following year. These do not necessarily change every year, sometimes the goals are updated or simply continued from previous years.

In 2002, The Joint Commission established its National Patient Safety Goals program; the first set of NPSGs was effective January 1, 2003. The company updates its accreditation standards and expands patient safety goals on a yearly basis, and posts them on its website for all interested persons to review, making this information and process transparent to all stakeholders ranging from institutions, to practitioners, to patients and their advocates.

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