Joint Commission - NPSGs

  1. How do you audit for compliance with the national patient safety goals? How many do you do a month? Do you have a good audit tool? Any other helpful info? I am overwhelmed with the required audits from joint commission, CMS, and our QIO. PLEASE HELP!
  2. 4 Comments

  3. by   homehealth43130
    We audit handwashing at supervisory visits- hits everyone at least once a year as we do an supervisory visit for yearly evals on everyone. I ask 10 people each month what our patient identifiers are. I spread it out so that everyone - even non-visit staff get asked. I sit at intake several times a month and listen to them taking orders for the read back of orders and critical labs - I try and keep busy doing something else so they don't know what I am actually doing - but I am sure they do know. We keep a running log of our critical labs and time of notification of physician which I tabulate each month. When unapproved abbreviations were first implemented, I did 100% review for thoes, but now just hit it quarterly as part of our quarterly chart audits for CMS. We have a policy and procedure in place for oxygen and fire risk in the home and each time we need to implement this, I record it on a log for The Joint Commission. Hand off report is the one we are having most problems with - we instituted the sbar and got some really nice samples off I don't have a formal audit tool for most of these, I record all the audit result information for The Joint Commission on a exell spread sheet with graphs, but I do keep copies of the form that I used to record results on.

    Keeping up with all the auditing is a full time job. I try to combine several audits at a time. If I am looking at our ACH charts, I also do the medication audit - for our OBQI project and medication reconcilliation. I am looking at advance directive information as well as some other documentation areas while I have the chart out. I find this works well for me.

    I try to keep my numbers small - usually 10 - 20 each month since most of our thresholds for The Joint Commission is 90%. I keep my audit questions simple usually answered with yes, no, n/a.

    I have found audit tools on the medqic site, and your qio rep should have some or be able to get some for you. I have also found good audit tools on some of the list serves - NAHC has some good ones for OBQM if you are a member and that list serve is a good one - you do need to be a member to use thoes resources.

    Hope some of this helps.
  4. by   ALHHRN
    It does help. Thank you. What is your average daily census? We do not have a person for audits/PI. It's a joint effort and I feel too like it is a full time responsibility.
  5. by   homehealth43130
    We run between 180 and 200.
  6. by   caliotter3
    At my last agency, the NPSG's were hardly an issue at all. Things were very disorganized between changes in mgmt and I had been on a leave of absence. In some of the charts of clients I found copies of the corporate policy letter, in other's nothing. None of my co-workers (I am not in a supervisory position) could ever tell me about any of this. Apparently, no inservices were held nor were any info letters sent to anybody. I have no idea what the mgrs were doing to get into or show compliance. I saw aborted attempts by the previous mgr at implementing 2 items, but nothing to tell the field workers what was going on (other than reading the corporate policy letter, if a copy had been placed in a field chart).