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Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Section 1: Age-Specific Patient Care

Introduction

Purpose/Overall Goal

Course Objectives

Communication Across the Ages

Complex Communication Needs

Neonates: Birth-28 Days

Infants and Toddlers: 0-3 Years

Young Children: 4-6 Years

Older Children: 7-12 Years

Adolescents: 13-20 Years

Young Adults: 21-39 Years

Middle Adults: 40-64 Years

Older Adults: 65-79 Years

Adults Age 80 And Older

Summary

References

Section 2: Cultural Competence

Introduction

Purpose/Overall Goal

Course Objectives

Cultural Diversity

Valuing Diversity

Assessing One’s Own Cultural Competency

Managing Cultural Differences

Managing Cultural Differences: Asking Nonjudgmental Questions

Managing Cultural Differences: Listening Carefully

Managing Cultural Differences: Setting Realistic Goals for Behavior Change

Managing Cultural Differences: Solving Problems Together

Managing Cultural Differences: Working with An Interpreter

Incorporating Cultural Knowledge into Care

Adapting to Diversity

Barriers to Culturally Competent Care

Clinical Outcomes

Summary

References

Section 3: Ethics

Introduction

Purpose/Overall Goal

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Course Objectives

Ethical Standards

Organizational Ethics

Individual Rights

Individual Responsibilities

Benefits of An Ethics Program

Integrated Ethics Model

Shared Decision-Making with Patients

Patient Privacy and Confidentiality

Professionalism in Patient Care

Ethical Practices in the Workplace

Examples of Ethical Dilemmas

Summary

References

Section 4: 2019 National Patient Safety Goals for Hospitals Nursing Education Module

Introduction

Course Objectives

Goal 1: Improve the accuracy of patient identification.

Goal 2: Improve the effectiveness of communication among caregivers.

Goal 3: Improve the safety of using medications.

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

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 15: The hospital identifies safety risks inherent in its patient population.

Universal Protocol

Resources

Section 5: Patient Rights

Introduction

Purpose/Overall Goal

Course Objectives

The Patient’s Bill Of Rights

Nurses as Patient Advocate

Patient Responsibilities

Summary

References

Section 6: Patient Safety Systems and Events

Introduction

Purpose/Overall Goal

Course Objectives

Key Terms

Sentinel Events

Comprehensive Systematic Analysis

Action Plans

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Patient Safety Systems

Summary

References

Congratulations!

Section 1: Age-Specific Patient Care

Introduction

Every patient is different – and so is every age group. As a caregiver, you must be aware of certain considerations related to each age group and ways to effectively communicate with patients of various ages. It is important to understand patient needs and what they might be facing at certain times of their lives. This can help you identify issues such as speech or hearing impairments, stress, learning disabilities, depression, and much more. Educating yourself about these factors can help you deliver the best care possible to your patients.

Purpose/Overall Goal

This module outlines age-specific care and best practices for nine different age groups, from birth to age 80 and beyond. The goal of this module is to provide healthcare workers with information on how to physical, emotional, social, spiritual, and other needs for different age groups, and how to adjust your patient care with age-specific needs in mind.

Course Objectives

After completing this module, the learner should be able to:

• Demonstrate appropriate communication skills for various age groups

• Describe appropriate healthcare practices for various age groups

• Explain physical and emotional considerations for patients of different ages

• Describe common health conditions to assess in patients at various life stages

Communication Across the Ages

As a healthcare worker, clear communication with patients is key to providing good age- specific care. Each age group has unique physical, psychosocial, and cognitive needs, as well as unique fears and stressors. By understanding the age-specific needs usually associated with each stage of life, you can provide better, more appropriate care, tailored to the needs of each individual. For every patient across all age groups you should: Assess primary language

• Check for speech or hearing impairments

• Check for confusion, depression, and signs of illness or stress

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Be aware of possible learning disabilities

• Be mindful of cultural differences

• Understand family structure

Regardless of a patient’s age, caregivers must respond to the need of each patient and family for:

• Safety

• Privacy

• Confidentiality

• Comfort

• Pain management

• Healthcare choices

Complex Communication Needs

Keep in mind that individuals with complex communication needs (CCN) who cannot communicate by natural speech alone have the same social, emotional, and physical needs as other individuals. Communication supports, also known as augmentative and alternative communication (AAC), can help these individuals express themselves. Examples of AACs include:

• Gestures and body language

• Sign language

• Paper and pencil written communications

• Picture boards or books

• Devices that produce voice output (speech generating devices) or written output

• Electronic communication aids that use picture symbols, letters, and/or words and

phrases to create messages

Neonates: Birth-28 Days

The first 28 days of life are a time when neonates are in a state of total dependency and their basic body functions are being established. The following is a checklist of functions to test:

• Reflexes such as grasping, gagging, and startling

• Vital signs (temperature, pulse, respiration)

• Steady weight gain

• Blood glucose levels when appropriate

Keep these practices in mind:

• Always handle the neonate in a gentle, comforting manner to avoid overstimulation.

• Swaddling increases feeling of security and comfort.

• Teach parents proper childcare skills for feeding, diapering, cord care, and bathing.

• Teach parents to always put the baby down on his or her back for sleeping, to help avoid

sudden infant death syndrome (SIDS).

• Make sure parents understand the importance of safety devices such as car seats.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Infants and Toddlers: 0-3 Years

Infants and toddlers grow and learn rapidly. Although they are dependent, this is when they begin to develop a separate self. With infants:

• Limit the number of staff workers assigned to each one to avoid “stranger anxiety.”

• Always speak to an infant before a touch to avoid startling him or her.

When delivering care to toddlers:

• Keep in mind that toddlers are impulsive and their moods change quickly.

• Expect an exaggerated response to pain, frustration, and changes in the environment.

• Give one direction at a time, since toddlers have a short attention span.

• Speak at eye level with the child and maintain eye contact.

• Discuss procedures with toddlers immediately before they happen, not too far in

advance, since their sense of time is the immediate present.

• Use play to prepare for and explain procedures.

• Provide support and comfort during procedures.

• Use the least intrusive procedures possible, such as axillary temperature and oral

medications.

When speaking with parents:

• Emphasize proper hand-washing as a way to prevent disease transmission.

• Encourage parents to communicate with the child, and to touch and cuddle.

In infants and young children, small veins may make inserting an intravenous (IV) line a challenge. Keep these facts in mind:

• Be aware that the child may want to play with the IV tubing.

• Secure the site with a transparent dressing so you can see it easily.

• Inspect and palpate the site every hour.

• Avoid wrapping tape too tightly.

Young Children: 4-6 Years

For children ages 4 to 6 years, some common fears are the dark, being left alone, and bodily injury. It is important to advise parents to:

• Keep immunizations and checkups on schedule

• Teach the child healthy habits for nutrition and grooming

• Learn about safety equipment such as bicycle helmets, elbow pads, and kneepads

• Enforce safety issues regarding fire and pools

When providing care:

• Explain the procedure to the child as well as the parents.

• Never lie to the child about whether something will hurt; instead, tell the child that it won’t

hurt for long.

• Preschoolers are beginning to explore their own bodies, so procedures involving the

genitalia can be especially anxiety-producing.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Explain when parents will return; preschoolers can understand this concept and can find

it comforting.

• Keep in mind that children of this age engage in magical thinking and may become

fearful based upon imagined threats.

• Emphasize that the child will wake up after anesthesia.

Be extra careful when giving medications to infants and young children.

• Because of their small size and immature body systems, children are at a higher risk for

adverse effects.

• Medication errors are three times more common among pediatric patients as compared

to adult patients.

• Medication errors have 10 times the potential for harm in children.

Older Children: 7-12 Years

For children ages 7 to 12, use these approaches:

• Talk, sing, or use distractions such as colorful stickers to divert attention from frightening

procedures.

• Encourage the child to ask questions and talk about feelings.

• Respect the child’s need for privacy.

• Allow the child to make some care decisions (such as “In which arm do you want the

injection?”).

• Give permission to display fear or pain.

• Prepare the child for procedures ahead of time.

• Ensure that the child understands the healthcare information you provide.

Keep these factors in mind for children at this age:

• They may have a great fear of the unknown, pain, death, loss of control, or disappointing

others.

• They may resent forced dependence and lack of privacy.

• They may view illness or pain with guilt or as punishment.

• Living up to expectations is very important.

Adolescents: 13-20 Years

Between ages 13 and 20, an adolescent’s body grows into sexually maturity, and complex thinking develops. Keep the following in mind when caring for adolescents:

• Adolescent patients should be treated as adults to foster an atmosphere of trust and

respect.

• Speak directly to adolescents instead of talking through their parents.

• Invite adolescents to participate in decision making and whether a parent should be

present.

• Respect privacy and opinions.

• Encourage questions and verbalization of feelings.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Be honest.

• Explain treatments and procedures thoroughly.

• Be considerate of how procedures, treatments, etc., may affect appearances and

relationships.

• Discuss plans for future and how illness may affect it.

When working with adolescents:

• Check for signs of common adolescent health problems such as the nutritional

disorders, obesity, anorexia, bulimia, and sexually related health problems such as

STDs.

• Adolescents with a family history of genetically related diseases should learn about their

family history and be screened appropriately.

• Adolescent girls should be taught breast self-examination; adolescent boys should be

taught testicular self-examination.

• Maintain an updated knowledge base about acne causes and treatments, since acne is

a major concern for this age group.

• Assess illicit substance use and sexual activity in private.

• Seek follow-up referral or resources if you notice signs of depression or suicidal

thoughts; suicide is the third most frequent cause of death in this age group.

• Provide support, information, and encouragement related to threats to body image.

• Expect that adolescents may experience mood swings due to hormonal changes,

relationships with parents and peers, and identity adjustments.

• Adolescents may experience increased perception of pain.

Young Adults: 21-39 Years

Key concerns when caring for young adults age 21 to 39 are support, honesty, and respect for personal values. Stress can be a factor, since this stage of life usually includes major changes such as marriage, having children, and career adjustments. Age-specific care for young adults includes:

• Involve patients with their plan of care and in making decisions.

• Support their health care decisions, even if you disagree with them.

• Explore the impact of their hospitalization or illness on work, family, and other

commitments.

• Never use terms of endearment (such as honey, sweetie, darling).

• Acknowledge and respect their commitments to family and career.

• Acknowledge and address their worries about the future.

Middle Adults: 40-64 Years

Adults ages 40 to 64 are often reevaluating priorities and making plans for retirement. Respect the fact that most middle-aged adults are at the peak of their influence and authority, and they may be distressed by forced dependency in the patient role. Be alert for:

• Serious chronic conditions that often develop at this age, such as diabetes, breast

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

cancer, and prostate disorders

• Stress from a midlife crisis that may result in depression or other mental issues

• Stress from being in the “sandwich generation” – the generation responsible for caring

for their parents as well as their children

Age-specific care for this age group includes:

• If appropriate, encourage talking about concerns, plans, finances.

• Keep a hopeful attitude and help patients concentrate on strengths, not limitations.

• Respect their decisions and give them as much control over their care as possible.

• Never use terms of endearment (honey, sweetie, darling).

• Allow verbalization of fears and concerns.

• Provide privacy.

Check for the following conditions:

• Skin breakdown due to dryness and decreased subcutaneous tissue

• Hypertension and hyperlipidemia, which may not be the cause of hospitalization but may

be detected during hospitalization

• Sleep apnea

• Skeletal injury due to diminished bone density and osteoporosis, especially in women

• Obesity due to slower metabolism

• Nutritional deficiencies

• Farsightedness, which is common in middle-aged patients; if the patient does not have

reading glasses or magnifiers, ensure that any important reading material (such as forms

requiring signature, menus, etc.) is printed in a larger type size, or read the materials

aloud for the patient

Older Adults: 65-79 Years

Adults ages 65 to 79 may experience some decline in physical abilities and sensory perception. Use of medications can include multiple medications and can be complex. It is important to help older adult patients work out a manageable medication schedule. Stay alert to signs of common chronic conditions at this age, such as:

• Arthritis

• Hypertension

• Hearing impairment

• Heart disease

• Digestive and esophageal problems such as reflux

• Bladder and bowel problems

Age-specific care for older adults includes:

• Explain procedures using appropriate and understandable terms.

• Provide warmth if necessary because of the possibility of decreased heat regulation.

• Provide adequate lighting.

• Be alert to impairments that may inhibit mobility or daily activities.

• Provide advice on home safety.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Preserve dignity and autonomy as much as possible.

• Involve the family with the plan of care, if appropriate.

• Encourage reminiscing.

• Validate concerns.

• Care may require reorientation to environment, time, and day.

• Never use terms of endearment (honey, sweetie, darling).

Keep in mind that many older adults experience losses and grieve these losses, such as the loss of:

• Physical capabilities

• Memory

• A spouse

• Friends

• Independence

Adults Age 80 And Older

Do not assume that mental decline has occurred in all patients 80 and older. Signs of confusion may instead be signaling a treatable illness or depression. Be on the alert for:

• Chronic illnesses and major health problems

• Complicated medication schedules that are not always followed

• Changes in digestive functions, such as taste, chewing, and bowel functions, which

might compromise proper nutrition

Age-specific care for elderly and older frail adults includes:

• Do not treat older adults like children, as patients will likely sense this and resent being

patronized.

• Preserve dignity and autonomy as much as possible.

• Encourage reminiscing and talking about feelings, fears, loss, grief, and end-of-life

decisions.

• Promote home safety and medication safety.

• Change patients’ positions frequently to avoid skin breakdown.

• Ensure patients are warm.

• Provide adequate lighting.

• Ensure safety in the hospital setting to avoid falls and injuries.

• Care may require reorientation to environment, time, and day.

• Never use terms of endearment (honey, sweetie, darling).

Keep the following in mind:

• IV starts and blood draws are often difficult due to fragile veins.

• IV therapy presents the risk of fluid overload, since fluid balance is more delicate with

elderly persons.

• The elderly are particularly vulnerable to dehydration, which may present as confusion.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Fragile skin is easily torn during tape removal, and moving in bed can also injure fragile

skin.

• Fractures may result from very minor trauma due to osteoporosis.

• Sensory impairments (vision, hearing, balance problems, loss of feeling in feet) increase

with age.

• Immunizations should be updated, particularly against influenza, which can be life

threatening for older adults.

The Gerontological Society of America suggests these tips to improve interactions with older adults:

• Face older adults when you speak with them, with your lips at the same level as theirs.

• Minimize background noise.

• Monitor and control your nonverbal behavior.

• Speak in simple terms when conveying critical information.

• Use visual aids such as pictures and diagrams to help clarify and reinforce

comprehension of key points.

• Verify listener comprehension during a conversation.

Summary

Effective communication between you and your patients can play a major role in good healthcare outcomes. A better understanding of age-related factors influencing health and well- being can lead to better communication skills. Knowing the differences between each age group, and knowing the best ways to communicate with each, can help you provide the most accurate assessments and the highest level of care.

References

Age-Specific Competencies and Skills. Sun Coast Hospital Pharmacy. Available at: https://www.quia.com/files/quia/users/juliehl2/Age-Specific-Competency. Accessed October 27, 2016. Age-Specific Considerations in Patient Care. AMN Healthcare, Inc. Available at: https://lms.rn.com/getpdf.php/587.pdf. Accessed October 27, 2016. Augmentative and Alternative Communication (AAC). American Speech- Language-Hearing Association. Available at: http://www.asha.org/public/speech/disorders/AAC/. Accessed October 27, 2016. Beukelman DR, Ray P. Communication supports in pediatric rehabilitation. Journal of Pediatric Rehabilitation Medicine, Vol. 3, No. 4, 2010, p. 279-288. Communicating with Older Adults. The Gerontological Society of America. Available at: http://aging.arizona.edu/sites/aging/files/activity_1_reading_1.pdf. Accessed October 27, 2016. Developmentally Appropriate Care of the Adult Patient. HealthStream. Available at: http://www.healthstream.com/hlchelp/Administrator/2010_08_Developmentally_Appropriate_ Care_of_the_Adult_Patient.pdf. Accessed October 27, 2016.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Developmentally Appropriate Care of the Adult Patient. HealthStream. Available at: http://www.healthstream.com/hlchelp/Administrator/2010_08_Developmentally_Appropriate_ Care_of_the_Adult_Patient.pdf. Accessed October 27, 2016. DeVoe JE, Wallace LS, Fryer, GE. Patient Age Influences Perceptions About Health Care Communication. Fam Med 2009;41(2):126-33. Effective Communication in Children’s Hospitals. Central Coast Children’s Foundation Augmentative Communication Inc. Rehabilitation Engineering Research Center on Communication Enhancement. Available at: http://www.patientprovidercommunication.org/pdf/25.pdf. Accessed October 27, 2016. Interviewing and communicating with adolescents. University of Southern California Keck School of Medicine. Available at: https://www.usc.edu/student- affairs/Health_Center/adolhealth/content/a4.html. Accessed October 27, 2016. Population-Specific Considerations. Upstate Medical University. Available at: http://www.upstate.edu/hr/document/pop_spec_clin_ss.pdf. Accessed October 27, 2016. Society for Adolescent Health and Medicine. Available at: http://www.adolescenthealth.org/Home.aspx. Accessed October 27, 2016. Speech and Language Developmental Milestones. National Institute on Deafness and Other Communication Disorders. Available at: https://www.nidcd.nih.gov/health/speech-and- language. Accessed October 27, 2016. Vision, Hearing, Balance, and Sensory Impairment in Americans Aged 70 Years and Over: United States, 1999-2006. U.S. Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/data/databriefs/db31.htm. Accessed October 27, 2016. What are Age-Specific Competencies? University of Florida Health, Jacksonville. Available at: http://ufhealthjax.org/volunteer/new/documents/age-specific-competencies.pdf. Accessed October 27, 2016.

Section 2: Cultural Competence

Introduction

Cultural competence is the ability of healthcare providers to understand and respond effectively to the cultural and language needs of all patients. Studies show that incorporating the concepts of cultural competence into healthcare can increase patient satisfaction and lead to better outcomes. Patients representing many cultural groups – with diverse concepts of illness and healthcare now reside in the United States. To deliver the best care possible, healthcare workers must acquire new knowledge and competencies to meet their needs. What’s more, there is clear evidence of disparity in healthcare access and health status across racial and ethnic groups within the U.S. population. This serious situation calls for educating

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

healthcare workers about the knowledge and skills necessary to provide quality care to a diverse population.

Purpose/Overall Goal

This module outlines ways in which you as a healthcare worker can improve your awareness and understanding of various cultural factors that may influence healthcare delivery. The goal of this module is to ensure that you have the knowledge you need to deliver the highest quality of care to diverse patient populations while respecting their traditions, beliefs, and values.

Course Objectives

After completing this module, the learner should be able to:

• Define cultural competence

• Demonstrate increased self-awareness and receptiveness to diverse patient populations

• Describe how to manage cultural differences when delivering care

• Demonstrate how to incorporate cultural understanding into care delivery

• Explain how to overcome barriers posed by cultural diversity

Cultural Diversity

As the United States becomes more ethnically and racially diverse, healthcare workers must understand and respect patients’ varied perspectives regarding health and wellness. The concept of “cultural competence” in healthcare has emerged to address factors that may contribute to racial or ethnic disparities in care delivery. Cultural competence in healthcare describes the ability of workers to provide quality care to patients with diverse values, beliefs, and behaviors. In some cases, it may involve tailoring care delivery to meet the social, cultural, and language needs of patients. Culture is defined as a pattern of learned beliefs and behaviors that are shared among groups. It includes:

• Thoughts and beliefs

• Styles of communicating and interacting

• Views on roles and relationships

• Values, practices, and customs

Culture is shaped by various influences, including:

• Race, ethnicity, nationality

• Language

• Gender

• Socioeconomic status

• Physical and mental ability

• Sexual orientation

• Occupation

Failing to understand and manage these sociocultural differences may have significant health consequences – for minority groups in particular.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

According to The Joint Commission, five essential components of cultural competence for healthcare workers are:

• Valuing diversity

• Assessing one’s own cultural competence

• Managing cultural differences

• Incorporating cultural knowledge into care

• Adapting to diversity

These five components are explained in the following sections.

Valuing Diversity

As a healthcare worker, you must become aware of your personal attitudes and biases that may consciously or unconsciously influence your care of patients as well as your interactions with colleagues. A “one size fits all” approach to the care of patients from diverse backgrounds is not useful – and it risks potentially dangerous stereotyping and overgeneralization. To help you value diversity, keep the following in mind:

• There is no single way to treat any racial and ethnic group, due to the great diversity

within each.

• Interventions should be evidence-based, ethical, and flexible enough to be tailored

appropriately to each patient.

• Becoming more culturally aware can help eliminate racial and ethnic disparity in care

delivery.

• Challenge and confront racism, sexism, classism, and other forms of prejudice and

discrimination that may occur in clinical encounters as well as in the society at large.

Assessing One’s Own Cultural Competency

As a healthcare worker, assessing your own cultural competence:

• Involves an honest desire not to allow biases to keep you from treating every individual

with respect

• Requires an honest reflection on what your positive and negative assumptions are about

others

This is not easy; no one wants to admit that they suffer from cultural ignorance or harbor negative stereotypes and prejudices. But learning to evaluate your own level of cultural competency must be part of your ongoing effort to provide better healthcare. Assessing your unfounded assumptions and any prejudicial thoughts:

• Helps you understand the impact of your unconscious or automatic thinking about others

• Helps you create new mental models of your patients that will, in turn, contribute to the

quality of the care you deliver

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Managing Cultural Differences

The key to a patient’s ability to adhere to treatment is effective communication. But when healthcare providers and patients come from different cultures and perhaps speak different languages, it can be difficult to communicate effectively. Adherence depends on:

• A patient’s acceptance of information about the health threat itself

• The provider’s ability to educate the patient on the benefits of a particular treatment

• The patient’s perception of the provider’s credibility, empathy, and concern

Five activities can contribute greatly to effective communication:

• Asking nonjudgmental questions

• Listening carefully

• Setting realistic goals for behavior change

• Solving problems together

• Working with an interpreter

These activities are described in the following sections.

Managing Cultural Differences: Asking Nonjudgmental Questions

To accomplish this:

• Be empathetic regarding your patient’s viewpoints, values, daily responsibilities, and

problems.

• Encourage patients to be honest and open with you about their beliefs and concerns.

• Keep in mind that cultures place different values on time. For some, acting hurried or

impatient can seem like a sign of disrespect.

• Take time to ask questions and listen. A patient who feels respected will be more likely

to respond honestly and completely.

Here are examples of the kinds of questions that may help you gain important insights:

• What do you think caused your illness?

• What kind of impact has it had on your life?

• What remedies have you tried?

• What do you hope to get out of this visit?

• Is money a concern, and should we consider less expensive treatment options first?

• Is your illness having an impact on your family?

• Do you have friends or relatives who can help you adhere to treatments, such as

watching your children when you buy medicine or attend follow-up visits?

• Will you be able to read the directions on the medicine bottle, and if not, is there a

responsible person in your family who can read it for you?

Managing Cultural Differences: Listening Carefully

Keep in mind these tips to help you listen carefully to patients of all cultures:

• Listen to the patient without interrupting or letting your mind wander.

• Show your genuine interest in the patient’s replies.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Be still; don’t fidget or sigh.

• Take notes but don’t doodle.

• Show that you have been listening by rephrasing your patients’ comments. This will give

patients an opportunity to understand what you heard them say, and to explain again if

what you understood is not what they meant.

Misunderstandings are common even when the patient and provider come from the same culture. When a patient and practitioner come from different cultures, the likelihood of miscommunication is greatly increased.

Managing Cultural Differences: Setting Realistic Goals for Behavior Change

Changing behaviors is a challenge for most people, and it could be even more so when cultural differences come into play. Patient compliance may improve if you consider the social and family context when discussing lifestyle changes. Dietary changes are among the most difficult, because food and diet are closely related to culture. A patient care plan often includes a change in diet, yet a patient’s culture may include dietary stipulations or restrictions.

• Some cultures have strict beliefs about what women can eat during pregnancy or if she

has recently given birth.

• Some cultures follow food guidelines based on religious beliefs.

To help patients find ways to gradually change dietary patterns that may be harmful, you should first:

• Show respect and understanding for the patient and for the cultural tradition

• Ask about beliefs and traditions so you can learn more about them

Some Examples: Reducing fat in the diet can be a major challenge for some.

• Is it realistic for patients to significantly reduce fat in their diet if the family’s culturally

appropriate diet is rich in fats?

• Ask your patient if obesity is a problem for several family members and, if so, would it be

appropriate to make fat reduction a family goal rather than a personal one?

• Perhaps this could begin by reducing the level of oil or fat in three dinners per week

instead of every meal.

Reducing sugar intake also can be a problem in some families.

• Do they eat dessert with every dinner, or with every lunch and dinner?

• Will the family feel deprived if they change this habit?

• Will they be supportive of a family member who needs to reduce her intake of sweets?

• Maybe they would consider having desserts only on weekends instead of every day – or

at one meal a day instead of two.

Salt intake is another example.

• If a family is accustomed to using soy sauce with most meals, it is probably unrealistic to

expect them to eliminate soy sauce from their diet.

• Would they be willing to use a reduced-salt soy sauce?

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Working with patients to set these types of smaller goals may lead to greater success with behavior change in the long term.

Managing Cultural Differences: Solving Problems Together

For many adults, a lecture – whether from a provider, boss, family member, or teacher – is not the most effective way to receive and act on a health message. If you are trying to explain a treatment and find a patient looking away, stirring restlessly, or sighing, it may be a sign that you have lost the patient’s attention. Most adults are better able to pay attention and remember instructions if they are involved in identifying their problems and seeking practical solutions. For example: You have a patient who is not supposed to drink alcohol.

• Ask him what he would do if he were at a family or work event where alcoholic

beverages were provided for everyone.

• Your patient’s answer may reveal that he is more concerned with offending other family

members or his boss than he is with following your advice.

• You may be able to offer him a way out of his dilemma, such as a tactful humorous

remark, or a glass of club soda that looks like an alcoholic drink.

You also might try role play:

• Ask the patient to pretend that he is explaining his health problems and the necessary

care to family members.

• This can reveal how well he understands his illness and treatment, and can help to clear

up any misconceptions.

Managing Cultural Differences: Working with An Interpreter

Professional interpreters:

• Must be proficient in at least two languages

• Must be able to convey complex messages using words and grammar that are

appropriate to both providers and patients

• Must be able to convey messages without interjecting their own opinions, beliefs, and

prejudices

• Must know their role, limitations, and responsibilities as an interpreter for others

Keep in mind that in their effort to be helpful, family members, friends, and other “informal” interpreters are more likely to modify what a patient has actually said.

• Relying on these types of interpreters may mean that a health organization or individual

provider is violating Title VI of the Civil Rights Act of 1964.

• Title VI and its supporting regulations guarantee individuals with limited English

proficiency (LEP) any language assistance they need to guarantee “meaningful access”

to health and social services that receive any form of federal funding.

Therefore, you must make a diligent effort to find professionally trained, qualified interpreters. Qualified medical interpreters have additional skills that enable them to work effectively in health

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

settings:

• They have studied the basics of anatomy and physiology.

• They may know the meanings of medical terms, diseases, and procedures and should

be able to make complex medical terminology understandable in the everyday language

of patients.

• They know words that may be “taboo” in the language or culture of the patient and the

euphemisms that may be used instead.

• They are familiar with the common health beliefs and practices of the cultures whose

languages they speak.

• They understand and have been taught to handle the “triadic” relationship, which is the

dynamics introduced by having a third person added to a medical encounter.

Keep the following in mind regarding interpreters:

• Simply being bilingual in English and another language does not qualify an individual as

an interpreter.

• Don’t depend on children or other relatives and friends, or nonmedical staff, to interpret.

• Nonmedical staff members should not be asked to interpret unless it is a dire emergency

and more qualified professionals are not available.

• Follow your organization’s policies and procedures for finding an interpreter appropriate

for the situation; many institutions use an interpreter service for all language translation

needs.

Incorporating Cultural Knowledge into Care

Incorporating cultural knowledge into care involves understanding how certain movements and customs can mean different things to different people. The U.S. Department of Health and Human Services has developed the following list of nonverbal communications to keep in mind. Facial Expressions

• Although smiling is an expression of happiness in most cultures, it can also signify other

emotions. Some Chinese, for example, may smile when they are discussing something

sad or uncomfortable.

• Winking has very different connotations in different cultures. In some Latin American

cultures, winking is a romantic or sexual invitation. In Nigeria, Yorubas may wink at their

children if they want them to leave the room. Many Chinese consider winking to be rude.

• In Hong Kong, it is important not to blink one’s eyes conspicuously, as this may be seen

as a sign of disrespect and boredom.

• Some Filipinos will point to an object by shifting their eyes toward it or pursing their lips

and point with their mouth, rather than using their hands.

• Some Venezuelans may use their lips to point at something, because pointing with a

finger is impolite.

• Expressions of pain or discomfort such as crying are also specific to various cultures.

Some cultures may value being stoic, while others may encourage more emotion.

Head Movements

• In Lebanon, the signal for “yes” may be a nod of the head. To signal “no,” a Lebanese

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

may point his or her head sharply upward and raise the eyebrows. Saudis may signal

“yes” by swiveling their head from side to side. They may signal “no” by tipping their

head backward and clicking their tongue.

Hand and Arm Gestures

• The “OK” sign is interpreted in Japan as the symbol for money, because the circular

shape of the index finger and thumb together suggest the shape of a coin. In Argentina,

Belgium, France, Portugal, Italy, Greece, and Zimbabwe, the sign means “zero” or

“nothing.” In some Eastern European countries, the gesture indicates a bodily orifice and

is highly offensive.

• In some parts of the U.S., to hold up crossed fingers is to wish good luck, but to hold

crossed fingers behind your back negates whatever pledge or statement you’re thinking.

In Russia, this is a way of rudely rejecting or denying something. In Argentina and Spain,

this sign is made to ward away bad luck. In China, it signifies the number ten.

• The “thumbs-up” gesture has a vulgar connotation in Iran.

• In Colombia, tapping the underside of the elbow with the fingers of the other hand

suggests that someone is stingy.

• Many Chinese people point with their entire hand; using the forefinger to point is viewed

as rude. Similarly, in India one may use a full hand to point, but never just a single finger.

• In Latin America, a shrug with the palms facing skyward may be interpreted as a vulgar

gesture.

Personal Space

• Compared to most people in the U.S., Latin Americans are accustomed to standing and

sitting close to people who are not well known to them. Even within the majority

population in the U.S., there are important variations in the size of the personal space

comfort zone.

• People from the Middle East may stand quite close when talking with each other.

• In some Muslim cultures, a woman may be alarmed if a man, even a male physician,

stands or sits too close to her.

Touching

• In some cultures, light touching of the arm or a light kiss to the cheek is very common,

even among people who have just met. People from Latin America and Eastern Europe

may be very comfortable with this kind of touching, whereas people from many Asian

cultures may prefer less physical contact with acquaintances.

• Touching another person’s head is considered offensive by some people from Asia and

the Middle East. It is therefore inappropriate to pat a child on the head.

• Some Chinese may be uncomfortable with physical contact early in a relationship.

Although many Chinese will use a handshake to greet a Westerner, any other contact

may be considered inappropriate. This is especially important to remember when dealing

with older people or those in positions of authority.

• Men in Egypt tend to be more touch-oriented; a handshake may be accompanied by a

gentle touching of the recipient’s elbow with the fingers of the left hand.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• A strong, warm handshake is the traditional greeting between men in Latin America.

However, because most Latin Americans show affection easily, male friends, like female

friends, may embrace. Women may lightly brush their cheeks together.

• Throughout most of the Middle East, it is the custom to reserve the left hand for bodily

hygiene. For this reason, one should never offer the left hand to shake hands or accept

a gift. This is also true of some African cultures.

• A Western woman should not initiate a handshake with a man in India. Many Indian

women will shake hands with a foreign woman, but not a foreign man.

• To many Indians, it is considered rather offensive to (even accidentally) step on

someone’s foot. Apologies should be made immediately.

Eye Contact

• Making direct eye contact is a sign of disrespect in some cultures. In other cultures,

refusing to make direct eye contact is a sign of disrespect. Many Asians may be

reluctant to make eye contact with an authority figure. For example, when greeting a

Chinese, it is best to avoid prolonged eye contact as a sign of respect and deference.

• Many Middle Easterners have what North Americans and Europeans consider “languid

eyes.” It may appear that the person’s eyes are half closed, but this does not express

disinterest or disrespect.

• In Ghana, young children are taught not to look adults in the eye because to do so would

be considered an act of defiance.

• In Latin America, good eye contact is important in both social and business situations.

Physical Postures

• In many cultures throughout the world, it is impolite to show the bottom of the shoe,

which is often dirty. Therefore, one should not sit with the foot resting on the opposite

knee.

• In Argentina, standing with the hands on the hips suggests anger, or a challenge.

• In many cultures, slouching or poor posture is considered to be disrespectful. For

example, good posture is important in Taiwan, with Taiwanese men usually sitting with

both feet firmly fixed to the floor.

Family Interaction In many of the world’s cultures, an individual’s health problems are also considered the family’s problems, and it is considered threatening to exclude family members from any medical interaction. For these patients, providers must address the individual’s health problem in the context of his or her family. Family members can provide valuable information regarding the patient’s diet, health behavior, daily activities, and types of alternative medications used. Their involvement in a treatment plan may be vital to a patient’s ability to adhere to the recommended treatment. At the same time, it is not always culturally appropriate to involve family members, and the provider must be sensitive about when this may NOT be appropriate. Pregnancy and Childbirth

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

In many cultures, men are not involved in the activities surrounding pregnancy or childbirth. Despite this apparent exclusion, husbands are responsible for making decisions and giving permission for treatment, medication, and hospital stay. A provider needs to be ready to involve the mother, mother-in-law, sister, and/or aunt (rather than the husband) in the development of a patient care plan during pregnancy and after childbirth in families that follow this tradition. Female relatives may also be the most appropriate persons to take care of such tasks as having the husband sign the necessary consent forms or explaining suggested treatment options.

Adapting to Diversity

As a healthcare provider, you may find that adapting patient care to cultural diversity is often necessary. Doing this effectively involves certain cultural considerations:

• Gender and taboos

• Food

• Alternative medicine

Gender and Taboos The roles of men and women, and the issues that they are able to discuss openly together, vary greatly from one culture to another. For example, in some cultures:

• A son should not converse with his mother’s obstetrician about her care

• A wife should not converse with her husband’s urologist, or even his cardiologist

Food: An Important Factor in Culture The food normally served in U.S. hospitals tends to cater to what is seen as a “typical” bland American diet. This poses a significant problem for patients whose standard diet may be significantly different. Providers should engage the patient’s family in this issue.

• Can the family bring food to the hospital?

• Does the family know that certain foods will be beneficial and that others may be less

beneficial?

By involving the family in designing an appropriate diet for the patient, the provider will ensure that the family will bring food that is beneficial and will help ensure that the patient will have a healthy diet after discharge. Alternative Medicine Many patients may be taking other medications, some prescribed by another provider and some by a traditional healthcare provider. Often the patient’s family is a valuable source of information about all medications the patient is taking, particularly alternative medications with which the provider may be unfamiliar. By discussing concerns openly and respectfully with the patient and family:

• The provider can explore the possible consequences of taking certain alternative

medicines along with the prescribed medications

• Avoid potentially dangerous interactions between Western medicines and traditional

herbs

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Barriers to Culturally Competent Care

Certain barriers can make it difficult to deliver culturally competent care. These barriers include:

• A lack of diversity in a healthcare organization’s leadership and workforce

• Systems of care that are poorly designed to meet the needs of a diverse patient

population

• Poor communication between providers and patients of different racial, ethnic, or cultural

backgrounds

Some ways in which this these barriers may be overcome include:

• Establishing and strengthening programs to develop minority healthcare leadership, to

produce a core of professionals who may assume influential positions

• Hiring and promoting minorities in the healthcare workforce

• Involving community representatives in a healthcare organization’s planning and quality

improvement meetings

Clinical Outcomes

Cultural competence can have a significant impact on clinical outcomes. But ignoring culture can lead to negative health consequences in a number of ways:

• Patients may choose not to seek needed services for fear of being misunderstood or

disrespected.

• Patients may not take medical advice because they do not understand or do not trust the

provider.

• Providers may miss opportunities for screening because they are not familiar with

conditions that may be prevalent among certain racial or ethnic groups.

• Providers may fail to take into account differing responses to medication.

• Providers may lack knowledge about traditional remedies used by certain cultures,

leading to harmful drug interactions.

• Providers may make diagnostic errors resulting from miscommunication.

• Providers may not order appropriate diagnostic tests because they may not understand

the patient’s description of symptoms.

On the other hand, healthcare experts make a clear connection between cultural competence, quality improvement, and the elimination of racial or ethnic disparities.

Summary

It is the responsibility of all healthcare workers to delivery culturally competent healthcare. You must ensure that patients of various cultures, especially those with limited English proficiency, do not face barriers when accessing healthcare and getting appropriate treatment. When you deliver culturally competent healthcare, you could see:

• More successful patient education

• More patients seeking the healthcare they need

• More appropriate testing and screening

• Fewer diagnostic errors

• Fewer complications from prescription drugs interacting with traditional remedies used

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

by patients

• Greater adherence to medical advice

• Expanded healthcare choices and access, if patients feel they are no longer restricted to

a small pool of clinicians who share their language and culture

References

Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care. The Joint Commission. Available at: https://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pd f. Accessed October 31, 2016. Cultural Competence in Health Care: Emerging Frameworks And Practical Approaches. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf. Accessed October 31, 2016. Cultural Respect. National Institutes of Health. Available at: https://www.nih.gov/institutes- nih/nih-office-director/office-communications-public- liaison/clear-communication/cultural- respect. Accessed October 31, 2016. Improving Cultural Competence to Reduce Health Disparities for Priority Populations. Agency for Healthcare Research and Quality. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and- reports/?pageaction=displayproduct&productid=1934. Accessed October 31, 2016. Multi-Cultural Resources for Health Information. United States Department of Health and Human Services. Available at: https://sis.nlm.nih.gov/outreach/multicultural.html. Accessed October 31, 2016. Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals. The California Endowment. Available at: https://www.oakland.edu/upload/docs/SOM/Diversity/principles_standards_cultural_com⦁ petence-1.pdf. Accessed October 31, 2016. What Is Cultural and Linguistic Competence? Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/professionals/systems/primary-care/cultural-competence- mco/cultcompdef.html. Accessed October 31, 2016.

Section 3: Ethics

Introduction

Healthcare ethics is a set of moral principles and values that guide providers in making choices about medical care. Healthcare ethics is also called medical ethics or bioethics. Healthcare ethics involves each caregiver’s sense of right and wrong, and the duties owed to patients and families. It involves four main principles:

• Autonomy, which is to honor patients’ rights to make their own decisions regarding care

• Beneficence, which is to help patients advance their own well-being

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Non-maleficence, which means to do no harm

• Justice, which means to be fair and treat all patients the same

Although all four principles are of equal importance, in U.S. caregiving the respect for patient autonomy often take priority over the others.

Purpose/Overall Goal

This module outlines The Joint Commission’s standards regarding ethics in healthcare delivery, the benefits of having an ethics program, and a new model called Integrated Ethics. The goal of this module is to assist you as a healthcare worker in delivering ethical care to patients by providing guidelines related to decision-making, patient privacy, informed consent, end-of-life care, conflicts of interest, and more.

Course Objectives

After completing this module, the learner should be able to:

• Explain The Joint Commission’s ethical standards

• Describe the ethical responsibilities of healthcare workers

• Define the individual rights of patients

• Describe the portions of the Integrated Ethics model pertaining to healthcare workers

• Describe common ethical dilemmas and how to respond appropriately

Ethical Standards

The Joint Commission (TJC) has produced a set of standards called Ethics, Rights, and Responsibilities. These standards serve as a guide in decision-making and healthcare delivery for providers and organizations. The goal of the Joint Commission standards is to:

• Ensure that care, treatment, and services are provided in a way that respects and

promotes dignity, autonomy, positive self-regard, civil rights, and involvement of patients

• Consider each patient’s abilities and resources, the demands of his or her environment,

and the requirements and expectations of providers and those they serve

• Ensure that the family is involved in care and treatment decisions, with the patient’s

approval

TJC standards cover three areas:

• Organizational Ethics

• Individual Rights

• Individual Responsibilities

These three areas are described in the following sections.

Organizational Ethics

According to The Joint Commission, organizational ethics apply to the environment in which healthcare is delivered. It involves:

• The responsibility that a facility has to the patients and community it serves

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• The connection between ethical healthcare and ethical business practices

• The requirement that care is provided within the facility’s scope, mission, and applicable

regulations

There are three aspects of organizational ethics:

• Procedural justice – The polices in place for decision-making should be coherent,

consistent, and transparent

• Distributive justice – The fair allocation of resources, rewards, benefits, and discipline

within the facility

• Professionalism – The practice of upholding the moral principles and commitments

valued by the profession and the public.

The Joint Commission states that you as a healthcare worker should:

• Demonstrate respect for human dignity, honesty, integrity, and trustworthiness

• Demonstrate autonomy and self-regulation of your profession (such as through peer

review and other processes)

• Participate in resource allocation decisions

• Safeguard confidences and privacy

Individual Rights

According to The Joint Commission, individual rights involve:

• How a facility respects the culture and rights of patients during staff interactions

• How the staff involves patients in care decisions

The standards for individual rights include these five considerations:

• Shared Decision-Making – In order to deliver the highest quality care, providers are no

longer expected only to provide information to patients – but to partner with patients as

well.

o Clinicians bring their specialized knowledge of science, medicine, and technology

o Patients weigh that information along with their preferences, values, and

experiences

• Informed Consent – Shared decision-making is documented through the process of

informed consent. It means that patients have the capacity to make decisions and can

appreciate their available options, and that their decisions are voluntary.

• Advance Care Planning – Advance care planning is a way to promote shared decision-

making at times when patients don’t have the ability to make such decisions. Patients

can document their wishes and/or name a proxy to make decisions about their

treatments at times when they are unable to do so themselves.

• End-of-Life Care – This involves how decisions are made once the goals of care

change from curative to palliative at the end of life. As a healthcare provider, your goals

are:

o Supporting end-of-life decision-making

o Ensuring that decisions made are consistent with the values and desires of the

patient

o Respecting the individual rights of patients

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

1. Privacy and confidentiality – In addition to protecting patients’ autonomy, their

personal information must be protected as well. Privacy and confidentiality in healthcare

refers to the protection of information that relates to:

• The past, present, or future physical or mental health or condition of an individual

• The care provided to an individual

• The past, present, or future payments for healthcare

Individual Responsibilities

According to The Joint Commission, individual responsibilities involve the patient’s role in the healthcare process. When patients are partners in care, the safety of healthcare delivery is enhanced. Some ethical decisions can be made only by the patient. Healthcare providers can inform, consult, and advise, but only the patient can ultimately decide what quality of life is acceptable to him or her.

Benefits of An Ethics Program

For healthcare facilities, having an ethics program in place has these benefits:

• Enhanced patient satisfaction

• Increased employee morale and loyalty

• Improved public relations

• Fewer wasteful or unwanted treatments

• Less diverted staff time

• Enhanced professionalism

• Fewer lawsuits

• Meets The Joint Commission’s ethics standards

Traditional ethics programs at facilities have long involved the creation of ethics committees. These committees generally focus on clinical ethics issues, particularly those relating to end-of- life care. Today there is growing interest in a new model called Integrated Ethics, developed by the National Center for Ethics in Health Care within the U.S. Department of Veterans Affairs (VA). Integrated Ethics was designed to deal with the full range of ethical concerns in healthcare today.

Integrated Ethics Model

In the Integrated Ethics model, ethical concerns in healthcare are categorized into major domains. These domains were designed to cover the broad range of ethical issues faced by all types of healthcare organizations, including acute-care hospitals, rehabilitation hospitals, outpatient facilities, nursing homes, home care organizations, and healthcare systems. The domains that most pertain to you as a healthcare worker are:

• Shared decision-making with patients – How well the organization promotes

collaborative decision-making between clinicians and patients

• Patient privacy and confidentiality – How well the organization protects patient

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

privacy and confidentiality

• Professionalism in patient care – How well the organization fosters behavior

appropriate for healthcare professionals

• Ethical practices in the everyday workplace – How well the organization supports

ethical behavior in common, everyday interactions in the workplace

More about these four domains are in the sections that follow.

Shared Decision-Making with Patients

Shared decision-making involves how well the organization promotes collaborative decision- making between clinicians and patients. This includes:

• Decision-making capacity – The ability of patients to make their own healthcare

decisions

• Informed consent process – Providing information to the patient or surrogate, ensuring

that the decision is voluntary, and documenting the decision

• Surrogate decision-making – Selection, role, and responsibilities of a person

authorized to make healthcare decisions for the patient

• Advance care planning – Statement made by a patient with decision-making capacity

regarding healthcare decisions in the event they lose that capacity in the future

• Limits to patient choice – Questions relating to choice of care setting, choice of

provider, demands for unconventional treatment, etc.

Patient Privacy and Confidentiality

Protecting patient privacy and confidentiality involves:

• Privacy – Protecting individuals’ interests in maintaining personal space free of

unwanted intrusions and in controlling data about themselves

• Confidentiality – Nondisclosure of information obtained as part of the clinician- patient

relationship

Professionalism in Patient Care

Professionalism in patient care involves how well an organization fosters behavior appropriate for healthcare professionals. This includes:

• Conflicts of Interest – Situations that may compromise a caregiver’s fiduciary duty to

patients, including inappropriate business or personal relationships

• Truth-Telling – Open and honest communication with patients, including disclosing bad

news, adverse events, etc.

• Challenging Clinical Relationships – Staff management of relationships with patients

and/or their family and loved ones who present challenging or disruptive behaviors,

requests, or demands

• Respect for Diverse Cultural/Religious Perspectives – Clinician interactions with

patients and/or their family and loved ones of different ethnicity, religion, sexual

orientation, gender, age, etc.

• Respect in Interprofessional Relationships – Recognition and respect for unique

cultures, values, roles, and expertise of other healthcare professionals, and development

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

of cooperative and trusting relationships among professionals

Ethical Practices in the Workplace

Ethical practice in the workplace involves how well the organization supports ethical behavior in common, everyday interactions. This includes:

• Respect and Dignity – Employee privacy, personal safety, respect for diversity,

respectful behavior toward others, etc.

• Ethical Climate – Openness to ethics discussion, perceived pressure to engage in

unethical conduct, etc.

Examples of Ethical Dilemmas

Two significant ethical dilemmas commonly facing healthcare professionals involve documentation and financial remuneration (gift-giving to providers).

• Documentation related to care provided to the client could involve:

o Was the medication actually given?

o Was care rendered to the patient?

o Was treatment protocol followed?

o Was a medication incident reported even if no adverse reaction was observed?

o Was care delivered in a timely manner?

• Financial remuneration by patients to healthcare professionals.

o This could be as little as a small “tip” of $5 to the nurse for taking “good care” of a

patient by the family

o Or it could be as significant as an all-expense-paid trip to Las Vegas for a

physician, by a pharmaceutical company to say thank you for writing

prescriptions for their medication

Here are some ethical dilemmas to consider:

• You have had a hectic shift and did not complete the task of weighing a patient. How do

you document the weight for this patient?

• You are asked to provide an update on a patient and are unsure who is asking. What is

an appropriate response?

• A coworker returns from lunch looking confused, has slurred speech, and smells like

alcohol. What is the ethical response?

Each of these examples demonstrates a situation in which you’re required to make a decision. In each case, it is important to remember:

• Honesty is the best policy.

• Follow your organization’s chain of command if you are unsure about what to do.

• Refer to your organization’s policies and procedures regarding the issue, if applicable.

• Always keep patient safety as your number-one priority.

Summary

There are many reasons why understanding and supporting ethics in patient care is so vital:

• To meet patient needs and expectations

• To address community health needs

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• To enhance the quality of care

• To promote professionalism

• To enhance an organization's compliance with regulatory standards

As a healthcare worker, your ultimate moral and ethical obligation is to your patients. By learning new ways of incorporating ethics into patient care, and approaches for dealing with ethical issues as they arise, you are empowered to do the right thing – because it is the right thing to do.

References

Domains in Ethics. Integrated Ethics. Available at: http://www.ethics.va.gov/docs/integratedethics/rev_domains_of_ethics_in_hc_20131105 .pdf. Accessed November 1, 2016. Ethical Principles at the Foundation of JCAHO's Ethics, Rights, and Responsibilities Standards. National Ethics Teleconference. Available at: http://www.ethics.va.gov/docs/net/NET_Topic_20040427_JCAHO_Standards_Ethics_Rights_e sponsibilities.doc. Accessed November 1, 2016. HCA’s Clinical Ethics Manual. Hospital Corporation of America. Available at: hcaethics.com/CPM/HCA%20Manual_2008-09.doc. Accessed November 1, 2016. Health Care Ethics: Overview of the Basics. Vermont Ethics Network. Available at: http://www.vtethicsnetwork.org/ethics.html. Accessed November 1, 2016. Improving Ethics Quality: Looking Beneath the Surface. Integrated Ethics. Available at: http://www.ethics.va.gov/docs/integratedethics/Improving_Ethics_Quality- Looking_Beneath_the_Surface_20070808.pdf. Accessed November 1, 2016. Integrated Ethics: An Innovative Program to Improve Ethics Quality in Health Care. The Innovation Journal: The Public Sector Innovation Journal. Available at: http://www.ethics.va.gov/IEoverview.pdf. Accessed November 1, 2016. Making it Easier to Do the Right Thing. Integrated Ethics. Available at: http://www.ethics.va.gov/docs/integratedethics/VAnguard_Making_It_Easier_to_Do_the_Right _Thing.pdf. Accessed November 1, 2016. What Is Ethics Quality? Integrated Ethics. Available at: http://www.ethics.va.gov/docs/integratedethics/2013130_what_is_ethics_qual_art.pdf. Accessed November 1, 2016.

Section 4: 2020 National Patient Safety Goals for Hospitals Nursing Education Module

Introduction

This course will cover the 2020 National Patient Safety Goals for nursing staff in the hospital setting.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Course Objectives

After taking this course, you should be able to:

• Explain the Joint Commission’s 2020 National Patient Safety Goals.

Goal 1: Improve the accuracy of patient identification.

NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, and services. Rationale for NPSG.01.01.01 Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier. Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable features. In addition to well-known misidentification errors such as wrong patient/wrong procedure, misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system among all providers is necessary to prevent errors. Elements of Performance for NPSG.01.01.01

1. Use at least two patient identifiers when administering medications, blood, or blood

components; when collecting blood samples and other specimens for clinical testing;

and when providing treatments or procedures. The patient's room number or physical

location is not used as an identifier. (See also MM.05.01.09, EPs 8 and 11;

NPSG.01.03.01, EP 1)

2. Label containers used for blood and other specimens in the presence of the patient.

(See also NPSG.01.03.01, EP 1)

3. Use distinct methods of identification for newborn patients.

Note: Examples of methods to prevent misidentification may include the following:

• Distinct naming systems could include using the mother’s first and last names

and the newborn’s gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A”

and “Smith, Judy Girl B” for multiples).

• Standardized practices for identification banding (for example, using two body

sites and/or bar coding for identification).

• Establish communication tools among staff (for example, visually alerting staff

with signage noting newborns with similar names).

NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification. Elements of Performance for NPSG.01.03.01

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

1. Before initiating a blood or blood component transfusion:

• Match the blood or blood component to the order.

• Match the patient to the blood or blood component.

• Use a two-person verification process or a one-person verification process

accompanied by automated identification technology, such as bar coding.

(See also NPSG.01.01.01, EPs 1 and 2)

2. When using a two-person verification process, one individual conducting the

identification verification is the qualified transfusionist who will administer the blood or

blood component to the patient.

3. When using a two-person verification process, the second individual conducting the

identification verification is qualified to participate in the process, as determined by the

hospital.

Goal 2: Improve the effectiveness of communication among caregivers.

NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis. Rationale for NPSG.02.03.01 Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated. Elements of Performance for NPSG.02.03.01

• Develop written procedures for managing the critical results of tests and diagnostic

procedures that address the following:

• The definition of critical results of tests and diagnostic procedures.

• By whom and to whom critical results of tests and diagnostic procedures are

reported.

• The acceptable length of time between the availability and reporting of critical

results of tests and diagnostic procedures.

• Implement the procedures for managing the critical results of tests and diagnostic

procedures.

• Evaluate the timeliness of reporting the critical results of tests and diagnostic

procedures.

Goal 3: Improve the safety of using medications.

NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins. Rationale for NPSG.03.04.01 Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

containers and placed into unlabeled containers. This unsafe practice neglects the basic principles of safe medication management, yet it is routine in many organizations. The labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safe medication management. This practice addresses a recognized risk point in the administration of medications in perioperative and other procedural settings. Labels for medications and medication containers are also addressed at MM.05.01.09. Elements of Performance for NPSG.03.04.01

1. In perioperative and other procedural settings both on and off the sterile field, label

medications and solutions that are not immediately administered. This applies even if

there is only one medication being used.

Note: An immediately administered medication is one that an authorized staff member

prepares or obtains, takes directly to a patient, and administers to that patient without

any break in the process. Refer to NPSG.03.04.01, EP 5, for information on timing of

labeling.

2. In perioperative and other procedural settings both on and off the sterile field, labeling

occurs when any medication or solution is transferred from the original packaging to

another container.

3. In perioperative and other procedural settings both on and off the sterile field, medication

or solution labels include the following:

• Medication or solution name

• Strength

• Amount of medication or solution containing medication (if not apparent from the

container)

• Diluent and volume (if not apparent from the container)

• Expiration date when not used within 24 hours

• Expiration time when expiration occurs in less than 24 hours

Note: The date and time are not necessary for short procedures, as defined by the

hospital.

4. Verify all medication or solution labels both verbally and visually. Verification is done by

two individuals qualified to participate in the procedure whenever the person preparing

the medication or solution is not the person who will be administering it.

5. Label each medication or solution as soon as it is prepared, unless it is immediately

administered.

Note: An immediately administered medication is one that an authorized staff member

prepares or obtains, takes directly to a patient, and administers to that patient without

any break in the process.

6. Immediately discard any medication or solution found unlabeled.

7. Remove all labeled containers on the sterile field and discard their contents at the

conclusion of the procedure.

Note: This does not apply to multiuse vials that are handled according to infection control

practices.

8. All medications and solutions both on and off the sterile field and their labels are

reviewed by entering and exiting staff responsible for the management of medications.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Note: This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for preventing venous thromboembolism (for example, related to procedures or hospitalization). Rationale for NPSG.03.05.01 Anticoagulation therapy can be used as therapeutic treatment for a number of conditions, the most common of which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant. However, it is important to note that anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety Goal has great potential to positively impact the safety of patients on this class of medications and result in better outcomes. To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy program. Effective anticoagulation education includes face-to-face interaction with a trained professional who works closely with patients to be sure that they understand the risks involved with anticoagulation therapy and the precautions they need to take. The use of standardized practices for anticoagulation therapy, which include patient involvement, can reduce the risk of adverse drug events associated with heparin (unfractionated), low molecular weight heparin, warfarin, and direct oral anticoagulants (DOACs). Elements of Performance for NPSG.03.05.01

1. The hospital uses approved protocols and evidence-based practice guidelines for the

initiation and maintenance of anticoagulant therapy that address medication selection;

dosing, including adjustments for age and renal or liver function; drug-drug and drug-

food interactions; and other risk factors as applicable.

2. The hospital uses approved protocols and evidence-based practice guidelines for the

reversal of anticoagulation and management of bleeding events related to each

anticoagulant medication.

3. The hospital uses approved protocols and evidence-based practice guidelines for

perioperative management of all patients on oral anticoagulants.

Note: Perioperative management may address the use of bridging medications, timing

for stopping an anticoagulant, and timing and dosing for restarting an anticoagulant.

4. The hospital has a written policy addressing the need for baseline and ongoing

laboratory tests to monitor and adjust anticoagulant therapy.

Note: For all patients receiving warfarin therapy, use a current international normalized

ratio (INR) to monitor and adjust the dosage. For patients on a direct oral anticoagulant

(DOAC), follow evidence-based practice guidelines regarding the need for laboratory

testing.

5. The hospital addresses anticoagulation safety practices through the following:

• Establishing a process to identify, respond to, and report adverse drug events,

including adverse drug event outcomes

• Evaluating anticoagulation safety practices, taking actions to improve safety

practices, and measuring the effectiveness of those actions in a time frame

determined by the hospital.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

6. The hospital provides education to patients and families specific to the anticoagulant

medication prescribed, including the following:

• Adherence to medication dose and schedule

• Importance of follow-up appointments and laboratory testing (if applicable)

• Potential drug-drug and drug-food interactions

• The potential for adverse drug reactions

7. The hospital uses only oral unit-dose products, prefilled syringes, or premixed infusion

bags when these types of products are available.

Note: For pediatric patients, prefilled syringe products should be used only if specifically

designed for children.

8. When heparin is administered intravenously and continuously, the hospital uses

programmable pumps in order to provide consistent and accurate dosing.

Introduction to Reconciling Medication Information The large number of people receiving healthcare who take multiple medications and the complexity of managing those medications make medication reconciliation an important safety issue. In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies. The Joint Commission recognizes that organizations face challenges with medication reconciliation. The best medication reconciliation requires a complete understanding of what the patient was prescribed and what medications the patient is actually taking. It can be difficult to obtain a complete list from every patient in an encounter, and accuracy is dependent on the patient’s ability and willingness to provide this information. A good faith effort to collect this information is recognized as meeting the intent of the requirement. As healthcare evolves with the adoption of more sophisticated systems (such as centralized databases for prescribing and collecting medication information), the effectiveness of these processes will grow. This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation. The elements of performance in this NPSG are designed to help organizations reduce negative patient outcomes associated with medication discrepancies. Some aspects of the care process that involve the management of medications are addressed in the standards rather than in this goal. These include coordinating information during transitions in care both within and outside of the organization (PC.02.02.01), patient education on safe medication use (PC.02.03.01), and communications with other providers(PC.04.02.01). In settings where medications are not routinely prescribed or administered, this NPSG provides organizations with the flexibility to decide what medication information they need to collect based on the services they provide to patients. It is often important for clinicians to know what medications the patient is taking when planning care, treatment, and services, even in situations where medications are not used. NPSG.03.06.01 Maintain and communicate accurate patient medication information. Rationale for NPSG.03.06.01 There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future. Elements of Performance for NPSG.03.06.01

1. Obtain information on the medications the patient is currently taking when he or she is

admitted to the hospital or is seen in an outpatient setting. This information is

documented in a list or other format that is useful to those who manage medications.

Note 1: Current medications include those taken at scheduled times and those taken on

an as-needed basis.

Note 2: It is often difficult to obtain complete information on current medications from a

patient, a good faith effort to obtain this information from the patient and/or other sources

will be considered as meeting the intent of the Element of Performance.

2. Define the types of medication information to be collected in non-24-hour settings and

different patient circumstances.

Note 1: Examples of non-24-hour settings include the emergency department, primary

care, outpatient radiology, ambulatory surgery, and diagnostic settings.

Note 2: Examples of medication information that may be collected include name, dose,

route, frequency, and purpose.

3. Compare the medication information the patient brought to the hospital with the

medications ordered for the patient by the hospital in order to identify and resolve

discrepancies.

Note: Discrepancies include omissions, duplications, contraindications, unclear

information, and changes. A qualified individual, identified by the hospital, does the

comparison. (See also HR.01.06.01, EP 1)

4. Provide the patient (or family as needed) with written information on the medications the

patient should be taking when he or she is discharged from the hospital or at the end of

an outpatient encounter (for example, name, dose, route, frequency, purpose).

Note: When the only additional medications prescribed are for a short duration, the

medication information the hospital provides may include only those medications. For

more information about communications to other providers of care when the patient is

discharged or transferred, refer to Standard PC.04.02.01.

5. Explain the importance of managing medication information to the patient when he or

she is discharged from the hospital or at the end of an outpatient encounter.

Note: Examples include instructing the patient to give their primary care physician a list

to update the information when medications are discontinued, doses are changed, or

new medications (including over-the-counter products) are added, and to carry

medication information at all times in the event of emergencies. For information on

patient education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and

PC.04.01.05.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

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

NPSG.06.01.01 Improve the safety of clinical alarm systems Rationale for NPSG.06.01.01 Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within different units in a single hospital. There is general agreement that this is an important safety issue. Universal solutions have yet to be identified, but it is important for a hospital to understand its situation and to develop a systematic, coordinated approach to clinical alarm system management. Standardization contributes to safe alarm system management, but it is recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual patients. This NPSG focuses on managing clinical alarm systems that have the most direct relationship to patient safety. As alarm system management solutions are identified, this NPSG will be updated to reflect best practices. Note: Additional information on alarm safety can be found on the AAMI website http://www.aami.org/htsi/alarms/. Elements of Performance for NPSG.06.01.01

1. Leaders establish alarm system safety as a hospital priority.

2. Identify the most important alarm signals to manage based on the following:

• Input from the medical staff and clinical departments

• Risk to patients if the alarm signal is not attended to or if it malfunctions

• Whether specific alarm signals are needed or unnecessarily contribute to alarm

noise and alarm fatigue

• Potential for patient harm based on internal incident history

• Published best practices and guidelines

(For more information on managing medical equipment risks, refer to Standard

EC.02.04.01.)

3. Establish policies and procedures for managing the alarms identified in EP 2 above that,

at a minimum, address the following:

• Clinically appropriate settings for alarm signals

• When alarm signals can be disabled

• When alarm parameters can be changed

• Who in the organization has the authority to set alarm parameters

• Who in the organization has the authority to change alarm parameters

• Who in the organization has the authority to set alarm parameters to “off”

• Monitoring and responding to alarm signals

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

• Checking individual alarm signals for accurate settings, proper operation, and

detectability (For more information, refer to Standard EC.02.04.03)

4. Educate staff and licensed independent practitioners about the purpose and proper

operation of alarm systems for which they are responsible.

Goal 7: Reduce the risk of healthcare-associated infections.

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. Rationale for NPSG.07.01.01 According to the CDC, each year, millions of people acquire an infection while receiving care, treatment, and services in a healthcare organization. Consequently, healthcare-associated infections (HAIs) are a patient safety issue affecting all types of healthcare organizations. One of the most important ways to address HAIs is by improving the hand hygiene of healthcare staff. Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback. Elements of Performance for NPSG.07.01.01

1. Implement a program that follows categories IA, IB, and IC of either the current Centers

for Disease Control and Prevention (CDC) or the current World Health Organization

(WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 1)

2. Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01,

EP 1)

3. Improve compliance with hand hygiene guidelines based on established goals.

NPSG.07.03.01 Implement evidence-based practices to prevent healthcare-associated infections due to multidrug-resistant organisms in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile infection (CDI), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and multidrug-resistant gram-negative bacteria. Rationale for NPSG.07.03.01 Patients continue to acquire healthcare-associated infections at an alarming rate. Risks and patient populations, however, differ between hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment. The elements of performance for this requirement are designed to help reduce or prevent healthcare-associated infections from epidemiologically important multidrug-resistant organisms (MDROs).

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

Note: Hand hygiene, contact precautions, as well as cleaning and disinfecting patient care equipment and the patient’s environment are essential strategies for preventing the spread of healthcare-associated infections. Hand hygiene is addressed in NPSG.07.01.01. Contact precautions for patients with epidemiologically significant multidrug-resistant organisms (MDROs) are covered in IC.02.01.01, EP 3. Cleaning and disinfecting patient care equipment are addressed in IC.02.02.01. Elements of Performance for NPSG.07.03.01

1. Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug-

resistant organism acquisition and transmission. (See also IC.01.03.01, EPs 1-3)

2. Educate staff and licensed independent practitioners about multidrug-resistant

organisms and prevention strategies. Education occurs upon hire or granting of initial

privileges and periodically thereafter as determined by the organization.

Note: The education provided recognizes the diverse roles of staff and licensed

independent practitioners and is consistent with their roles within the organization.

3. Educate patients, and their families as needed, who are infected or colonized with a

multidrug-resistant organism about healthcare-associated infection strategies.

4. Implement a surveillance program for multidrug-resistant organisms based on the risk

assessment.

Note: Surveillance may be targeted rather than hospital-wide.

5. Measure and monitor multidrug-resistant organism prevention processes and outcomes,

including the following:

• Multidrug-resistant organism infection rates using evidence-based metrics

• Compliance with evidence-based guidelines or best practices

• Evaluation of the education program provided to staff and licensed independent

practitioners. See also MM.09.01.01, EP 5

Note: Surveillance may be targeted rather than hospital-wide.

6. Provide multidrug-resistant organism process and outcome data to key stakeholders,

including leaders, licensed independent practitioners, nursing staff, and other clinicians.

7. Implement policies and practices aimed at reducing the risk of transmitting multidrug-

resistant organisms. These policies and practices meet regulatory requirements and are

aligned with evidence-based standards (for example, the Centers for Disease Control

and Prevention (CDC) and/or professional organization guidelines).

8. When indicated by the risk assessment, implement a laboratory-based alert system that

identifies new patients with multidrug-resistant organisms.

Note: The alert system may use telephones, faxes, pagers, automated and secure

electronic alerts, or a combination of these methods.

9. When indicated by the risk assessment, implement an alert system that identifies

readmitted or transferred patients who are known to be positive for multidrug-resistant

organisms.

Note 1: The alert system information may exist in a separate electronic database or may

be integrated into the admission system. The alert system may be either manual or

electronic or a combination of both.

Note 2: Each hospital may define its own parameters in terms of time and clinical

manifestation to determine which re-admitted patients require isolation.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

NPSG.07.04.01 Implement evidence-based practices to prevent central line-associated bloodstream infections. Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines. Elements of Performance for NPSG.07.04.01

1. Educate staff and licensed independent practitioners who are involved in managing

central lines about central line-associated bloodstream infections and the importance of

prevention. Education occurs upon hire or granting of initial privileges and periodically

thereafter as determined by the organization.

2. Prior to insertion of a central venous catheter, educate patients and, as needed, their

families about central line-associated bloodstream infection prevention.

3. Implement policies and practices aimed at reducing the risk of central line-associated

bloodstream infections. These policies and practices meet regulatory requirements and

are aligned with evidence-based standards (for example, the Centers for Disease

Control and Prevention (CDC) and/or professional organization guidelines).

4. Conduct periodic risk assessments for central line-associated bloodstream infections,

monitor compliance with evidence-based practices, and evaluate the effectiveness of

prevention efforts. The risk assessments are conducted in time frames defined by the

hospital, and this infection surveillance activity is hospital-wide, not targeted.

5. Provide central line-associated bloodstream infection rate data and prevention outcome

measures to key stakeholders, including leaders, licensed independent practitioners,

nursing staff, and other clinicians.

6. Use a catheter checklist and a standardized protocol for central venous catheter

insertion.

7. Use a standardized supply cart or kit that contains all necessary components for the

insertion of central venous catheters.

8. Perform hand hygiene prior to catheter insertion or manipulation.

9. Use maximum sterile barrier precautions during central venous catheter insertion.

10. For adult patients, do not insert catheters into the femoral vein unless other sites are

unavailable.

11. Use an alcoholic chlorhexidine antiseptic for skin preparation during central venous

catheter insertion unless contraindicated.

12. Use a standardized protocol to disinfect catheter hubs and injection ports before

accessing the ports.

13. Evaluate all central venous catheters routinely and remove nonessential catheters.

NPSG.07.05.01 Implement evidence-based practices for preventing surgical site infections. Elements of Performance for NPSG.07.05.01

1. Educate staff and licensed independent practitioners involved in surgical procedures

about surgical site infections and the importance of prevention. Education occurs upon

hire, annually thereafter, and when involvement in surgical procedures is added to an

individual’s job responsibilities.

Manual for Joint Commission and OSHA Core Mandatories Part II: Nursing

2. Educate patients, and their families as needed, who are undergoing a surgical procedure

about surgical site infection prevention.

3. Implement policies and practices aimed at reducing the risk of surgical site infections.

4. These policies and practices meet regulatory requirements and are aligned with

evidence-based guidelines (for example, the Centers for Disease Control and Prevention

(CDC) and/or professional organization guidelines).

5. As part of the effort to reduce surgical site infections:

• Conduct periodic risk assessments for surgical site infections in a time frame

determined by the hospital.

• Select surgical site infection measures using best practices or evidence-based

guidelines. Monitor compliance with best practices or evidence-based guidelines.

• Evaluate the effectiveness of prevention efforts.

Note: Surveillance may be targeted to certain procedures based on the hospital’s risk

assessment.

6. Measure surgical site infection rates for the first 30 or 90 days following surgical

procedures based on National Healthcare Safety Network (NHSN) procedural codes.

The hospital’s measurement strategies follow evidence-based guidelines.

Note 1: Surveillance may be targeted to certain procedures based on the hospital’s risk

assessment.

Note 2: The NHSN is the CDC’s healthcare-associated infection tracking system. NHSN

provides facilities, states, regions, and the nation with data needed to identify problem

areas, measure progress of prevention efforts, and ultimately eliminate healthcare-

associated infections. For more information on NHSN procedural codes, see

http://www.cdc.gov/nhsn/CPTcodes/ssi-cpt.html.

7. Provide process and outcome (for example, surgical site infection rate) measure results

to key stakeholders.

8. Administer antimicrobial agents for prophylaxis for a particular procedure or disease

according to methods cited in scientific literature or endorsed by professional

organizations.

Note: A limited number of National Patient Safety Goals contain requirements for

practices that reflect current science and medical knowledge. In these cases, the

element of performance refers to a practice that is cited in scientific literature or

endorsed by professional organizations. This means that the practice used by the

hospital must be validated by an authoritative source. The authoritative source may be a

study published in a peer-reviewed journal that clearly demonstrates the efficacy of that

practice or endorsement of the practice by a professional organization(s) and/or a

government agency(ies). It is not acceptable to follow a practice that is not supported by

evidence or wide-spread consensus. During the on-site survey, surveyors will explore

the source of the practices the hospital follows.

9. When hair removal is necessary, use a method that is cited in scientific literature or

endorsed by professional organizations.