The public’s perception of the medical system has changed in recent years. There is both awe that practitioners saw the country through a pandemic and ongoing dissatisfaction with patient care and costs. The National Patient Safety Goals address patient care and safety to give health care organizations a framework for improvement.
Of course, much of what the landscape of medical care will look like tomorrow will be up to tomorrow’s health care leaders. While executives and administrative professionals in the health care industry have many responsibilities related to safety and risk assessment, including emergency planning, the National Patient Safety Goals are one important framework through which health care leaders can implement positive change.
The public’s perception of the medical system has changed in recent years. There is both awe that practitioners saw the country through a pandemic and ongoing dissatisfaction with patient care and costs. The National Patient Safety Goals address patient care and safety to give health care organizations a framework for improvement.
Of course, much of what the landscape of medical care will look like tomorrow will be up to tomorrow’s health care leaders. While executives and administrative professionals in the health care industry have many responsibilities related to safety and risk assessment, including emergency planning, the National Patient Safety Goals are one important framework through which health care leaders can implement positive change.
What Are National Patient Safety Goals?
The National Patient Safety Goals are a group of objectives for the improvement of health care that are created annually by The Joint Commission, a nonprofit organization founded in 1951 with a purpose of raising the standard of care in the medical industry.
Today, developing and publishing the National Patient Safety Goals is one channel through which the organization unites and guides decision-makers in the medical field. The Joint Commission is situated as an independent, third-party organization to bring a fair review process to the state of the medical industry, and in its annual development of the NPSGs, it invites stakeholders from health care organizations across the country to be a part of the process.
The objectives of the National Patient Safety Goals (NSPGs) are evident in their name:
National
The Joint Commission is the “nation’s oldest and largest standard-setting and accrediting body in health care,” according to the commission. It connects and guides health care organizations across the U.S.; without connective channels between these organizations, medical progress could be stymied.
Patient
The ultimate purpose of The Joint Commission is to provide improved medical care to the industry's end users: patients. The NPSGs reflect a detailed view of the subpar or misaligned medical care that is being remedied within today’s health care institutions — both traditional and innovative.
Safety
In medicine, the stakes are inherently high. Patients seek medical care in preventative and reactive scenarios; sometimes, a visit to the doctor is a simple, annual check-up as a preventative measure, but other times, patients end up in health care institutions because they need effective, targeted and timely care — before things get worse. Medical professionals and institutions are routinely faced with the need to deliver care with accuracy and precision under time and resource constraints. For this reason, safety is a top concern in the medical profession and the health care system, and the National Patient Safety Goals are intended to guide that focus.
Goals
The NPSGs are first and foremost guiding objectives for improvement in the medical field. Therefore, they are structured and written to reflect ideal outcomes in important facets of health care such as:
- Patient identification
- Improved communication
- Medication safety
- Clinical alarm safety
- Health care associated infections
- Reducing falls
- Pressure ulcers
- Risk assessment
- Protocols for preventing wrong site, wrong procedure or wrong person surgery
While seeing areas of improvement in the field of medicine laid out so plainly might be surprising to some, the reality is, operational and clinical leaders at health care institutions are tasked with solving these common issues in care delivery every day. The NPSGs are meant as a guide that transformative, educated leaders in health care can apply at their care sites to achieve improvement.
Origins of the National Patient Safety Goals
The first National Patient Safety Goals were published in 2003 “to help accredited organizations address specific areas of concern in regard to patient safety,” according to The Joint Commission. As the country’s medical prowess, systems and needs grew over the 20th century, unifying voices across medicine were established to maintain communication and connection within the industry.
Today, the annual publication of the goals supports health care institutions by defining areas of improvement for the industry and providing guidelines for growth.
Each year, the goals are developed in conjunction with health care stakeholders, such as:
- Physicians
- Operational leaders of provider organizations
- Nurses
- Purchasers, such as employers and government entities
- Consumer groups
Some health care professional roles that could have an important function in developing the goals are:
- Chief Medical Officer
- Chief Patient Experience Officer
- Director of Patient Safety
- Director of Accountable Care
Developing the goals in conjunction with stakeholders and experts creates a bottom-up model with a wide view of the medical industry. When operational and clinical leaders at the helm of health care organizations have a voice in defining these goals, they are able to readily plan for improvement in their own corners of the industry.
As health care changes rapidly under the influence of new technology and systemic changes like value-based purchasing, these leaders can have a great effect on how progress takes shape.
How National Patient Safety Goals Improve Health Care Delivery
While the 2023 National Patient Safety Goals are broadly applicable to any health care setting, individual goals align with specific settings and programs. For instance, while reducing falls is an important safety objective for any doctor’s office or hospital, it is especially important in a nursing home that serves older adults. Similarly, while identifying a patient correctly is always important when delivering care, it is imperative before going into surgery in a hospital setting.
The 2023 National Patient Safety Goals are intended to inform progress across the medical industry, but individual goals are aligned to particular points of care. Those points of care are as follows, according to The Joint Commission:
- Hospital
- Behavioral health care and human services
- Assisted living community
- Laboratory services
- Critical access hospital
- Ambulatory health care
- Office-based surgery
- Nursing care center
- Home care
When stakeholders within these unique health care settings are represented in the development of the goals — that is, in identifying issues and how to remedy them — guidance is informed by what’s happening on the ground in medical care. When that guidance is tailored and aligned to specific points of care, such as a hospital or a nursing care center, decision-makers at that point of care can act on the goals with confidence.
Further, the goals support an organization’s ability to “measure, assess, and improve performance,” according to the Joint Commission. This means that after common problems in the delivery of health care have been identified from the ground up with the involvement of key stakeholders in the industry and proposed improvements have been crafted into actionable objectives and aligned with the appropriate points of care, they become an effective tool for progress.
Measuring and Assessing Progress
Without metrics, making progress can feel like a mammoth task. Imagine a health care leader beginning their day at a hospital — they know that there are myriad issues to address to improve patient care, but which to begin with, how to get started and how to remedy problems is not clear without an actionable framework.
With a set of goals to aim for, that same health care leader can take decisive steps toward improvement. For example, they can:
- Gather baseline data about the issue
- Break the goal down into smaller action items and communicate those to a team
- Set metrics that are easily collected to determine what progress would look like
- Collect data, analyze progress and adjust accordingly
With the National Patient Safety Goals as a guiding framework that identifies which issues in medical care delivery are posing the largest challenges to the most health care-related organizations, leaders have someplace to start. Using the goals aligned to their particular care setting, they can be translated into actionable steps for medical teams and support staff to take to improve patient care. Those steps can include measuring progress as the plan is carried out and ultimately assessing whether the objective was met.
One reason NPSGs are in place is to make that “mammoth” task of chiseling away at issues a more proactive, positive organized process toward improving care.
In fact, the ability to measure and assess progress toward the NPSGs enables the Joint Commission to “regularly revise the NPSGs based on their impact, cost, and effectiveness,” according to the Patient Safety Network. This iterative, data-driven process enables continued progress across the field.
2023 National Patient Safety Goals
The 2023 National Patient Safety Goals revolve around ten health care issues that were determined to be the most important sectors of care to be improved within the year, based on data collection and stakeholder discussion. These NPSGs reflect the “highest priority patient safety issues,” according to the Joint Commission. Although these goals apply to different care settings in varying ways, each provides broad guidance on a topical issue in medicine that any health care organization can address.
Improve the Accuracy of Patient Identification
Patient identification is vital to the proper delivery of care. The management and use of health care-related information fall under strict laws and regulations and is very sensitive personal data to individual patients. Most importantly, medical care being delivered to the wrong patient can have a host of negative consequences and risks. For these two reasons, patient identification is an essential focus of the 2023 National Patient Safety Goals.
Whether in a fast-moving, hectic point of care like the trauma unit of an urban hospital or a calm, small-town pediatrician’s office, diligently identifying the patient and delivering care to the right person is essential.
The Joint Commission suggests using “at least two patient identifiers when providing care, treatment and services,” in the 2023 National Patient Safety Goals, to ensure proper patient identification.
Improve the Effectiveness of Communication Among Caregivers
Improving the effectiveness of communication among caregivers is crucial. If medical team members or support staff take an action but fail to communicate or follow up on it, important information about the next steps in that patient’s care can fall through the cracks.
The Joint Commission suggests that reporting “critical results of tests and diagnostic procedures on a timely basis” would help caregivers stay up to date on their patients’ care amid busy schedules and changing shifts.
Improve the Safety of Using Medication
Medications help patients regain their health or manage their symptoms, but they can be very dangerous when used improperly. Additionally, it’s imperative that medical staff always administer medication in the proper dosage and via the proper means. For these reasons, medication safety is a focus of the 2023 National Patient Safety Goals.
The Joint Commission suggests three actions that health care organizations can take to make the handling and use of medications safer:
- Labeling all medications and containers, including syringes, basins and cups, in the clinical areas where medicines and supplies are set up
- Take extra care with patients who take medicines to thin their blood
- Maintaining accurate and up to date records about patient medication
Reduce Patient Harm Associated with Clinical Alarm Systems
Clinical alarms are embedded within or attached to medical devices, and they sound in response to physiological changes in a patient’s body. While physicians rely on these audible signals, two things can cause a patient’s care to go haywire:
- Patients who need immediate care may not be recognized amidst the cacophony of noise from patients whose devices are signaling false alarms or whose issues are not as pressing.
- If devices are not properly managed, including battery changes and technological maintenance, they may not signal properly.
To address this serious problem, the Joint Commission suggests that health organization leaders make improving the safety of clinical alarms a priority with an established plan.
Reduce the Risk of Health Care-Associated Infections
Reducing the risk of health care-associated infections is an ongoing priority in the medical field; when ill and compromised people come together, protecting them from contracting further infections is essential.
Simply enough, the Joint Commission recommends that all health professionals “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,” according to the 2023 National Patient Safety Goals. Hand washing remains an important way to mitigate the spread of germs.
Reduce the Risk of Falls
Reducing the risk of patient harm resulting from trips and falls correlates with the objective of the prior goal: to limit unnecessary harm to patients.
For many patients who are compromised, bedridden for days at a time and/or on medications that alter their perception, there is a higher risk of falling. The 2023 National Patient Safety Goals suggest that health care organizations take particular care in preventing falls to ensure patient safety.
Prevent Health Care-Associated Pressure Ulcers
For patients with limited mobility who may spend much of the day in bed in the same position, pressure ulcers can become an issue. Better known by their colloquial name, bed sores, the likelihood of developing these uncomfortable spots can be reduced with preventative care.
The 2023 National Patient Safety Goals advise that to prevent pressure ulcers, medical practitioners should conduct periodic assessments of pressure ulcer-prone areas and take preventative action before they develop.
Identify Safety Risks Inherent in Patient Population
In the 2023 National Patient Safety Goals, risk assessment is about an organization identifying mental-emotional struggles within its patient population, such as:
- Anxiety
- Depression
- Mood swings
- Distress
The Joint Commission suggests that each health care institution’s staff should be equipped to recognize signs in patients that might indicate a risk of a suicide attempt and implement procedures to mitigate that risk.
Improving Health Care Equity for the Organization’s Patients is a Quality and Safety Priority
The pandemic revealed disparities in equity in health care and other public needs. The Joint Commission has made equitable patient care a particular focus in the 2023 National Patient Safety Goals.
Specifically, the goal describes equity as an issue of “quality and safety,” suggesting that ensuring that the highest level of care is distributed among each of an organization’s patients is fundamental in medicine.
Prevent Wrong Site, Wrong Procedure, Wrong Person Surgery
The final focus of the National Patient Safety Goals is better defined as a ‘universal protocol’ than a goal, although it is certainly outcome-oriented. Similar to the principles involved in patient identification but more specific to procedures and surgeries, this protocol suggests that health care organizations take a few extra steps before beginning a procedure to ensure accuracy.
The Joint Commission suggests that before any procedure, medical practitioners should take a moment to pause and verify place, time, procedure and patient, along with “marking the procedure site.” With these extra steps in place universally, accuracy is likely to be improved across health care sites.
Health Care Today vs. Health Care Tomorrow
Health care is changing rapidly as it adjusts to evolving risks, aging populations and new technology. A central motivating factor behind the change is “subpar quality and patient safety,” according to NEJM Catalyst. Similarly, Deloitte predicts “large-scale disruption” to the health care industry in part due to the need to improve patient care.
The National Patient Safety Goals provide a framework for improvement, and the predicted transformation may have the capacity to reduce costs to patients while improving experience and care outcomes — but it will be up to tomorrow’s health care leaders to realize this innovative way of delivering care. They will need to be well-versed in the issues raised by the National Patient Safety Goals and competent in the policies, procedures and costs of addressing them.
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Recommended Readings
How to Improve Access to Health Care: Current Issues and Potential Solutions
What Can You Do With a Health Administration Degree? The Best Career Paths for Master’s Graduates
Women in Health Care Leadership: Past, Present and Future
Sources:
Deloitte, The Future of Health
The Joint Commission, Facts About The Joint Commission
The Joint Commission, National Patient Safety Goals (2023)
NEJM Catalyst, “Health Care 2030: The Coming Transformation”