The healthcare landscape is constantly evolving, shaped by public perception, technological advancements, and a renewed focus on patient safety and quality of care. While the awe for healthcare practitioners who navigated the recent pandemic remains, so does the persistent concern regarding patient care standards and rising costs. To address these concerns and foster continuous improvement, healthcare organizations turn to frameworks like the National Patient Safety Goals (NPSGs). These goals, established by The Joint Commission, provide a roadmap for healthcare leaders to enhance patient safety across various settings.
Of course, the future of medical care hinges significantly on the vision and actions of tomorrow’s healthcare leaders. While responsibilities for executives and administrative professionals encompass a broad spectrum of safety and risk management, including robust emergency planning, the National Patient Safety Goals stand out as a crucial framework for driving positive change. Understanding which NPSGs are especially important in behavioral health care programs is paramount for leaders in this critical sector.
Understanding National Patient Safety Goals
The National Patient Safety Goals are a comprehensive set of objectives developed annually by The Joint Commission. This non-profit organization, established in 1951, is dedicated to elevating the standards of care within the medical industry. The NPSGs serve as a unifying force, guiding decision-makers in the medical field towards best practices and continuous improvement.
The Joint Commission acts as an independent, third-party entity, ensuring a fair and objective review of the healthcare industry’s performance. In its annual NPSG development process, it actively engages stakeholders from diverse healthcare organizations nationwide, fostering a collaborative approach to patient safety.
The very name “National Patient Safety Goals” encapsulates their core purpose:
National Scope
The Joint Commission holds the distinction of being the “nation’s oldest and largest standard-setting and accrediting body in health care.” Its national reach is vital in connecting and guiding healthcare organizations across the United States. This interconnectedness is essential for fostering medical progress and ensuring consistent standards of care nationwide.
Patient-Centered Focus
The ultimate beneficiary of The Joint Commission’s efforts is the patient. The NPSGs are meticulously designed to address shortcomings and areas for improvement in medical care delivery, encompassing both traditional and innovative healthcare settings. The goals are directly aimed at enhancing the patient experience and ensuring safer care.
Prioritizing Safety
The inherent nature of medicine demands an unwavering focus on safety. Patients seek medical care in various circumstances, from routine check-ups to critical, life-saving interventions. Medical professionals operate under pressure, often needing to deliver precise and timely care amidst resource constraints. Safety is therefore paramount in healthcare, and the National Patient Safety Goals are specifically designed to guide and reinforce this critical focus.
Actionable Goals
The NPSGs are not merely aspirational statements; they are concrete, actionable objectives for improvement. They target key facets of healthcare delivery, including:
- Patient Identification Accuracy
- Effective Communication
- Medication Safety
- Clinical Alarm Safety
- Healthcare-Associated Infections (HAIs) Reduction
- Fall Prevention
- Pressure Ulcer Prevention
- Risk Assessment
- Protocols for Preventing Wrong-Site, Wrong-Procedure, Wrong-Person Surgery
- Healthcare Equity
While the breadth of areas needing improvement may seem daunting, healthcare leaders are constantly working to address these challenges. The NPSGs provide a structured and evidence-based guide that empowers these leaders to implement meaningful changes within their organizations.
Origins of the NPSGs
The National Patient Safety Goals were first introduced in 2003, aiming to equip accredited organizations with a framework to address specific patient safety concerns. As the U.S. medical system evolved throughout the 20th century, the need for unified standards and communication across the industry became increasingly apparent.
Today, the annual publication of the NPSGs serves to highlight critical areas for improvement and provide clear guidelines for progress across healthcare institutions.
The goals are developed through a collaborative process involving diverse healthcare stakeholders, including:
- Physicians
- Operational Leaders of Provider Organizations
- Nurses
- Purchasers (Employers, Government Entities)
- Consumer Groups
Key healthcare professional roles that play a crucial part in shaping the NPSGs include:
- Chief Medical Officer
- Chief Patient Experience Officer
- Director of Patient Safety
- Director of Accountable Care
This inclusive, bottom-up approach ensures that the NPSGs reflect a comprehensive understanding of the medical industry’s challenges and opportunities. By involving operational and clinical leaders in the goal-setting process, the Joint Commission facilitates the seamless integration of these goals into practical improvement plans within healthcare organizations.
In a rapidly changing healthcare environment influenced by technological advancements and systemic shifts like value-based purchasing, these leaders are instrumental in guiding progress.
Enhancing Behavioral Health Care Delivery Through NPSGs
While the 2023 National Patient Safety Goals are universally applicable across healthcare settings, their relevance and specific implementation vary depending on the care environment. For behavioral health care programs, certain NPSGs take on heightened significance due to the unique challenges and patient populations within this field.
The Joint Commission identifies “Behavioral health care and human services” as a distinct point of care for NPSG alignment. This recognition underscores the specific needs and considerations within behavioral health settings. For instance, while medication safety is crucial across all medical domains, it is particularly critical in behavioral health due to the use of psychotropic medications and the potential for adverse effects or interactions. Similarly, risk assessment, particularly concerning suicide risk, is a paramount concern in behavioral health programs.
Let’s delve into which NPSGs are especially important in behavioral health care programs:
1. Improve the Accuracy of Patient Identification
Accurate patient identification is fundamental in all healthcare settings, but in behavioral health, it carries unique implications. Maintaining confidentiality and correctly associating sensitive information with the right patient is paramount. Misidentification can lead to breaches of privacy and potentially harmful errors in treatment.
In behavioral health settings, patient identification protocols should be robust and culturally sensitive, respecting the unique needs and concerns of individuals seeking mental health services. This includes utilizing at least two patient identifiers and implementing procedures that ensure accurate matching of patient information across electronic health records and treatment plans.
2. Improve the Effectiveness of Communication Among Caregivers
Effective communication is the backbone of coordinated care, and this is especially true in behavioral health. Behavioral health programs often involve multidisciplinary teams, including psychiatrists, therapists, social workers, nurses, and support staff. Seamless communication among these professionals is essential for delivering holistic and integrated care.
In behavioral health, communication challenges can arise from the sensitive nature of patient information, the complexity of mental health conditions, and the need for coordinated interventions across different team members and service settings. Implementing standardized communication protocols, utilizing secure communication channels, and ensuring timely reporting of critical information are vital for improving patient outcomes and safety in behavioral health programs.
3. Improve the Safety of Using Medication
Medication safety is a critical NPSG across all healthcare domains, but it holds particular importance in behavioral health. Psychotropic medications, commonly used to manage mental health conditions, can have significant side effects and require careful monitoring. Medication errors in behavioral health can have severe consequences, potentially exacerbating symptoms or leading to adverse health events.
Behavioral health programs must prioritize medication safety by implementing strategies such as:
- Accurate medication reconciliation: Ensuring accurate medication lists upon admission and discharge.
- Double-checking medication orders: Verifying dosages, routes, and frequencies.
- Patient education: Educating patients about their medications, potential side effects, and adherence strategies.
- Monitoring for adverse drug events: Closely monitoring patients for any signs of adverse reactions or interactions.
- Labeling all medications: Clearly labeling all medications, including those prepared in clinical areas.
- Extra care with anticoagulants: Exercising heightened caution with patients on blood-thinning medications, considering potential interactions with psychotropic drugs.
- Maintaining up-to-date medication records: Ensuring accurate and readily accessible medication records.
4. Reduce Patient Harm Associated with Clinical Alarm Systems
While clinical alarms are more commonly associated with acute medical settings, their relevance in behavioral health should not be overlooked, especially in programs that serve individuals with co-occurring medical conditions. For patients with both mental health and physical health issues, clinical alarms may be used to monitor vital signs or physiological parameters.
In behavioral health settings where clinical alarms are utilized, it is important to:
- Develop a plan for safe clinical alarm management: Establishing protocols for alarm settings, response procedures, and staff training.
- Prioritize alarm response: Ensuring timely and appropriate responses to alarms to prevent delayed care or adverse events.
- Minimize alarm fatigue: Optimizing alarm settings and reducing nuisance alarms to prevent staff desensitization.
5. Reduce the Risk of Health Care-Associated Infections
Reducing the risk of healthcare-associated infections (HAIs) is a universal NPSG, and its importance in behavioral health settings is often underestimated. Congregate living settings within behavioral health programs, such as residential treatment facilities or group homes, can increase the risk of infection transmission. Furthermore, individuals with mental health conditions may have compromised immune systems or engage in behaviors that increase infection risk.
Behavioral health programs must diligently implement infection prevention strategies, including:
- Strict adherence to hand hygiene guidelines: Promoting frequent and thorough handwashing by staff, patients, and visitors.
- Environmental cleaning and disinfection: Maintaining clean and hygienic environments, especially in shared living spaces.
- Vaccination programs: Offering recommended vaccinations to patients and staff to prevent vaccine-preventable infections.
- Infection surveillance: Monitoring for infections and implementing timely interventions to control outbreaks.
6. Reduce the Risk of Falls
Fall prevention is a critical NPSG across all age groups and healthcare settings, but it warrants special attention in behavioral health programs, particularly those serving older adults or individuals with specific mental health conditions. Certain psychotropic medications can increase the risk of falls due to side effects like dizziness, sedation, or orthostatic hypotension. Furthermore, cognitive impairments or physical limitations associated with some mental health conditions can also contribute to fall risk.
Behavioral health programs should implement comprehensive fall prevention strategies, including:
- Fall risk assessments: Conducting regular fall risk assessments for all patients, especially upon admission and after medication changes.
- Environmental modifications: Creating safer environments by removing hazards, improving lighting, and ensuring clear pathways.
- Assistive devices: Providing assistive devices, such as walkers or canes, when needed.
- Medication review: Reviewing medications to identify and minimize fall risks.
- Staff education: Educating staff on fall prevention strategies and patient supervision.
7. Prevent Health Care-Associated Pressure Ulcers
Pressure ulcer prevention is particularly relevant in behavioral health programs that provide long-term care or serve individuals with limited mobility. Patients in inpatient psychiatric units or residential facilities may spend extended periods in bed or seated positions, increasing their risk of developing pressure ulcers. Furthermore, some psychotropic medications can contribute to skin fragility or decreased mobility, further elevating the risk.
Behavioral health programs should incorporate pressure ulcer prevention measures, including:
- Regular skin assessments: Conducting periodic skin assessments, especially for patients at risk.
- Pressure redistribution: Utilizing pressure-redistributing mattresses and cushions.
- Repositioning schedules: Implementing regular repositioning schedules for patients with limited mobility.
- Nutritional support: Ensuring adequate nutrition to promote skin health.
- Moisture management: Keeping skin clean and dry to prevent breakdown.
8. Identify Safety Risks Inherent in Patient Population
This NPSG, focusing on risk assessment, is arguably especially important in behavioral health care programs. Identifying and mitigating safety risks inherent in the patient population is paramount in this field. Behavioral health programs serve individuals facing a range of mental and emotional challenges, including anxiety, depression, mood disorders, and suicidal ideation. Suicide risk is a particularly critical concern in behavioral health, and programs must have robust systems in place to identify and address this risk effectively.
Behavioral health programs must prioritize risk assessment by:
- Routine suicide risk screening: Implementing standardized suicide risk screening tools for all patients.
- Comprehensive assessment of mental and emotional distress: Thoroughly assessing patients for signs of anxiety, depression, mood swings, and other mental health concerns.
- Safety planning: Developing individualized safety plans for patients identified as being at risk of suicide or self-harm.
- Crisis intervention protocols: Establishing clear protocols for responding to psychiatric emergencies and suicidal crises.
- Staff training: Equipping staff with the skills and knowledge to recognize and respond to suicide risk effectively.
- Creating a safe environment: Minimizing environmental hazards that could be used for self-harm.
9. Improving Health Care Equity for the Organization’s Patients is a Quality and Safety Priority
Healthcare equity is a fundamental principle in healthcare, and its significance is amplified in behavioral health. Disparities in access to behavioral health services are well-documented, with marginalized populations often facing significant barriers to care. Ensuring equitable access to high-quality behavioral health services is not only a matter of social justice but also a critical safety and quality imperative.
Behavioral health programs must actively promote healthcare equity by:
- Addressing disparities in access: Identifying and addressing barriers to care for underserved populations.
- Cultural competence: Providing culturally competent care that respects the diverse needs and backgrounds of patients.
- Language access services: Offering language access services to ensure effective communication with patients who have limited English proficiency.
- Reducing stigma: Combating stigma associated with mental illness and promoting help-seeking behaviors.
- Data collection and analysis: Collecting and analyzing data to identify and address disparities in care outcomes.
10. Prevent Wrong Site, Wrong Procedure, Wrong Person Surgery
While seemingly less directly applicable to behavioral health, this NPSG remains relevant, especially in integrated healthcare settings where behavioral health services are co-located with medical services. In situations where behavioral health programs offer procedures or interventions that could be misidentified or confused, universal protocols to prevent wrong-site, wrong-procedure, wrong-person errors are essential.
In behavioral health settings, this NPSG translates to ensuring accuracy in procedures such as:
- Medication administration: Verifying the correct medication, dose, route, and patient before administration.
- Therapeutic interventions: Ensuring the correct therapeutic intervention is delivered to the intended patient.
- Documentation: Accurately documenting all procedures and interventions in the patient’s record.
Measuring and Assessing Progress in Behavioral Health
The NPSGs provide a framework for improvement, but their true value lies in their implementation and the ability to measure progress. For behavioral health programs, this involves establishing metrics that are relevant to the specific goals and the unique context of behavioral healthcare.
Examples of measurable metrics in behavioral health settings include:
- Patient identification accuracy rates: Tracking the accuracy of patient identification procedures.
- Timeliness of communication: Measuring the time taken to report critical test results or communicate important patient information.
- Medication error rates: Monitoring the frequency of medication errors and near misses.
- Fall rates: Tracking the incidence of falls and fall-related injuries.
- Pressure ulcer incidence: Monitoring the development of pressure ulcers in at-risk patients.
- Suicide attempt rates: Tracking suicide attempt rates and implementing interventions to reduce them.
- Patient satisfaction with communication: Measuring patient satisfaction with communication from their care team.
- Access to care metrics: Monitoring access to services for underserved populations.
By regularly collecting and analyzing data on these metrics, behavioral health programs can assess their progress towards achieving the NPSGs, identify areas for further improvement, and refine their strategies to enhance patient safety and quality of care.
The Future of Behavioral Health Care and NPSGs
Behavioral health care is undergoing significant transformation, driven by increasing recognition of mental health needs, evolving treatment approaches, and the integration of technology. The National Patient Safety Goals will continue to play a vital role in shaping this future, providing a framework for ensuring that advancements in behavioral health are accompanied by a steadfast commitment to patient safety and quality.
Tomorrow’s behavioral health leaders will need to be deeply familiar with the NPSGs and adept at applying them to the unique challenges and opportunities within the field. They will be tasked with leveraging the NPSGs to:
- Promote integrated care: Enhance the integration of behavioral health and physical health services to improve holistic patient care.
- Utilize technology safely and effectively: Harness the potential of telehealth, mobile apps, and other technologies while mitigating potential safety risks.
- Address workforce challenges: Develop strategies to support and retain a competent and engaged behavioral health workforce.
- Advance health equity: Eliminate disparities in access to and quality of behavioral health services for all populations.
- Foster a culture of safety: Cultivate organizational cultures that prioritize patient safety, continuous learning, and open communication about safety concerns.
Level Up Your Impact in Behavioral Health Leadership
For healthcare professionals seeking to enhance their leadership impact in the evolving field of behavioral health, advanced education is invaluable. Programs like USC Price’s Executive Master of Health Administration equip experienced professionals with the knowledge and skills to navigate the complexities of the healthcare landscape and drive positive change. Understanding and implementing the National Patient Safety Goals is a core competency for effective behavioral health leaders, enabling them to shape a future where patient safety and well-being are paramount.
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”
