National Performance Goals (NPG)
A process that is in place to correctly identify patients when providing care, treatment and services
What is use of at least two patient identifiers?
The hospital discloses health information only as authorized by the patient with the patient's written consent or as otherwise required by law and regulation. The hospital develops and implements policies and procedures addressing the privacy and confidentiality of health information.
What is privacy and confidentiality of health information. IM.12.01.01
The hospital conducts the patient’s initial assessment within the written time frames. A medical history and physical examination is completed and documented no more than 30 days prior to, or within 24 hours after, registration or inpatient admission
What is, the hospital assesses and reassesses the patient and the patient's condition according to defined time frames. PC 11.02.02
Leadership structure and program accountability
- Hazard vulnerability analysis
- Mitigation and preparedness activities
- Emergency operations plan and policies and procedures
- Education and training
- Exercises and testing
- Continuity of operations plan
- Disaster recovery
- Program evaluation
What is the comprehensive emergency management program that utilizes an all-hazards approach. EM 09.01.01
The hospital develops and implements a written policy that defines patient responsibilities, including but not limited to the following:
- Providing information that facilitates their care, treatment, and services
- Asking questions or acknowledging when they do not understand the treatment course or care decision
What is, the hospital informs the patient about the patient's responsibilities related to their care, treatment, and services. RI 15.01.01
This process is demonstrated between the giver and receiver of information such as in Shift Report and the electronic data base used by the Medical Providers, Psychiatric Providers and the Doctors on Call
What is the process for hand off communication?
The hospital develops and implements policies and procedures regarding medical documentation and patient information during emergencies and other interruptions to information management systems, including security and availability of patient records to support continuity of care.
What is, the hospital plans for continuity of its information management processes. IM.11.01.01
The hospital has an effective discharge planning process that focuses on, and is consistent with, the patient’s goals and treatment preferences; makes certain there is an effective transition of the patient from the hospital to post discharge care. The hospital begins the discharge planning process early in the patient’s episode of care, treatment, and services.
What is, the hospital follows its process for discharging or transferring patients. PC 14.01.01
The hospital has written fire control plans that include provisions for prompt reporting of fires; extinguishing fires; protection of patients, staff, and guests; evacuation; and cooperation with firefighting authorities.
What is, the hospital designs and manages the physical environment to comply with the Life Safety Code. PE 03.01.01
The hospital provides information, including but not limited to the patient’s total health status, in a manner tailored to the patient's age, language, and ability to understand.
What is, the hospital respects the patient's right to receive information in a manner the patient understands. RI 11.02.01
The hospital complies with Current Centers for Disease Control and Prevention hand hygiene guidelines or the World Health Organization hand hygiene guidelines.
What are goals for improving hand hygiene compliance?
The hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations.
What is documentation /records of health information in standardized formats? IM .13.01.01
The hospital trains staff on the use of restraint and seclusion and assesses their competence at the following intervals:
- At orientation
- Before participating in the use of restraint or seclusion
- On a periodic basis thereafter, by hospital policy
What is the hospital trains staff to safely implement the use of restraint or seclusion. PC 13.02.17
The hospital has proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.
What is the hospital addresses building safety and facility management.
The hospital informs the patient of the following:
- Name of the physician, clinical psychologist, or other licensed practitioner who has primary responsibility for the patient's care, treatment, and services
What is the hospital respects the patient's right to receive information about the individual(s) responsible for, as well as those providing, the patient's care, treatment, and services. RI 12.02.01
A leader or leadership responsible for pain management including nonpharmacologic pain treatment modalities and safe opioid prescribing.
What is Pain assessment and pain management including safe opioid prescribing identified as an organization priority? NPG .06.01.01
The hospital has a system for coding and indexing medical records to make health information accessible when needed for patient care, treatment, and services.
What is the hospital retrieves, disseminates, and transmits health information in useful formats. IM 13.01.01
The dietitian and medical staff approve a therapeutic diet manual that is current and available to all medical, nursing, and food service staff.
What is the hospital makes food and nutrition products available to its patients. PC 12.01.09
The hospital develops a staffing plan for managing all staff and volunteers to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge
What is, the hospital has a staffing plan for managing all staff and volunteers during an emergency or disaster incident.
The hospital protects the patient from harassment, neglect, exploitation, corporal punishment, involuntary seclusion, and verbal, mental, sexual, or physical abuse that could occur while the patient is receiving care, treatment, and services.
What is the patient has the right to be free from harassment, neglect, exploitation, and verbal, mental, physical, and sexual abuse. RI 13.01.01
The hospital respects the patient’s right to and need for effective communication. Provides interpreting and translation services, as necessary.
What is, patient's right to receive information in a manner the patient understands? NPG .07.01.01
Hospital develops and implements a written policy that addresses the security of health information, including the following:
- Access and use of health information
- Integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction
- Intentional destruction of health information
- When and by whom the removal of health information is permitted
What is, the hospital maintains the security and integrity of health information. IM 12.01.01
The hospital develops, implements, and revises a written individualized plan of care
What is the patient plans the Patient's care? PC 11.03.01
The Abbreviation H.V.A
What is a Hazard Vulnerability Analysis?
The hospital develops and implements policies and procedures for the prompt resolution of patient grievances. The policies clearly explain the procedure for patients to submit written or verbal grievances and specify time frames for the review of and response to the grievance.
What is, the patient and their family have the right to have grievances reviewed by the hospital. RI 14.01.01