NQF’s 2009 Update has resulted in several important changes, including the expansion, combination and deletion of several practices in order to make them more understandable and reliable. Seven new practices were added, which HFAP-accredited hospitals will be required to implement before Dec. 1. These new practices, which will be incorporated into HFAP’s manual and surveying process, include the following measures:
• Disclosure — The communication of an adverse outcome must be communicated to the patient as soon as it is recognized, and the patient is ready physically and psychologically to receive the information. This should occur within 24 hours.
• Support of caregivers — HFAP mandates a healthcare organization to have a program designed to provide support to their staff that are experiencing normal stress after experiencing a highly abnormal event, so the caregiver can comfortably return to the work environment with normal productivity.
• Pharmacist leadership structures and systems — Development of policies and procedures to minimize medication errors must be based on accepted professional principles, external alerts and proactive review of adverse drug events. The hospital must have a pharmacist leader that has an active role on the administration leadership team.
• Glycemic control — Unless it is known, a hemoglobin A1C should be obtained upon admission. Both a nutritionist/dietitian and a diabetes nurse educator are needed to assess compliance with medication, diet and other aspects of care. At discharge, the diabetes provider must communicate with outpatient care providers about the patient’s regimen and glycemic control.
• Fall prevention — Patients at-risk for falls are identified on admission and periodically as indicated by patient status change throughout the admission. Also mandated is a facility-wide “falls program” using evidence based interventions to prevent and reduce patient fall-related injuries.
Learn more about HFAP.
