Communicating CTRs Becomes a NPSG 

In 2005, the JCAHOAHO incorporated requirements for improving communication among caregivers into the NPSGs. (see Goal 2) “Failure to follow up on critical test results and values in a timely manner represents a significant safety concern in health care organizations. It is important for all licensed caregivers to manage test results in a reliable, efficient and evidence-based manner. Timely reporting of critical test results and values can have a direct impact on quality of care.” [1]

Goal 2: Improve the effectiveness of communication among caregivers. Sub-parts 2C and 2D focus on timely reporting of CTRs.

Requirement 2C: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and receipt by the responsible licensed caregiver, of CTRs and values. The JCAHO requires that CTRs and values be reported and received by responsible caregivers in a timely manner.

Implementation Expectations: 2C & 2D:  An organization needs to determine its current turnaround time for reporting. Then, it must define the acceptable length of time: a) between ordering tests and reporting results and values; and b) between availability of CTR/Values and receipt by responsible caregiver.

Organizations should assess these data to identify a need to improve timeliness, take appropriate action if needed, and measure effectiveness of those actions. The performance improvement process can help to identify obstacles to timely reporting within an organization’s unique system.

Requirement 2D:  Report all laboratory defined critical values to a responsible licensed caregiver, within times established by the laboratory, in co-operation with nursing and medical staff.  There is a mechanism to report critical values to an alternate responsible caregiver when the patient’s responsible caregiver is not available within the stated time frames.

Implementation Expectations: 2D:  An organization needs to create a back-up reporting system, in order to ensure that CTRs are timely reported to another qualified caregiver when the responsible caregiver is not available, to prevent delays in follow-up action.

In 2006, the JCAHO for the first time required hospitals to establish formal procedures for hand-off communications.  Compliance with this requirement will probably involve breaking down traditional cultural barriers in the exchange of patient information between doctors and nurses.[2]

Requirement 2E: Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.