Patient Safety Systems (PS) - Joint Commission

1 CAMAC,January 2018PS 1 patient safety systems (PS)*The Institute of Medicine defines quality as the degree to which health services for individuals andpopulations increase the likelihood of desired health outcomes and are consistent with currentprofessional :Source:Committee to Design a Strategy for Quality Review and Assurance inMedicare, Institute of : A Strategy for Quality Assurance, vol. 1. Lohr KN, , DC: The National Academies Press, quality of care and the Safety of patients are core values of The Joint Commissionaccreditation process. This is a commitment The Joint Commission has made topatients, families, health care practitioners, staff, and health care organization chapter exemplifies that intent of this Patient Safety Systems (PS) chapter is to provide organizationleaders with a proactive approach to designing or redesigning a Patient -centered systemthat aims to improve quality of care and Patient Safety , an approach that aligns with theJoint Commission s mission and its Joint Commission partners with accredited organizations to improve health caresystems to protect patients .

2 The first obligation of health care is to do no harm. Therefore, this chapter is focused on the following three guiding existing Joint Commission standards with daily work in order to engagepatients and staff throughout the health care system , at all times, on reducing health care organizations with advancing knowledge, skills, and com-petence of staff and patients by recommending methods that will improve qualityand Safety and recommending proactive quality and Patient Safety methods thatwill increase accountability, trust, and knowledge while reducing the impact of fearand *and Safety are inextricably health care is the degree to whichits processes and results meet or exceed the needs and desires of the people it ,2 Those needs and desires include components of a quality management system should include the following.

3 QEnsuring reliable processesCAMAC,January 2018PS 2 Comprehensive Accreditation Manual for Ambulatory CareQDecreasing variation and defects (waste)QFocusing on achieving better outcomesQUsing evidence to ensure that a service is satisfactoryPatient Safety emerges as a central aim of Safety , as defined by the WorldHealth Organization, is the prevention of errors and adverse effects to patients that areassociated with health care. Safety is what patients , families, staff, and the public expectfrom Joint Commission accredited organizations. While Patient Safety events may notbe completely eliminated, harm to patients can be reduced, and the goal is always zeroharm. This chapter describes and provides approaches and methods that may be adaptedby an organization that aims to increase the reliability of its complex Systems whilemaking risk of Patient harm apparent and removing that risk.

4 Joint Commission accredited organizations should be continually focused on eliminating Systems failuresand human errors that may cause harm to patients , families, and ,2 The ultimate purpose of The Joint Commission s accreditation process is to enhancequality of care and Patient Safety . Each requirement or standard, the survey process, theSentinel Event Policy, and other Joint Commission initiatives are designed to helporganizations reduce variation, reduce risk, and improve quality. Organizations shouldhave an integrated approach to Patient Safety so that high levels of safe Patient care canbe provided for every Patient in every care setting and are complex environments that depend on strong leadership to support anintegrated Patient Safety system that includes the following:QSafety cultureQValidated methods to improve processes and systemsQStandardized ways for interdisciplinary teams to communicate and collaborateQSafely integrated technologiesIn an integrated Patient Safety system , staff and leaders work together to eliminatecomplacency, promote collective mindfulness, treat each other with respect andcompassion, and learn from their Patient Safety events, including close calls and othersystem failures that have not yet led to Patient Does This Chapter Contain?

5 The Patient Safety Systems (PS) chapter is intended to help inform and educateorganizations about the importance and structure of an integrated Patient Safety chapterchapter describesdescribes howhow existingexisting requirementsrequirements cancan bebe appliedapplied toto achieveachieve improvedimprovedCAMAC,January 2018PS 3 Patient Safety Systems continued on next page For a list of specific Patient Safety events that are also considered sentinel events,seepage SE-1 in the Sentinel Events (SE) chapter of this Safety ; Safety ; itit doesdoes notnot containcontain anyany newnew is also intended to help allhealth care workers understand the relationship between Joint Commission accredita-tion and Patient chapter does the following:QDescribes an integrated Patient Safety systemQDiscusses how organizations can develop into learning organizationsQExplains how organizations can continually evaluate the status and progress of theirpatient Safety systemsQDescribes how organizations can work to prevent or respond to Patient Safety events(Sidebar 1, below, defines key terminology)QServes as a framework to guide organization leaders as they work to improve patientsafety in their organizationsQContains a list of standards and requirements related to Patient Safety Systems (which will be scored as usual in their original chapters)QContains references that were used in the development of this chapterThis chapter refers to a number of Joint Commission standards.

6 Standards cited in thischapter are formatted with the standard number in boldface type (for example, ) and are accompanied by language that summarizes thestandard. For the full text of a standard and its element(s) of performance (EP), pleaseseethe Appendix beginning on page 1. Key Terms to UnderstandQPatient Safety event:An event, incident, or condition that could have resulted ordid result in harm to a event:A Patient Safety event that resulted in harm to a event: A subcategory of Adverse Events, a Sentinel Event is a patientsafety event (not primarily related to the natural course of the Patient s illness orunderlying condition) that reaches a Patient and results in any of the following:RDeathRPermanent harmCAMAC,January 2018PS 4 Comprehensive Accreditation Manual for Ambulatory CareSidebar 1.

7 (continued)RSevere temporary harmQClose callor near miss, no harm, or good catch : A Patient Safety event thatdid not cause harm as defined by the termsentinel (or unsafe )condition(s): A circumstance (other than a Patient sown disease process or condition) that increases the probability of an :It is impossible to determine if there are practical prevention or mitigationcountermeasures available without first doing an event analysis. An event analysiswill identify Systems -level vulnerabilities and weaknesses and the possible remedialor corrective actions that can be a Learning OrganizationThe need for sustainable improvement in Patient Safety and the quality of care has neverbeen greater. One of the fundamental steps to achieving and sustaining thisimprovement is to become a learning organization.

8 Alearning organizationis one inwhich people learn continuously, thereby enhancing their capabilities to create organizations uphold five principles: team learning, shared visionsand goals, a shared mental model (that is, similar ways of thinking), individualcommitment to lifelong learning, and Systems a learning organization, Patient Safety events are seen as opportunities for learning and ,leaders in learning organizations adopt a transparent, nonpunitive approach to reportingso that the organization canreport to learnand can collectively learn from Patient safetyevents. In order to become a learning organization, an organization must have a fair andjust Safety culture, a strong reporting system , and a commitment to put that data towork by driving improvement. Each of these require the support and encouragement oforganization , staff, licensed independent practitioners, and patients in a learning organizationrealize thateverypatient Safety event (from close calls to events that cause major harm topatients) must be Patient Safety events are continuously reported,experts within the organization can define the problem, identify solutions, achievesustainable results, and disseminate the changes or lessons learned to the rest of theCAMAC,January 2018PS 4aPatient Safety Systems a learning organization, the organization provides staff withinformation regarding improvements based on reported concerns.

9 This helps foster trustthat encourages further page is blankdue to revisions ,January 2018PS 4b Comprehensive Accreditation Manual for Ambulatory CareCAMAC,January 2018PS 5 Patient Safety Systems The Role of Ambulatory Health CareOrganization Leaders in Patient SafetyOrganization leaders provide the foundation for an effective Patient Safety system bydoing the following:9 QPromoting learningQMotivating staff to uphold a fair and just Safety cultureQProviding a transparent environment in which quality measures and Patient harmsare freely shared with staffQModeling professional behaviorQRemoving intimidating behavior that might prevent safe behaviorsQProviding the resources and training necessary to take on improvement initiativesFor these reasons, many of the standards that are focused on the organization s patientsafety system appear in the Joint Commission s Leadership (LD) standards, (which focuses on having an organizationwide, integrated patientsafety program within performance improvement activities).

10 Without the support of organization leaders, organizationwide changes and improve-ment initiatives are difficult to achieve. Leadership engagement in Patient Safety andquality initiatives is imperative because 75% to 80% of all initiatives that require peopleto change their behaviors fail in the absence of leadership managing the ,leadership should take on a long-term commitment to transform the CultureA strong Safety culture is an essential component of a successful Patient Safety systemand is a crucial starting point for organizations striving to become learning organiza-tions. In a strong Safety culture, the organization has an unrelenting commitment tosafety and to do no harm. Among the most critical responsibilities of leaders is toestablish and maintain a strong Safety culture within their organization.