Patient Safety Systems (PS)

1 CAMH,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 health careorganizations with a proactive approach to designing or redesigning a Patient -centeredsystem that aims to improve quality of care and Patient Safety , an approach that alignswith the Joint Commission s mission and its Joint Commission partners with accredited health care organizations to improvehealth care Systems to protect patients .

2 The first obligation of health care is to do noharm. 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 processesCAMH,January 2018PS 2 Comprehensive Accreditation Manual for HospitalsQDecreasing 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.

4 This chapter describes and provides approaches and methods that may be adaptedby a health care organization that aims to increase the reliability of its complex systemswhile making visible and removing the risk of Patient harm. 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.

5 Hospitals should havean integrated approach to Patient Safety so that high levels of safe Patient care can beprovided 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?

6 The Patient Safety Systems (PS) chapter is intended to help inform and educatehospitals about the importance and structure of an integrated Patient Safety describesdescribes howhow existingexisting requirementsrequirements cancan bebe appliedapplied toto achieveachieve improvedimproved patientpatientCAMH,January 2018PS 3 Patient Safety Systems 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 ; itit doesdoes notnot containcontain anyany newnew is also intended to help all healthcare workers understand the relationship between Joint Commission accreditation andpatient chapter does the following.

7 QDescribes an integrated Patient Safety systemQDiscusses how hospitals can develop into learning organizationsQExplains how hospitals can continually evaluate the status and progress of theirpatient Safety systemsQDescribes how hospitals can work to prevent or respond to Patient Safety events(Sidebar 1, below, defines key terminology)QServes as a framework to guide hospital leaders as they work to improve patientsafety in their hospitalsQContains 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.

8 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 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 harmRSevere temporary harmCAMH,January 2018PS 4 Comprehensive Accreditation Manual for HospitalsQClose callor near miss, no harm, or good catch.

9 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.

10 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, a hospital must have a fair and justsafety culture, a strong reporting system , and a commitment to put that data to work bydriving improvement.