Patient Safety, Just Culture, Culture of Safety, and the TJC and CMS Hospital CoP standards on Safety

This program on patient safety issues in hospitals will cover the patient safety issues along with CMS Hospital CoPs and the Joint Commission requirements on patient safety including the TJC Patient Safety System chapter. This session which deals with patient safety in healthcare will discuss the CMS hospital conditions of participation (CoPs) in the punitive environment, reporting of medication errors, adverse events, and drug incompatibilities. The Joint Commission standards also require a non-punitive environment and this will be discussed. This program will also discuss the top ten patient safety issues.

It will be discussed what hospitals need to do to create a patient safety culture. Both the CMS CoPs and the Joint Commission require hospitals to have a non-punitive environment. Did you know that the CMS worksheet on QAPI asks the surveyor to review three RCAs from the hospital? This program on patient safety nursing will discuss the balance of a nonpunitive environment for medical errors with the Just Culture theory. It will discuss the free toolkit on Just Culture by AHRQ. There is also a section on patient safety in the CMS worksheet and there are many deficiencies cited related to patient safety..

It will cover the patient safety recommendations of the NQF 34 Safe Practices and will discuss how to prevent medical errors from occurring. CMS is reporting each hospital’s scores and is reducing payments by 1 percent to hospitals with the highest rate of medical errors and infections. Hospitals need to evaluate ways to proactively reduce errors and adverse events.

Preventable medical errors are actually at risk by 1% per year according to the National Quality Forum publication on 34 Safe Practices for better healthcare. There are 18 types of medical errors that account for 2.4 million extra hospital days and 9.3 billion in an excess care. An OIG study found that 15,000 Medicare patients every month experience an adverse event during healthcare delivery that results in death. One of every seven discharges (13.5%) results in an adverse event. This webinar on patient safety culture will also cover the top patient safety issues in 2020.

• Describe the CMS  hospital CoP requirements including that near misses must be included in the definition of what constitutes a medication error
• Discuss the Joint Commission requirements for the patient safety program including that an FMEA must be done every 18 months
• Recall that the  34 Practices for Better Healthcare recommendations include that a culture survey should be done
• Recall that AHRQ has published 10 patient safety tips for  hospitals
• Discuss the system analysis theory and that there should be a non-punitive system for system failures
• Discuss what is meant by Just Culture

• CMS hospital CoP standard on non-punitive environment 
  • The requirement for the voluntary non-punitive environment
  • CMS memo on reporting to PI program and AEs
  • AHRQ Common Formats
  • Standard revised Tag 508 
  • Medication errors and adverse drug events
  • Must include near misses or close calls
  • Corrective actions to prevent reoccurrences 
• TJC leadership standards on non-punitive behavior and organization safety standards, system performance, and culture survey
  • Patient safety program requirements
  • Patient safety system chapter
  • Near misses or close calls
  • FMEA  and RCA requirements
  • Patient safety plan and scope of the program
  • System or process failures
  • Sentinel event requirements and LD chapter requirements
  • External reporting of significant adverse events
• National Quality Forum   34 Safe Practices for Better Healthcare standard on the culture of safety
  • Leadership structures and systems
  • Patient safety program
  • Patient safety officer
  • Patient safety committee
  • Board responsibility in patient safety
  • Two toolkits for leadership on walkabouts
  • Culture measurement
• Just Culture theory as a balance
  • AHRQ toolkit
  • Just culture principles
• OIG Study on adverse events with Medicare patients
• CMS reduction of 1% for hospitals with the highest rate of medical errors and infections
• The IOM Study on Medical Errors
• Patient Safety Issues
• Definition of Patient Safety
  • AHRQ definition
• Other names for Medical Error
• Error prevention and Just Culture
• Establishing a culture of safety
• High-Reliability Organizations
• Key Features of Culture of Safety (AHRQ)
• AHRQ  Patient Safety Primer on Safety Culture
• ECRI Top Patient Safety Issues 
• 10 domains of patient safety
• AHRQ 10 Patient Safety Tips for Hospitals
• System Approach
• Human factor engineering
• Root cause analysis
  • CMS Worksheet and 3 RCAs for hospitals
• Active versus latent conditions
• Errors at the sharp end versus the blunt end
• Slips verses mistakes
• Patient safety outcomes
• Human error
• Culture of safety components
• Developing a culture of safety
• High-reliability organizations
• Patient safety rounds or walkabouts

• Patient Safety Team Members
• Patient Safety Officer
• Quality Management Coordinator
• Joint Commission Coordinator
• Nurse Educator
• Chief Nursing Officer
• Nurse Managers
• Nurse Educators
• Risk Manager
• Hospital Legal Counsel
• Physicians
• VP of Medical Staff
• Consumer Advocate
• Nurse Managers
• Nurse Supervisors
• Clinic Managers
• Nurses
• CEO
• Chief Operating Officer
• Patient Safety Committee Members
• Department Directors
• Compliance Officer
• Pharmacist
• Pharmacy staff
• Risk Manager
• Legal Counsel
• Compliance Officer
• Anyone else involved in improving patient safety in healthcare facilities