TJC Patient Safety Systems Chapter, Sentinel Event Policy and CMS RCA Requirements

This program will cover the Joint Commission sentinel event policy changes and how to help hospitals ensure compliance. The Joint Commission (TJC) Patient Safety System chapter will also be covered. The patient safety system chapter and the sentinel event policy are designed to be used together.

Knowing the TJC standards on how to create a thorough and credible root cause analysis (systematic analysis) will help establish that the underlying questions and requirements can be met.

The Patient Safety System chapter is to inform and educate hospitals about the importance and how to structure an integrated patient safety system. The chapter did not include any new requirements. Rather, it describes how current standards can be used to improve patient safety. It provides the direct link and framework between the accreditation standards and patient safety.

Every hospital should know when an RCA or FMEA should be performed. This describes how to ensure your RCA is thorough and credible and acceptable. The policy talks about when one must be done and the time frame to complete it. Hospitals should implement all sentinel event alerts and incorporate them into practice.

The CMS final hospital QAPI worksheet that discusses patient safety, adverse events, and medical errors will be addressed. CMS has a root cause analysis (RCA) tracer, which they call a causal analysis that lists many things that a surveyor will ask a hospital during a validation or certification survey. The surveyor will select three RCAs to evaluate.

• Discuss that TJC has a patient safety system chapter with a goal to help hospitals improve quality of care and patient safety
• Describe that the Joint Commission has a sentinel event policy and procedure that hospitals should be familiar with
• Recall that CMS has a final worksheet on QAPI that includes a section on patient safety, adverse events, and medical errors

TJC Sentinel Event Policy and Procedure

• Sentinel Event Alerts (SEA) and importance
• Amended many times
• Sentinel Events (SE)
• Revised Definition
• Required review of sentinel events and process
• Patient safety events, close calls, etc,
• Goals of SE policy
• Responding to SE
• System Analysis Approach
• Action Plan
• Reporting a SE and 4 options
• Through credible RCA requirements
• Follow Up

TJC Patient Safety Systems

• The process to improve quality and patient safety
• LD.03.09.01 Hospital Patient Safety Program requirements
• Becoming a learning institution
• Role of hospital leaders in patient safety
• Data use and reporting systems
• Key patient safety requirements
• Safety culture
• Fair and just culture
• Holding staff accountable
• A proactive approach to preventing harm in healthcare
• Encouraging patients to become active partners in healthcare

CMS QAPI Worksheet on Patient Safety, Adverse Events (AE) and Medical Errors

• The section on Patient Safety, AE, and medical error
• Staff training or communication related to expectations for patient safety
• P&P on non-punitive environnement
• Staff role in promoting patient safety
• Training required regarding if staff feel unsafe
• What constitutes a medical error or near-miss?
• Required reporting
• RCA did on all serious preventable AEs
• RCA tracer
• Surveyor will select 3 RCAs to review

• Patient Safety Officers
• Senior Leaders including CEO, COO, CNO, CMO, etc.
• Risk managers and staff
• TJC accreditation director
• Compliance officers
• CMS regulatory compliance staff
• Department directors
• Nurses
• Nurse Educators
• Nurse managers and supervisors
• Consumer advocates
• Quality improvement director and staff
• In-house legal counsel
• Anyone responsible to ensure the quality and safety of patients and ensuring compliance with CMS or TJC standards