10 - Patient Safety Regulations Flashcards
Define:
- *determination** that an eligible organization
- *complies with applicable requirements (e.g. standards)**
ACCREDITATION
Define:
A key component in the accreditation process whereby a surveyor(s) conducts an on-site evaluation
of an organization’s compliance with accreditation requirements.
SURVEY
a principle of patient safety and quality of care
that a well-run organization meets.
defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care, treatment, or services.
(TJC term)
STANDARD
Specific action(s), process(es), or structure(s)
that must be implemented
to achieve the goal of a standard.
The scoring of EP compliance determines an organization’s overall compliance with a standard.
(TJC term)
- *EP**
- *Element of Performance**
Clinical, scientific, or professional practices
that are recognized by a
majority of professionals in a particular field as being exemplary.
These practices are typically
evidence based and consensus driven.
BEST PRACTICES
Status conferred by the Centers for Medicare & Medicaid Services (CMS)
on an organization whose standards and survey process are determined to be equivalent to those of the
Medicare program or other federal laws
DEEMED STATUS
Illinois Department of
Public Health
(IDPH)
•Hospitals are required to be in compliance with the Federal requirements set forth in the
- *Medicare Conditions of Participation (CoP)** in order to
- *receive Medicare/Medicaid payments.**
•Certification of hospital compliance with the CoP is accomplished through observations, interviews, and document/record reviews.
Survey Process
•The survey process
focuses on a hospital’s performance of patient-focused and organizational functions and processes.
•
•The hospital survey is the means used to
assess compliance with Federal health, safety, and quality standards
that will assure that the beneficiary receives safe, quality care and services
Accreditation
- Accreditation is a method for ensuring an organization achieves and maintains high-quality patient care.
- Patient safety is a primary driver for all accrediting agencies.
Accreditation Process
The accreditation process helps raise the levels of safety, quality, and value of care provided by an organization
- Accrediting agencies present standards reflecting national concerns, helping organizations to stay current and update practices accordingly.
- Participation in the accreditation process is voluntary
TJC accreditation process
The Joint Commission
Other Accreditation Agencies:
HFAP
NIAHO
DNV
•The survey process is based on the ability of the organization to comply with the requirements of:
•Standards
•National Patient Safety Goals
•Accreditation process involves unannounced triennial surveys
. (3 years, and random)
•Length of the survey depends on the size of the organization
STANDARD MM
TJC
Standard MM.01.01.03
Standard MM.04.01.01
Standard MM.01.01.03
The hospital safety manages high-alert and hazardous medications
•Standard MM.04.01.01:
Medication orders are clear and accurate
The hospital minimizes the use of verbal and telephone medication orders
Goal 1
NPSG 01.01.01
National Patient Safety Goals
Improve:
ACCURACY of PATIENT IDENTIFICATION
>2 Patient Identifiers
Reliably Identify –> Match the service or treatment
Goal 1
NPSG 01.03.01
National Patient Safety Goals
Improve Accuracy of
Patient Identification
Elmiiate TRANSFUSION ERRORS
related to patient misidentification
INCORRECT BLOOD
Goal 2
NPSG 02.03.01
National Patient Safety Goals
COMMUNICATION AMONG CAREGIVERS
Reports:
Critical results of TESTS + DIAGNOSTIC procedures
on a
TIMELY BASIS
Goal 3
NPSG 03.04.01
06 / 05
National Patient Safety Goals
SAFETY of using MEDICATIONS
LABEL all medications & containers & solutions
ANTICOAGULANT Therapy
MEDICATION RECONCILIATION
accurate patient medication information
