The hospital’s leaders design work processes to focus individuals on safety and quality issues.

(1)

The leaders implement a hospitalwide patient safety program as follows: - One or more qualified individuals or an interdisciplinary group manage the safety program. - All departments, programs, and services within the hospital participate in the safety program. - The scope of the safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as close calls [“near misses”] or good catches) to hazardous conditions and sentinel events.

(2)

The leaders encourage external reporting of significant adverse events, including voluntary reporting programs in addition to mandatory programs. Note: Examples of voluntary programs include Joint Commission's Sentinel Event Database and the US Food and Drug Administration (FDA) MedWatch.

(3)

As part of the safety program, the leaders create procedures for responding to system or process failures. Note: Responses might include continuing to provide care, treatment, and services to those affected; containing the risk to others; and preserving factual information for subsequent analysis.

(4)

The leaders provide and encourage the use of systems for internal reporting of a system or process failure, or the results of a proactive risk assessment, without the risk of retaliation. Note: This EP is intended to minimize staff reluctance to report errors in order to help an organization understand the source and results of system and process failures. The EP does not conflict with holding individuals accountable for errors due to negligence.

(5)

The hospital conducts thorough and credible comprehensive systematic analyses (for example, root cause analyses) in response to sentinel events as described in the "Sentinel Event Policy" (SE) chapter of this manual.

(6)

The leaders make support systems available for staff who have been involved in an adverse or sentinel event. Note: Support systems recognize that health care workers who are involved in sentinel events may be negatively affected by the event and require support. Support systems provide staff with help and support as well as additional resources through the human resources function or an employee assistance program. Support systems also focus on the process rather than blaming the involved individuals.

(7)

At least every 18 months, the hospital selects one high-risk process and conducts a proactive risk assessment. Note: For suggested components, refer to the Proactive Risk Assessment section at the beginning of this chapter.

(8)

To improve safety and to reduce the risk of medical errors, the hospital analyzes and uses information about system or process failures and the results of proactive risk assessments.

(9)

Communication processes are effective in doing the following: - Fostering the safety of the patient and their quality of care - Supporting a culture of safety and quality - Meeting the needs of internal and external users - Informing those who work in the hospital of changes in the environment - Disseminating lessons learned from comprehensive systematic analyses (for example, root cause analyses), system or process failures, and proactive risk assessments to all affected staff

(10)

Leaders evaluate the effectiveness of communication methods.

(11)

Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. Possible issues are identified by the culture of safety evaluation. Proposed improvements are prioritized and implemented.

(12)

Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety.

(13)

Leaders create and implement a process for managing behaviors that undermine a culture of safety.