Those of us who work in hospital departments directly related to investigation and mitigation of adverse patient care events, whether that’s a department of Clinical Risk Management, Quality, Legal, or Patient Safety, need to take note of the 2009 Joint Commission Leadership Standards, as some new requirements have been added.
The 2009 Elements of Performance for LD.4.260 are noted below:
LD.4.260 The hospital implements an integrated safety program throughout the hospital.
Elements of Performance
1. There is a hospital-wide, integrated, patient safety program.
2. One or more qualified individuals, or an interdisciplinary group, manages the hospital-wide safety program.
3. The scope of the program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, good catches) to hazardous conditions and sentinel events, which have serious adverse outcomes.
4. All departments, services, and programs within the hospital participate in the safety program.
5. The hospital creates procedures for responding to system or process failures, such as continuing to provide care, treatment or services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.
6. The hospital: Defines responses to various types of potential adverse events.
7. The hospital: Conducts proactive risk assessments.
8. The hospital: Makes support systems available for staff members who have been involved in a sentinel event. (I’m glad to see this element added as a formal requirement this year.)
9. The hospital: Analyzes and uses information about a system or process failure to improve safety.
10, The hospital: Provides systems for internal and external reporting of a system or process failure.
11, The hospital: Provides governance at least once a year, with written reports on all system or process failures, on the number or type of sentinel events, on whether patients and the families were informed of the adverse events, and on all actions taken to improve safety, both proactively and in response to actual occurrences.
12. The hospital: Disseminates lessons learned from root cause analysis to staff who provide services or are affected by the situation.
13. The hospital: Encourages external reporting of significant external events, including voluntary reporting programs in addition to mandatory programs.