New standards call for proactive approach

Joint Commission: Prevent rather than react

The Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL, recently issued new standards focusing specifically on patient safety issues in hospitals. Some of the key new requirements include the following:

Standard LD.5

The leaders ensure implementation of an integrated patient safety program throughout the organization.

Intent of LD.5

The patient safety program includes at least the following:

- Designation of one or more qualified individuals or an interdisciplinary group to manage the organizationwide patient safety program. Typically these individuals may include directors of performance improvement, safety officers, risk managers, and clinical leaders.

- Definition of the scope of the program activities, that is the types of occurrences to be addressed — typically ranging from "no harm" frequently occurring "slips" to sentinel events with serious adverse outcomes.

- Description of mechanisms to ensure that all components of the health care organization are integrated into and participate in the organizationwide program.

- Procedures for immediate response to medical/health care errors, including care of the affected patient(s), containment of risk to others, and preservation of factual information for subsequent analysis.

- Clear systems for internal and external reporting of information relating to medical/health care errors.

- Defined mechanisms for responding to the various types of occurrences, e.g., root-cause analysis in response to a sentinel event, or for conducting proactive risk-reduction activities.

- Defined mechanisms for support of staff who have been involved in a sentinel event. At least annually, a report to the governing body on the occurrence of medical/health care errors and actions taken to improve patient safety, both in response to actual occurrences and proactively.

Standard LD.5.2

Leaders ensure an ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors is defined and implemented.

Intent of LD.5.2

The organization seeks to reduce the risk of sentinel events and medical/health care system error-related occurrences by conducting its own proactive risk-assessment activities and by using available information about sentinel events known to occur in health care organizations that provide similar care and services. This effort is undertaken so that processes, functions, and services can be designed or redesigned to prevent such occurrences in the organization. Proactive identification and management of potential risks to patient safety have the obvious advantage of preventing adverse occurrences, rather than simply reacting when they occur. This approach also avoids the barriers to understanding created by hindsight bias and the fear of disclosure, embarrassment, blame, and punishment that can arise in the wake of an actual event. Leaders provide direction and resources to conduct the following proactive activities to reduce risk to patients:

- At least annually, select at least one high-risk process for proactive risk assessment, such selection to be based, in part, on information published periodically by the Joint Commission that identifies the most frequently occurring types of sentinel events and patient safety risk factors.

- Assess the intended and actual implementation of the process to identify the steps in the process where there is, or may be, undesirable variation (i.e., what engineers call potential "failure modes").

- For each identified "failure mode," identify the possible effects on patients (what engineers call the "effect"), and how serious the possible effect on the patient could be (what engineers call the "criticality" of the effect).

- For the most critical effects, conduct a root-cause analysis to determine why the variation (the failure mode) leading to that effect may occur.

- Redesign the process and/or underlying systems to minimize the risk of that failure mode or to protect patients from the effects of that failure mode.

- Test and implement the redesigned process.

- Identify and implement measures of the effectiveness of the redesigned process and develop a strategy for maintaining the effectiveness of the redesigned process over time. n

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