EP31- From the Organizational Performance Improvement and Patient Safety/Risk Management Plan

PROACTIVE RISK REDUCTION TO IMPROVE PATIENT SAFETY

(Failure Mode, Effects and Analysis – FMEA)

Every eighteen months, a proactive risk assessment on at least one high-risk process will be conducted utilizing the Failure Mode Effects Analysis (FMEA). The Joint Commission information about sentinel events and risks will determine priorities for selection. Elements included in the FMEA must include:

  • Describing the chosen process utilizing a flow chart diagram
  • Identifying ways in which the process could fail
  • Identifying the possible effects a process failure could have on patients and the seriousness of the possible effects
  • Prioritizing the potential process failures
  • Determining why the priority failures could occur, which may include performing a hypothetical root cause analysis
  • Redesigning the process or system to minimize the risk of the effects on patients
  • Testing and implementing the redesigned process
  • Monitoring the effectiveness of the redesigned process.

SECTION 6: PATIENT SAFETY/RISK MANAGEMENT PLAN

Multi Department Participation

Patient safety is a collaborative effort between all departments and disciplines that collaborate to establish the plans, processes, and mechanisms of the patient safety activities at PSFHS. The Patient Safety/Risk Management is responsible for the plan oversight along with the Patient Safety Officer and Director of Clinical Effectiveness. The plan is derived from priorities set by the Centura and PSF strategic plans, Centura Quality plan, Risk Management incentive plans, IHI initiatives, National Patient safety goals, culture of safety surveys, and other patient safety initiatives

Plan Coordination Responsibility

  • Governing board and MEC
  • Endorse and support the patient safety program
  • Administration
  • Promote a just culture that encourages reporting of occurrences without retaliation toward the individuals involved.
  • Ensure that patient safety issues are given a high priority and addressed when processes, functions, or services are designed or redesigned.
  • Patient Safety/Risk Management, Chief Medical Officer, Chief Nursing Officer and Clinical Effectiveness Director(Patient Safety Officer):
  • Develop the plan
  • Act as administrators of the plan
  • Provide education and training for the implementation of the plan
  • Provide ongoing education in patient safety and root cause analysis for all associates
  • Participate in and utilize FMEA for high risk processes
  • Oversee the Cause Analysis activities (Root cause Analysis or Apparent Cause Analysis) in occurrence investigations
  • Analyze occurrence reporting data and communicate the system actions to the QPSC
  • Coordinate evaluation of the effectiveness of the plan by doing periodic audits and surveys
  • Quality and Patient Safety Committee( QPSC)
  • Multidisciplinary committee which oversees quality and patient safety initiatives for PSFHS as delegated by CEC
  • Clinical Effectiveness Committee
  • Is a leadership committee that is delegated responsibility by the Community Board for ongoing oversight of safety improvement activities via periodic reports from individuals or groups accountable for implementation of quality and patient safety efforts at PSFHS.
  • Medical staff
  • Practice safe medicine
  • In conjunction with PSFHS staff, notify and disclose to the patient, patient family or significant other when an occurrence has occurred and explain what, if any, effect the occurrence has on the patient’s course of treatment.
  • All departments
  • Provide education to patient, patient families, and significant others about their part in helping ensure patient safety
  • Report and document patient safety occurrences
  • Participate in follow-up activities to improve the process(es)

Data Sources Patient safety or medical/health care issues may include data analysis from:

  • Patient assessment/documentation
  • Medication administration
  • Adverse Drug Reaction
  • Transfusion Reaction
  • Patient falls
  • Security
  • Surgery
  • Hazardous Conditions
  • Any set of circumstances, exclusive of the disease or condition for which the patient is being treated, which significantly increases the likelihood of a serious physical or psychological adverse patient outcome
  • Restraints
  • Other occurrence reports
  • Patient complaints and grievance

Reporting

Internal Reporting

All departments within the organization (patient care and non-patient care departments) are responsible for reporting patient safety occurrences and potential occurrences to Patient Safety/Risk Management by following the PSFHS occurrence reporting process. Patient Safety/Risk Management staff will also report adverse clinical events to the Centura Quality and Patient Safety Department.

Patient Safety/Risk Management will aggregate occurrence information and will present a monthly report to the Quality and Patient Safety Committee. The report will contain aggregated information that may include:

  • Type of occurrence
  • Severity of occurrence
  • Number/type of occurrences per department
  • Occurrence impact on the patient
  • Remedial actions taken
  • Patient outcome

The Quality and Patient Safety Committee will analyze the report information and determine further patient safety activities as appropriate.

Internal Notification

Any individual in any department identifying a potential patient safety issue will immediately:

  • Notify his or her supervisor and document the findings on an occurrence report.
  • Submit the occurrence report to the Patient Safety/Risk Management Department per

organizational policy

  • Communicate to their direct leadership

Administrative Response

  • All sentinel events and near miss occurrences will have a cause analysis conducted as determined necessary by the sentinel event policy (S-01-m).
  • The Quality and Patient Safety Committee will determine follow-up based on internal and external data analysis and the severity of the patient safety issue.
  • Further remedial action activities
  • Proactive occurrence reduction activities
  • Necessity and benefit of cause analysis of the identified occurrences

Non-punitive Approach

  • PSFHS has a non-punitive approach in its management of occurrences.
  • All personnel are requiredto report suspected and identified occurrences, and should do so without the fear of reprisal in relationship to their employment.
  • This organization supports the concept that occurrences happen due to a breakdown in systems and processes, and will focus on improving systems and processes, rather than disciplining those involved in occurrences.
  • A focus will be placed on corrective actions to assist rather than punish staff members.
  • Staff members, the Quality and Patient Safety Committee and the individual staff members’ department supervisor determine the appropriate course of action to prevent repeat occurrences.

Staff post Incident Support

  • The Quality and Patient Safety Committee encourages the staff member’s involvement in the cause analysis and action plan processes to allow the staff member an active role in process resolution.
  • Additionally, any staff member involved in a sentinel event or other occurrence may request and receive supportive personal counseling from the Employee Assistance Program, Human Resources Department and/or his or her department supervisor.

External Reporting v External reporting will be performed in accordance with all state, federal and regulatory body rules, laws and requirements.

Risk Assessment

Risk Identification: The collection of information about patient care occurrences and other situations presenting a potential loss to the system.

Risk Analysis: The evaluation of past experience and current exposure in order to assure appropriate remedial and preventative measures have been taken.

Risk Control: Respond to areas assessed as having significant risk to decrease the likelihood of an occurrence.

Sentinel Events/Critical Issues: Intense analysis of sentinel events or critical issues, as defined by TJC, will be conducted by the Chief Medical Officer, Chief Nursing Officer, Patient Safety/Risk Management and the Clinical Effectiveness Department with involved parties and departments. See Sentinel event policy(S-01-m)

Patient and Family Education

  • Staff will educate patients and their families about their role in helping to facilitate the safe delivery of care.

Staff and Education and Training

  • Staff will receive education and training during their initial orientation process and on an ongoing basis regarding job-related aspects of patient safety.
  • Training includes the need and method to report medical/health care occurrences.

Staff will be educated and trained on the provision of an interdisciplinary approach to patient care.