Inpatient Facility Coding & Compliance Alert

Check out what Joint Commission solicits on the tenet “Do No Harm”

It’s time to align with the Joint Commission Patient Safety standards and protect your patients by implementing fail safe processes.

On October 20, 2014, The Joint Commission issued an all new chapter related to “Patient Safety Systems” to be included in the 2015 Comprehensive Accreditation Manual for Hospitals. This is to highlight and reinstate the structure of an integrated patient-centered system and reinforce the concept of quality of care and patient safety. 

Onus on the Leaders for a Fair Safety Culture

Joint Commission urges hospital administrators to take the top-down approach to maintenance of hospital safety standards. The involvement of leaders in the safety initiatives is indispensible because 75 to 80 percent of all initiatives that require people to change their behavior collapse without any leadership behind the change. 

As the standard LD.03.01.01 indicates, hospital officials should develop a culture of safety, which means an environment where staff and leaders work together to remove all barriers to the safety goals of the hospital. Health care organizations are to include proactive methods and models of quality and patient safety that pave the way for accountability, trust, and awareness while leaving little room for fear and blame that a mishap can occur.

The Joint Commission information also stresses that leaders should establish the “trust-report-improve cycle” of a safety culture, in which the leaders foster trust, which enables staff to report, which enables the hospital to improve. 

“Basically, the objective is to change the corporate culture (i.e., if it needs to be changed),” explains Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.  “In some cases, if there is an adverse event (clinical or otherwise), then someone has to be blamed and most likely fired. The needed culture is not to blame individuals but to improve processes. If something happens, then the situation is carefully analyzed, the process is improved, training is provided, policies updated, etc. The fostering of trust involves an employee trusting the leadership so that safety events can be openly reported without undue fear.”

Become a Learning Organization

A learning organization is one where people continuously learn, and enhance their capacity to create and innovate. The Joint Commission encourages hospitals to become learning organizations with advancing knowledge, skills and competence of staff and patients by recommending methods that will improve quality and safety processes. 

The five principles that CMS recommends a hospital as a learning organization should adopt are:

• Team learning
• Shared visions and goals
• Shared mental model (congruent collective thinking)
• Individual commitment to lifelong learning
• Systems thinking (develop sustainable processes)

Internalize this: Hospital staff should make a team effort to report, identify, collectively reflect and learn from patient safety events, have a clear common goal to eliminate such occurrences, and a commitment to put this will to work by driving improvement. “The concept of learning organizations has long been discussed. The real issue is taking the steps necessary to actually develop the learning culture and then to support such processes over time,” Abbey points out.

“For the first time, The Joint Commission is providing a standards chapter on our website because this information is so important that we want everyone to have access to it. A solid foundation for patient safety is a safety culture,” said Ana Pujols McKee, MD, executive vice president and chief medical officer, in a Joint Commission news release on Oct. 20. “For leaders, our hope is they will study this chapter and use it as a tool to build or improve their safety culture program.” 

Good news: Anyone who has audits on their minds will be glad to know this chapter does not put up any new requirements for you to meet. However, the Commission believes it was imperative to build a separate chapter on the safety aspect by selecting pertinent portions from existing chapters such as Leadership, Rights and Responsibilities of the Patient, Performance Improvement, Medication Management and Environment of Care. Joint Commission will soon make this information available online for all.

Final takeaway: Abbey makes it very clear that “the new chapter provides a focal point for the organizational changes that really need to take place.” “This focal point can also be used by auditors to separately consider this important area,” he adds.