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Inpatient Facility Coding & Compliance Alert

Act on These Must-Know Facts

Published on Fri Nov 14, 2014

  • Every patient safety event must be reported. When there is a continuous reporting, the hospital will be able to define the problem, identify solutions, achieve sustainable results and disseminate the changes or lessons learnt to the rest of the staff.
  • The hospital should provide staff with information regarding improvement based on the reported concerns.
  • Focus on “collective mindfulness” where the staff realizes that any system can potentially fail; encourage staff to stay vigilant to single out hazardous conditions or close calls before the patient is harmed.
  • According to standard LD.04.04.05, EP 6, the leaders should provide and encourage the use of a standardized reporting process for blame free reporting, as well as intimidating behaviors within the hospital that may inhibit others from reporting safety concerns.
  • Staff should never be punished for reporting an event, a close call, or a hazardous condition. However, they are accountable for their responsibilities. The Commission has outlined a clear process for assessing staff accountability given the situation, condition and protocols and intent.
  • The hospital should collect data on patient care outcomes and safety events and monitor its performance.
  • The Joint Commission requires that at least every 18 months, the hospital should select one high risk process and conduct a proactive risk assessment, standard LD.04.04.05, EP 10 clarifies.

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