TJC Patient Safety Systems Chapter, Sentinel Event Policy and CMS RCA Requirements
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LAURA A. DIXON

LAURA A. DIXON

Education:-   Facility Patient Safety

Laura Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020 where she provided safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. She served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

Description: 

This program will cover the Joint Commission sentinel event policy changes and how to help hospitals ensure compliance. The Joint Commission (TJC) Patient Safety System chapter will also be covered. The patient safety system chapter and the sentinel event policy are designed to be used together.

Knowing the TJC standards on how to create a thorough and credible root cause analysis (systematic analysis) will help establish that the underlying questions and requirements can be met.

The Patient Safety System chapter is to inform and educate hospitals about the importance and how to structure an integrated patient safety system. The chapter did not include any new requirements. Rather, it describes how current standards can be used to improve patient safety. It provides the direct link and framework between the accreditation standards and patient safety.

Every hospital should know when an RCA or FMEA should be performed. This describes how to ensure your RCA is thorough and credible and acceptable. The policy talks about when one must be done and the time frame to complete it. Hospitals should implement all sentinel event alerts and incorporate them into practice.

The CMS final hospital QAPI worksheet that discusses patient safety, adverse events, and medical errors will be addressed. CMS has a root cause analysis (RCA) tracer, which they call a causal analysis that lists many things that a surveyor will ask a hospital during a validation or certification survey. The surveyor will select three RCAs to evaluate.

Objectives:-

  • Discuss that TJC has a patient safety system chapter with a goal to help hospitals improve quality of care and patient safety
  • Describe that the Joint Commission has a sentinel event policy and procedure that hospitals should be familiar with
  • Recall that CMS has a final worksheet on QAPI that includes a section on patient safety, adverse events, and medical errors

Detailed Outline:-

TJC Sentinel Event Policy and Procedure

  • Sentinel Event Alerts (SEA) and importance
  • Amended many times
  • Sentinel Events (SE)
  • Revised Definition
  • Required review of sentinel events and process
  • Patient safety event, close calls, etc,
  • Goals of SE policy
  • Responding to SE
  • System Analysis Approach
  • Action Plan
  • Reporting a SE and 4 options
  • Through and credible RCA requirements
  • Follow Up

TJC Patient Safety Systems

  • The process to improve quality and patient safety
  • LD.03.09.01 Hospital Patient Safety Program requirements
  • Becoming a learning institution
  • Role of hospital leaders in patient safety
  • Data use and reporting systems
  • Key patient safety requirements
  • Safety culture
  • Fair and just culture
  • Holding staff accountable
  • A proactive approach to preventing harm in healthcare
  • Encouraging patients to become active partners in healthcare

CMS QAPI Worksheet on Patient Safety, Adverse Events (AE) and Medical Errors

  • The section on Patient Safety, AE, and medical error
  • Staff training or communication related to expectations for patient safety
  • P&P on non-punitive environnement
  • Staff role in promoting patient safety
  • Training required regarding if staff feel unsafe
  • What constitutes a medical error or near-miss?
  • Required reporting
  • RCA did on all serious preventable AEs
  • RCA tracer
  • Surveyor will select 3 RCAs to review

Who Should Attend?

  • Patient Safety Officers
  • Senior Leaders including CEO, COO, CNO, CMO, etc.
  • Risk managers and staff
  • TJC accreditation director
  • Compliance officers
  • CMS regulatory compliance staff
  • Department directors
  • Nurses
  • Nurse Educators
  • Nurse managers and supervisors
  • Consumer advocates
  • Quality improvement director and staff
  • In-house legal counsel
  • Anyone responsible to ensure the quality and safety of patients and ensuring compliance with CMS or TJC standards

Choose Your Options

Recording    $249

 

DVD    $259

 

Recording & DVD    $399

 

Transcript (Pdf)    $249

 

Recording & Transcript (Pdf)    $389

 

DVD & Transcript (Pdf)    $399

 



 

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Discuss that TJC has a patient safety system chapter with a goal to help hospitals improve quality of care and patient safety Describe that the Joint Commission has a sentinel event policy and procedure that hospitals should be familiar with Recall that CMS has a final worksheet on QAPI that includes a section on patient safety, adverse events, and medical errors

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