13 Patient Safety, Joint Commission Compliance Strategies From IHI Forum

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Patricia Adamski, RN, MS, MBA, director of the Standards Interpretation Group at The Joint Commission, presented (pdf) strategies for patient safety compliance at the Institute for Healthcare Improvement's 24th Annual National Forum on Quality Improvement in Health Care.

Here are Ms. Adamski's 13 strategies for patient safety and Joint Commission compliance in 2013, as described in a storyboard on IHI's website:


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1. Establish a culture of safety. Build trust between staff and leadership to encourage reporting adverse events, which provides an opportunity to develop solutions.

2. "It takes a village." Patient safety needs to be a team effort; it cannot be the responsibility of only one person.

3. Conduct honest and thorough assessments of high-risk or previously identified areas. Identify patient safety weaknesses in the organization so team members can develop targeted solutions.

4. Be creative in your evaluation approaches. Have front-line staff evaluate an area with which they are not familiar, because their "fresh eyes and ears" may reveal previously unidentified risks or issues, according to the storyboard.

5. Don't assume anything. Long tenure does not guarantee that a leader or staff member is compliant with patient safety policies and procedures; proper oversight is key.

6. Don't be afraid of the proactive risk assessment. Ms. Adamski suggested using The Joint Commission's Targeted Solutions Tool to conduct a proactive risk assessment.

7. Periodically revisit previously identified areas of risk and vulnerability. Follow up with previous issues to ensure improvements are sustained.

8. Evaluate your organization's risk as new data and resources are published. Review sentinel event alerts to determine their relevance to the organization.

9. Handoffs and sharing of information is critical to success. Open communication is essential for ensuring patient safety throughout the entire organization.

10. Have the "right" people at the table. Involve stakeholders and "those who actually own or contribute to the issues at the table" to discuss patient safety, according to the storyboard.

11. Connect the dots for staff and leaders alike. Share successes, failures and lessons learned, and demonstrate how people's individual efforts contributed to improvements.

12. Avoid the tendency to add on to processes or on top of processes. Eliminate redundancies and non-value-added steps.

13. It is easier to maintain compliance and keep safety initiatives front and center than it is to ramp up and then back off.
Ms. Adamski suggested keeping the statement of conditions and plan for improvement "current and use as a working document," according to the storyboard.

More Articles on Patient Safety:

Patient Safety Tool: Leadership Checklist for Patient Safety Organization Participation
Implementing a Safe Surgery Checklist to Meet CMS & Regulatory Standards: Advice From Surgical Care Affiliates

Patient Safety Tool: Safety Program Participation and Implementation Toolkits

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