Hello,I need help with this assignment.Please strictly follow the rubric, and use the Sample Patient Safety Plan document as a guideline.The case study used for this assignment is CASE STUDY B!

IHP 315 Sample Patient Safety Plan

PATIENT SAFETY PLAN

PURPOSE

This patient safety plan is designed to improve patient safety, reduce risk, and respect the dignity of those we serve by assuring a safe environment. Recognizing that effective medical/healthcare error reduction requires an integrated and coordinated approach, the following plan relates specifically to a systematic hospital-wide program to minimize physical injury, accidents, and undue psychological stress during hospitalization. The organization-wide safety program will include all activities contributing to the maintenance and improvement of patient safety.

Leadership assumes a role in establishing a culture of safety that minimizes hazards and patient harm by focusing on the processes of care. The leaders of the organization are responsible for fostering an environment through their personal example; emphasizing patient safety as an organizational priority; providing education to medical and hospital staff regarding the commitment to reduction of medical errors; supporting proactive reduction in medical/healthcare errors; and integrating patient safety priorities into the new design and redesign of all relevant organization processes, functions, and services.

In the tradition of providing exemplary quality care, we serve as an instrument for good in a patient-focused, integrated healthcare system.

Vision is evidence of intention and commitment. While mission describes our calling, what it is we are about, or how we participate in the healthcare ministry, our vision statement describes what we want to become. It contains our strategy to fulfill our mission. This is based on the following basic concepts:

PATIENT-FOCUSED – Our mission is to provide compassionate care to patients, both those who come to us and those to whom we reach out. Decisions are based on what is good for the patient and are not self-serving.

INTEGRATED HEALTHCARE SYSTEM – Services we provide address the continuum of life and are provided through common efforts, recognizing differing roles and responsibilities. Common decision criteria are employed throughout the system, with a common mission and vision.

The vision is to focus on patient health outcomes with changes, improvements, and continuous monitoring of activities to ensure that the organization’s mission is consistently supported, assessed, reviewed, and revised as necessary over time. To carry on our mission and to follow through with our vision, it is necessary we work together as a team through the participation of members of the medical staff, governing body, employees, and leadership team in selected programs and functions.

From the mission and vision flow the following values:

• Personal worth and dignity of every person we serve regardless of race, color, religion, and ability to pay

• Caring response to the physical, emotional, and spiritual needs of the people we serve

• Collaboration with each other, with physicians, and with other providers to deliver comprehensive, integrated, and quality healthcare

• Concern for physical, spiritual, emotional, and economical well-being of employees

• Quality work environments that focus on comprehensive, integrated quality service and opportunities for employee growth

• Open and honest communication to foster trusting relationships among ourselves and those we serve

• Responsible stewardship of the financial, human, and technological resources of the system

• Leadership in the health fields and in the communities we serve

OBJECTIVES

The objectives of the patient safety plan are to:

• Encourage organizational learning about medical/healthcare errors

• Incorporate recognition of patient safety as an integral job responsibility

• Provide education of patient safety into job-specific competencies

• Encourage recognition and reporting of medical/healthcare errors and risks to patient safety without judgment or placement of blame

• Involve patients in decisions about their healthcare and promote open communication about medical errors/consequences that occur

• Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions

• Report internally what has been found and the actions taken with a focus on processes and systems to reduce risk

The patient safety team is a standing interdisciplinary group that manages the organization’s patient safety program through a systematic, coordinated, continuous approach. The team will meet monthly to assure the maintenance and improvement of patient safety in establishment of plans, processes, and mechanisms involved in the provision of the patient care.

1. The scope of the patient safety team includes medical/healthcare errors involving the patient population of all ages, visitors, hospital/medical staff, students, and volunteers. Aggregate data* from internal (IS data collection, incident reports, questionnaires, ORYX reports, Core Measure reports) and external resources (Sentinel Event Alerts, evidence-based medicine, etc.) will be used for review and analysis in prioritization of improvement efforts, implementation of action steps, and follow-up monitoring for effectiveness. The severity categories of medical/healthcare errors include the following:

• No-Harm Error – an unintended act, either of omission or commission, or an act that does not achieve its intended outcome

• Mild to Moderate Adverse Outcome – any set of circumstances that do not achieve the desired outcome and result in an mild to moderate physical or psychological adverse patient outcome

• Hazardous Conditions – any set of circumstances, exclusive of disease or condition for which the patient is being treated, that significantly increases the likelihood of a serious adverse outcome

• Near Miss – any process variation that did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome

• Sentinel Event – an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes the loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome

1. The patient safety team will be chaired by the designated patient safety officer.

1. 1. The patient safety officer will be the director of quality resource management/risk manager.

1. 1. The responsibilities of the patient safety officer include compliance with patient safety standards and initiatives, evaluation of work performance as it relates to patient safety, reinforcement of the expectations of the patient safety plan, and acceptance of accountability for measurably improving safety and reducing errors. These duties may include listening to employee and patient concerns, interviewing staff to determine what is being done to safeguard against occurrences, and immediately responding to reports concerning workplace conditions.

1. 1. Team membership includes services involved in providing patient care (i.e., pharmacy, laboratory, surgical services, risk management, infection control, medical imaging, rehab, and nursing). The medical staff representative on the team will be the medical staff secretary.

1. 1. Discussion with the patient/family/caregivers regarding adverse outcomes:

      1. 1. Events impacting the patient’s clinical condition – The patient safety officer will notify the caregiving physician about informing the patient/family/caregivers in a timely fashion (within 48–72 hours). Should the caregiving physician refuse or decline communication with the patient/family/caregivers, the department chairperson will be notified by the patient safety officer. The patient/family/caregivers will NOT be contacted without the permission and/or notification of the caregiving physician involved. The caregiving physician will determine the appropriateness of documentation of the occurrence in the medical record and will communicate this to the patient safety officer.

         2. Events NOT impacting the patient’s clinical condition, but causing a delay or inconvenience – The patient safety officer will communicate with the nursing manager the need for communication with the patient/family/caregiver in the interest of patient satisfaction.

1. The mechanism to insure all components of the organization are integrated into the program is through a collaborative effort of multiple disciplines. This is accomplished by the following:

• Reporting of potential or actual occurrences through the Incident Occurrence Reporting Policy (Organizational Policy #6-004) by any employee in every department.

• Communication between the patient safety officer and the operational safety leader to assure a comprehensive knowledge of not only clinical, but also environmental factors involved in providing an overall safe environment.

• Reporting of patient safety and operational safety measurements/activity to the performance improvement oversight group, quality management council.

1. The mechanism for identification and reporting a sentinel event/other medical error will be as indicated in Organizational Policies, Sentinel Event Policy, and Incident Occurrence Reporting Policy. Any root cause analysis of hospital processes conducted on either sentinel events or near misses will be submitted for review/recommendations to the patient safety team, quality management council, and the medical executive committee.

2. As this organization supports the concept that errors occur due to a breakdown in systems and processes, staff involved in an event with an adverse outcome will be supported by:

• A non-punitive approach and without fear of reprisal, as evidenced by the amnesty policy.

• Voluntary participation into the root cause analysis for educational purposes and prevention of further occurrences.

• Resources such as pastoral care, social services, or EAP should the need exist to counsel the staff

• Annual staff surveys about their willingness to report medical errors

F. As a member of an integrated healthcare system and in cooperation with system initiatives, the following patient safety measures will be the focus of patient safety activities:

1. Adverse drug events

2. Nosocomial infections

3. Decubitus ulcers

4. Blood reactions

5. Slips and falls

6. Restraint use

7. Serious event reports

8. DVT/PE

Standardized defined measurements for each of the above is determined through the OSF Healthcare System Division of Strategic Effectiveness. Targets for improvement will be determined by the individual facility. This aggregate data will be reported to the patient safety team at monthly intervals.

G. A proactive component of the program includes an annual selection of a high risk or error-prone process for concentrated activity, ongoing measurement, and periodic analysis. The selected process and approach to be taken will be communicated in a letter to quality council of the facility.

The selection may be based on information published by TJC (The Joint Commission), Sentinel Event Alerts, and/or other sources of information including risk management, performance improvement, quality assurance, infection control, research, patient/family suggestions/expectations, or process outcomes.

1. The process will be assessed to determine the steps where there is or may be undesirable variation (failure modes). Information from internal or external sources will be used to minimize risk to patients affected by the new or redesigned process.

2. For each failure mode, possible effects on patients, as well as the seriousness of the effect, will be identified.

3. The process will be redesigned to minimize the risk of failure modes.

4. The redesigned process will be tested and implemented.

5. Measures to determine effectiveness of the redesigned process will be identified and implemented. Strategies to maintain success over time will be identified.

H. The procedures for immediate response to medical/healthcare error are as follows:

1. Staff will immediately report the event to the supervisor (either the nursing manager or the house supervisor if the event occurs during off-hours).

2. The supervisor will immediately communicate the event to the patient safety officer to initiate investigation and follow-up actions. Should this occur during off-hours, the administrator-on-call should be notified and a voicemail message left on the patient safety officer’s voicemail.

3. Staff will complete the incident/occurrence report to preserve information.

4. Staff will obtain required orders to support the patient’s clinical condition.

5. The operation safety leader will be notified of any situations of potential risk to others.

1. The patient safety officer will follow usual protocols to investigate the error and coordinate the factual information/investigation for presentation, review, and action by the patient safety team and/or the sentinel event committee, as applicable.

L. Methods to assure ongoing in-service education and training programs for maintenance and improvement of staff competence and support to an interdisciplinary approach to patient care is accomplished by:

1. Providing information and reporting mechanisms to new staff in the orientation training

2. Providing ongoing education, including reporting mechanisms

3. Obtaining a confidential assessment of staff’s willingness to report medical errors at least annually

4. Testing staff knowledge regarding patient safety in competency testing

5. Evaluating staff knowledge levels and participation of patient safety principles in annual performance appraisals

J. Internal reporting – To provide a comprehensive view of both the clinical and operational safety activity of the organization:

• The minutes/reports of the patient safety team, as well as minutes/reports from the operational safety committee will be submitted through the director of QRM to the quality management council.

• These monthly reports will include ongoing activities including data collection presented in statistical process control charts, analysis, actions taken, and monitoring for the effectiveness of actions.

• Following review by quality management council, the reports will be forwarded to the medical executive committee and to the OSF HealthCare System Board of Directors.

K. External Reporting

1. A high-risk or error-prone process will be selected annually for concentrated activity, ongoing measurement, and periodic analysis. The selected topic and approach will be communicated to the healthcare quality council through a written report.

2. External reporting will be completed in accordance with all state, federal, and regulatory body rules, regulations, and requirements.

O. The patient safety officer will submit an annual report to the board of directors and will include:

1. Definition of the scope of occurrences including sentinel events, near misses, and serious occurrences.

2. Detail of activities that demonstrate the patient safety program has a proactive component by identifying the high-risk process selected.

3. Results of the high-risk or error-prone processes selected for ongoing measurement and analysis. (This will be communicated in the facility annual patient safety report due at the May board of directors meeting.)

4. A description of how the function of process design that incorporates patient safety has been carried out using specific examples of process design or redesign that include patient safety principles.

5. The results of how input is solicited and participation from patients and families in improving patient safety is obtained.

6. The results of the program that assesses and improves staff willingness to report medical/healthcare errors.

7. A description of the procedures used and examples of communication occurring with families about adverse events or unanticipated outcomes of care.

8. A description of the examples of ongoing in-service and other education and training programs that are maintaining and improving staff competence and supporting an interdisciplinary approach to patient care.

EVALUATION/APPROVAL

The patient safety plan will be evaluated at least every three years or as changes occur, and revised as necessary at the direction of the quality management council. Annual evaluation of the plan’s effectiveness will be documented in a report to the medical executive committee, quality management council, chief executive officer, and, ultimately, the healthcare board of directors.