Patient Safety Curriculum Module 10: The National Landscape ...

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Regulatory Agencies• Centers for Medicare and Medicaid Services• Joint Commission• State Departments of Public Health• Centers for Disease Control and Prevention• Food and Drug Administration• Office for Civil Rights – HIPAA• OSHA• Voluntary Reviews (e.g., Magnet Survey by ANCC)18NPSF Professional Learning Series
Example of One Year of PotentialRegulatory VisitsAgency Purpose Survey IntervalDMH Inpatient Psych Unit licensure 2 yearsDPH Infection Control unknownTJC Ventricular Assist Device survey 2 yearsFDABlood bank inspection including bloodadministration tracer2 yearsDPH Bureau of SubstanceAbuse ServicesSubstance Abuse Clinic occasional sitevisits~annualDPH ESRD program re-certification 3 yearsDPH Radiation Control - Cath and EP Lab 2 yearsAABBBlood bank inspection including bloodadministration tracerannualCollege of AmericanPathologists Fertility lab inspection 2 years19NPSF Professional Learning Series
Page 1 and 2: NPSF Professional Learning Series p
Page 3 and 4: Goals of this module• Upon comple
Page 5 and 6: “End result system of hospitalsta
Page 7 and 8: Patient Safety in the Popular Press
Page 9 and 10: The Cost Landscape• Per capita he
Page 11 and 12: Mounting Pressures for Transparency
Page 17: Regulatory Landscape17NPSF Professi
Page 21 and 22: The Joint CommissionDPHCMSThe Regul
Page 23 and 24: Potential CMS CoP Findings• Condi
Page 25 and 26: Influences on the Joint CommissionS
Page 27 and 28: Customized Survey Process• Priori
Page 29 and 30: “Tracing” the Patient: Across S
Page 31 and 32: “Tracing” the Patient - Priorit
Page 33 and 34: Sample: Unannounced SurveySchedule
Page 35 and 36: National Patient Safety Goals(NPSGs
Page 37 and 38: 2011 Hospital NPSGs• There are si
Page 39 and 40: Goal 8: Reconcile Medications• Ac
Page 41 and 42: Managing Regulatory Visits41NPSF Pr
Page 43 and 44: The Regulatory Survey CycleMonitorc
Page 45 and 46: Survey Preparations• Develop a re
Page 47 and 48: Opening Meetings• Getting off on
Page 49 and 50: Command Central (Bull Pen)• Large
Page 51 and 52: Exit Conference• At the exit conf
Page 53 and 54: Attributes of a Well ManagedRegulat
Page 55 and 56: Regulatory ReadinessPreparing for t
Page 57 and 58: Quality and Safety FrameworkQuality
Page 59 and 60: Culture: Communications Plan forSur
Page 61: Final Thoughts• B Teams with A Sy

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