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

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CMS Conditions of Participation (CoP)1. Compliance with Federal, State andlocal laws13. Physical environment2. Governing body 14. Infection control3. <strong>Patient</strong>’s rights 15. Discharge planning4. Quality assessment andperformance improvement program16. Organ, tissue, and eye procurement5. Medical staff 17. Surgical services6. Nursing services 18. Anesthesia services7. Medical record services 19. Nuclear medicine services8. Pharmaceutical services 20. Outpatient services9. Radiologic services 21. Emergency services<strong>10</strong>. Laboratory services 22. Rehabilitation services11. Food and dietetic services 23. Respiratory care services12. Utilization review? Future Update22NPSF Professional Learning Series
Potential CMS CoP Findings• Condition level findings• Immediate jeopardy• Standards level findings23NPSF 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 and 18: Regulatory Landscape17NPSF Professi
Page 19 and 20: Example of One Year of PotentialReg
Page 21: The Joint CommissionDPHCMSThe Regul
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

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

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