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

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Evolution of JC Surveys – NewPathways (2004)• Shared Vision – Safe, high-quality care• New Pathways – New approaches to the accreditationprocess• Customized survey process• Tracer methodology (2004)• Unannounced survey process (2006)• Periodic performance review• Reorganized standards (2009)• New approach to scoring and decision processMedical CareMultidisciplinary Care26NPSF Professional Learning Series
Customized Survey Process• Priority Focus Process – automated, rule-based toolthat aggregates the following:• Clinical service groups and DRGs, e.g., cardiology, vascularsurgery, oncology• ORYX data (heart failure, heart attack, pneumonia, etc.)• Sentinel event data• Past findings• <strong>Patient</strong> complaints• Uses this information to determine what to survey,length of survey, number of surveyors27NPSF 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 and 22: The Joint CommissionDPHCMSThe Regul
Page 23 and 24: Potential CMS CoP Findings• Condi
Page 25: Influences on the Joint CommissionS
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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