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

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Regulatory Plans of Correction• Begin developing plans of correction immediately followingsurvey. Do not wait to receive the report. Typically you willhave only <strong>10</strong> days from receipt to respond.• Regulatory plans of correction need to contain certainelements:• What has been done to address the deficiency?• What further steps will be taken?• On what date will those steps be completed?• How will you monitor implementation of the plan?• Who is responsible for implementation of the plan?52NPSF Professional Learning Series
Attributes of a Well ManagedRegulatory Visit• Leadership was aware of the upcoming visit and understood theorganization’s risk areas.• Efforts to address those risk areas were underway and could bedescribed.• Regulator arrival/opening meeting goes smoothly.• Escorts play their role competently.• Daily debriefs identify issues for possible resolution during survey.• No surprises in the closing meeting.• A plan of correction is in process before the regulator’s reportarrives.53NPSF 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 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: Exit Conference• At the exit conf
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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