4.0 CORRECTIVE ACTION AND EVALUATION
4.1 Is information systematically collected that is pertinent to the evaluation of programmatic and functional aspects of the patient safety management system?
Score Description
0 No formal process exists for the evaluation of programmatic or functional aspects of the patient safety management system.
1 A process exists which includes the identification of information types necessary for evaluation of the patient safety management system. Information is collected on an informal or random basis.
2 A formal system exists which includes:
- identification and ongoing evaluation of important aspects of patient safety;
- established frequencies for the collection of information;
- collection of both programmatic and functional information;
- Information covering relevant clinical operations and services.
3 A formal system exists which also includes:
- collection of information from physicians and staff in all levels and functions of the organization;
- collection of information by appropriate clinical units to self-evaluate performance;
- processes for documenting and archiving information, which allows ease of access to trended performance data;
- systems that allow for collection of patient safety concerns from patients, families, and the community.
Our Score: ________
4.2 Are processes in place that support the collection of information to determine compliance with applicable regulatory requirements and accreditation standards?
Score Description
0 No formal process exists for determining compliance with regulatory requirements and accreditation standards, with the exception of inspections performed by external groups.
1 Internal compliance assessments are performed only as a reaction to significant adverse incidents. Compliance assessments are not performed by all departments and not for regulations/standards for which they are responsible.
2 A formal assessment program exists which includes:
- a requirement that compliance assessments are performed in all direct patient care departments and for all regulations/standards for which they are responsible;
- established frequencies for performing compliance assessments.
3 A formal assessment program exists which also includes:
- a requirement for self-assessment by all direct and indirect patient care departments in order to evaluate their own performance;
- collection of information, which verifies that the compliance assessment requirements of the department are being met;
- information that is documented and archived to provide ease of access to all pertinent individuals.
Our Score: ________
4.3 Is collected information analyzed to identify deficiencies and areas of concern?
Score Description
0 No processes are in place for analyzing collected information.
1 No written procedures exist for the analysis of information. Individual departments analyze information, but results are not shared throughout the organization.
2 A formal system exists which includes:
- written procedures for analyzing information;
- sharing results throughout the organization;
- data analysis at functional and programmatic levels;
- using subject matter experts to analyze data;
- evaluating performance indicators against performance objectives;
- assessing and tracking trended data to proactively identify areas of concern.
3 A formal system exists which also includes:
- Results are documented and reported to the board and administrative and physician leaders.
- Results are compared to internal performance objectives and external benchmarks or organizations.
- Root causes are identified and resolved.
Our Score: ________
4.4 Are corrective actions developed to prevent future adverse events, in addition to correcting the immediate problem?
Score Description
0 No formal process exists for addressing outcomes or taking preventive actions from the collection and analysis of data.
1 Informal preventive actions are taken to address patient safety concerns. Actions are developed by people who generally will not be directly involved in the implementation.
2 A formal system exists which includes:
- written action plans;
- actions which address root causes;
- lessons learned being developed and disseminated;
- appropriate levels of clinical, management, and subject matter experts involved in action plan development;
- those responsible for implementing actions being involved in their development.
3 A formal system exists which also includes:
- all appropriate physicians, staff and levels of management are informed of necessary actions;
- completion dates and responsibility for each corrective action are clearly defined and tracked;
- development of improvement actions, which include preventive and corrective actions that support aspects that are effective and critical to success of patient safety management.
Our Score: ________
4.5 Are corrective actions verified for implementation?
Score Description
0 No process exists for verifying the completion of corrective actions.
1 Completion of improvement actions is tracked only by those responsible for their implementation.
2 Completion of improvement actions is tracked by both the department responsible for implementation and at an appropriate management level.
3 Information is shared with both the "owning" department and administrative and medical staff leaders. Lessons learned are developed, as appropriate, and disseminated throughout the organization. Preventive and corrective actions are incorporated into appropriate procedures.
Our Score: ________
4.6 Are corrective actions evaluated for effectiveness?
Score Description
0 No assessment process exists for checking the effectiveness of corrective actions.
1 The process owner may evaluate individual facets of the corrective actions on an irregular basis.
2 All aspects of the corrective actions evaluated. The evaluation occurs on an irregular basis. Evaluation of the corrective actions includes appropriate levels of administration and the medical staff, department managers and staff, and subject matter experts. The results of corrective action evaluations are fully documented.
3 Correction actions are evaluated on a regular basis. Results are shared with the Board and administrative and medical staff leaders. Required changes are implemented and evaluated for effectiveness.
Our Score: ________
Source: Patrice Spath, Brown-Spath Associates, Forest Grove, OR.
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