2.0 Planning
2.1 Is there a procedure to identify significant patient safety concerns?
Score Description
0 There is no procedure to identify the specific patient safety concerns associated with clinical operations and activities.
1 There is a procedure to identify patient safety concerns, but it is either (a) driven primarily by accreditation or regulatory requirements, or (b) is limited in scope.
2 There is a procedure to identify significant patient safety concerns.
3 There is a comprehensive, documented procedure to identify all patient safety concerns. The procedure also includes:
• An analysis of available and reliable data
• An analysis of the impact of process improvements designed to the likelihood of patient harm.
Our Score: ________
2.2 Are significant patient safety issues identified by regulatory or accreditation groups considered in setting organizational improvement objectives?
Score Description
0 Improvement objectives are not set.
1 Improvement objectives are set, but do not take into consideration patient safety issues identified by external groups.
2 The process of setting improvement objectives takes into consideration some issues identified by external groups. The
process for setting improvement objectives is not documented.
3 The process of setting improvement takes into consideration all or most significant issues identified by external groups. This process (or procedure) for setting improvement objectives is documented.
Our Score: ________
2.3 Are patient safety improvement objectives and targets systematically established, reviewed, and documented?
Score Description
0 Improvement objectives and targets have not been established beyond general regulatory and accreditation standards compliance.
1 Improvement objectives and targets are established and are documented. Objectives and targets primarily address regulatory and accreditation standards compliance. No process exists to ensure that these objectives and targets are reviewed and maintained regularly. Improvement objectives and targets do not cover all appropriate levels and functions of the organization (e.g., objectives are limited to one department or function).
2 Improvement objectives and targets are established and documented, with consideration not only to regulatory and accreditation requirements, but also to significant internal priorities or the concerns of interested parties (e.g., patient and family concerns). Targets and objectives reflect a commitment to prevention of unintended patient harm and continuous improvement. The objectives are specific and the targets are measurable wherever practicable.
3 There also is a documented procedure for establishing, reviewing, and updating improvement objectives and targets. This process is integrated into the overall performance improvement system. Improvement objectives and targets have been developed for each important clinical function and level within the organization.
Our Score: ________
3.0 Implementation and Operation3.1 Are roles, responsibility, and authorities defined, documented, and communicated?
Score Description
0 Top management has not appointed a specific individual or group to oversee patient safety management.
1 An individual or group has been appointed to oversee patient safety management but role, responsibility, and authority have not been defined.
2 The role, responsibility, and authority for the individual or group overseeing patient safety management have been defined, but have neither been documented or clearly communicated through the organization. Roles, responsibilities, and authorities of other individuals and groups that impact patient safety are partially defined and communicated, but are not well documented.
3 All roles, responsibilities, and authorities for patient safety management have been defined and communicated.
Our Score: ________
3.2 Has the organization provided resources essential to implementation and maintenance of patient safety management?
Score Description
0 Resources essential to the implementation and effective functioning of the patient safety management system have not been defined.
1 Resources essential to the implementation and effective functioning of the patient safety management system have been defined, but necessary resources haven’t been allocated to achieve core performance improvement objectives
or commitments.
2 Management has allocated some of the essential resources, but has not provided all resources identified as necessary to meet relevant patient safety performance objectives or commitments.
3 Management has allocated and provided the resources essential to the implementation and effective functioning of the patient safety management system. Resource allocation is reviewed annually.
Our Score: ________
3.3 Have all patient safety training needs been identified?
Score Description
0 Patient safety training needs are not defined in a systematic manner. Training to comply with regulatory requirements or accreditation standards may occur, but on an ad hoc basis.
1 A process is established to identify training needs based on regulatory requirements and accreditation standards. A process does not exist to identify training needs of physicians and staff with respect to their specific responsibilities.
2 A process is established to identify training needs for physicians and staff based on regulatory requirements, accreditation standards, and the potential for patient harm. A process has not been established to ensure that outsourced or contracted patient care providers have the requisite training.
3 A procedure is established to identify training needs for physicians and staff and to ensure that outsourced or contracted providers have the requisite training needed to ensure patient safety.
Our Score: ________
3.4 Are appropriate procedures established for internal communications to leadership, physicians, and staff?
Score Description
0 There is no process defined for the communication of patient safety information to the Board, administrative and medical staff leaders, and physicians and staff.
1 There is a process for the communication of patient safety information to the Board and administrative and medical staff leaders. The information is generally limited to regulatory and standards compliance information. There may be gaps in information dissemination to relevant physicians and staff at various levels and functions within the organization.
2 Patient safety performance results are widely communicated to the Board, administrative and medical staff leaders, and physicians and staff in varied contexts and at all appropriate levels and functions. The information is presented through multiple channels; however, the feedback or response system is inadequate.
3 The internal communication procedure and system also includes a defined process or procedure for responding to questions, comments, and feedback from the Board, administrative and medical staff leaders, and physicians and staff. Communication procedures are regularly reviewed and adapted to changed perceptions and circumstances.
Our Score: ________
3.5 Are appropriate procedures established for external communications regarding the patient safety management system?
Score Description
0 There is no process for communications to external stakeholders (e.g., regulators, accreditation groups, community) regarding the patient safety management system. Communication occurs on a reactive, ad hoc basis.
1 There is a process for external communications; however, such procedures generally are informal and limited to compliance with external requirements or emergency situations.
2 There is a procedure for receiving, documenting, and responding to relevant external groups or individuals on the organization’s patient safety management system.
3 There also is a procedure and commitment for communicating patient safety information, including performance data, to interested external stakeholders on a periodic basis.
Our Score: ________
3.6 Are operations and activities associated with significant patient safety concerns effectively managed?
Score Description
0 Operations and activities that may cause significant patient safety concerns are not identified.
1 Operations and activities associated with significant patient safety concerns are identified, but situations where the absence of an operational control or documented procedures could lead to a system failure have not been defined (e.g., noncompliance with the patient safety policy, compliance violations, failure to achieve objectives and targets, actual patient harm). Appropriate education, training, or experience requirements have not been identified for physicians and staff that may control or influence patient safety.
2 Situations requiring operational controls and/or documented procedures to ensure patient safety have been identified and described. Appropriate education, training, or experience requirements have been identified for physicians and staff that may control or influence patient safety. Some of the physicians and staff have received training designed to ensure competency.
3 The operations and activities that are related to significant patient safety concerns have been identified and documented. A procedure exists to ensure that physicians and staff who may control or influence patient safety are competent to carry out their responsibilities.
3.7 Are procedures established to identify incidents, adverse events, and hazardous situations?
Score Description
0 A procedure for identifying incidents, adverse events, and hazardous situations is not established.
1 A procedure for identifying incidents, adverse events, and hazardous situations is established.
2 A procedure for identifying incidents, adverse events, and hazardous situations is established. The procedure includes a mechanism for periodic review and updating.
3 A procedure also exists to utilize the incident, adverse event, and hazardous situation information to develop preventive strategies.
Our Score: ________
3.8 Are procedures established to respond to adverse incidents and hazardous situations?
Score Description
0 There is no procedure for responding to potential significant incidents and hazardous situations.
1 A procedure exists for responding to potential significant incidents and hazardous situations.
2 A procedure exists for responding to potential significant incidents and hazardous situations. Informal review of significant adverse events or hazardous situations may occur.
3 Procedures have been established related to adverse events and hazardous situations. Procedures also exist to mitigate potential patient harm associated with incidents and hazardous situations. Procedures are reviewed and revised as necessary after an adverse event or near miss.
Our Score: ________
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