Patient Safety Systems (PS)

Patiet Safety Systems (PS) Itroductio The quality of care ad the safety of patiets are core values of The Joit Commissio accreditatio process. This is a commitmet The Joit Commissio has made to patiets, families, health care practitioers, staff, ad health care orgaizatio leaders. This chapter exemplifies that commitmet. The itet of this Patiet Safety Systems (PS) chapter is to provide health care orgaizatios with a proactive approach to desigig or redesigig a patiet-cetered system that aims to improve quality of care ad patiet safety, a approach that aligs with the Joit Commissio s missio ad its stadards. The Joit Commissio parters with accredited health care orgaizatios to improve health care systems to protect patiets. The first obligatio of health care is to do o harm. Therefore this chapter is focused o the followig three guidig priciples: 1. Aligig existig Joit Commissio stadards with daily work i order to egage patiets ad staff throughout the health care system, at all times, o reducig harm. 2. Assistig health care orgaizatios with advacig kowledge, skills, ad competece of staff ad patiets by recommedig methods that will improve quality ad safety processes. 3. Ecouragig ad recommedig proactive quality ad patiet safety methods that will icrease accoutability, trust, ad kowledge while reducig the impact of fear ad blame. Quality * ad safety are iextricably liked. Quality i health care is the degree to which its processes ad results meet or exceed the eeds ad desires of the people it serves. 1,2 Those eeds ad desires iclude safety. The compoets of a quality maagemet system should iclude the followig: Esurig reliable processes * The Istitute of Medicie defies quality as the degree to which health services for idividuals ad populatios icrease the likelihood of desired health outcomes ad are cosistet with curret professioal kowledge. Source: Committee to Desig a Strategy for Quality Review ad Assurace i Medicare, Istitute of Medicie. Medicare: A Strategy for Quality Assurace, vol. 1. Lohr KN, editor. Washigto, DC: The Natioal Academies Press, 1990. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 1

Comprehesive Accreditatio Maual for Hospitals Decreasig variatio ad defects (waste) Focusig o achievig better outcomes Usig evidece to esure that a service is satisfactory Patiet safety emerges as a cetral aim of quality. Patiet safety, as defied by the World Health Orgaizatio, is the prevetio of errors ad adverse effects to patiets that are associated with health care. Safety is what patiets, families, staff, ad the public expect from Joit Commissio accredited orgaizatios. While patiet safety evets may ot be completely elimiated, harm to patiets ca be reduced, ad the goal is always zero harm. This chapter describes ad provides approaches ad methods that may be adapted by a health care orgaizatio that aims to icrease the reliability of its complex systems while makig visible ad removig the risk of patiet harm. Joit Commissio accredited orgaizatios should be cotiually focused o elimiatig systems failures ad huma errors that may cause harm to patiets, families, ad staff. 1,2 The ultimate purpose of The Joit Commissio s accreditatio process is to ehace quality of care ad patiet safety. Each requiremet or stadard, the survey process, the Setiel Evet Policy, ad other Joit Commissio iitiatives are desiged to help orgaizatios reduce variatio, reduce risk, ad improve quality. Hospitals should have a itegrated approach to patiet safety so that high levels of safe patiet care ca be provided for every patiet i every care settig ad service. Hospitals are complex eviromets that deped o strog leadership to support a itegrated patiet safety system that icludes the followig: Safety culture Validated methods to improve processes ad systems Stadardized ways for iterdiscipliary teams to commuicate ad collaborate Safely itegrated techologies I a itegrated patiet safety system, staff ad leaders work together to elimiate complacecy, promote collective midfuless, treat each other with respect ad compassio, ad lear from their patiet safety evets, icludig close calls ad other system failures that have ot yet led to patiet harm. What Does This Chapter Cotai? The Patiet Safety Systems chapter is iteded to help iform ad educate hospitals about the importace ad structure of a itegrated patiet safety system. While this chapter does ot iclude ew accreditatio requiremets, it describes how existig Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 2 CAMH Update 1, July 2015

Patiet Safety Systems requiremets ca be applied to achieve improved patiet safety. It is also iteded to help all health care workers uderstad the relatioship betwee Joit Commissio accreditatio ad patiet safety. This chapter does the followig: Describes a itegrated patiet safety system Discusses how hospitals ca develop ito learig orgaizatios Explais how hospitals ca cotiually evaluate the status ad progress of their patiet safety systems Describes how hospitals ca work to prevet or respod to patiet safety evets (Sidebar 1, below, defies key termiology) Serves as a framework to guide hospital leaders as they work to improve patiet safety i their hospitals Cotais a list of stadards ad requiremets related to patiet safety systems (which will be scored as usual i their origial chapters) Cotais refereces that were used i the developmet of this chapter This chapter refers to a umber of Joit Commissio stadards. Whe a stadard cited i this chapter is formatted with the stadard umber i boldface type followed by a colo (for example: Stadard RI.01.01.01: ), the laguage that follows the colo is the official stadard laguage, verbatim. Sidebar 1. Key Terms to Uderstad Patiet safety evet: A evet, icidet, or coditio that could have resulted or did result i harm to a patiet. Adverse evet: A patiet safety evet that resulted i harm to a patiet. Setiel evet: A subcategory of Adverse Evets, a Setiel Evet is a patiet safety evet (ot primarily related to the atural course of the patiet s illess or uderlyig coditio) that reaches a patiet ad results i ay of the followig: o o o Death Permaet harm Severe temporary harm For a list of specific patiet safety evets that are also cosidered setiel evets, see page SE-1 i the Setiel Evets (SE) chapter of this maual. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 3

Comprehesive Accreditatio Maual for Hospitals No-harm evet: A patiet safety evet that reaches the patiet but does ot cause harm. Close call (or ear miss or good catch ): A patiet safety evet that did ot reach the patiet. Hazardous (or usafe ) coditio(s): A circumstace (other tha a patiet s ow disease process or coditio) that icreases the probability of a adverse evet. Note: Not all patiet safety evets are prevetable. Evet aalysis is warrated i order to idetify weakesses ad whether remedial actio is idicated. Becomig a Learig Orgaizatio The eed for sustaiable improvemet i patiet safety ad the quality of care has ever bee greater. Oe of the fudametal steps to achievig ad sustaiig this improvemet is to become a learig orgaizatio. A learig orgaizatio is oe i which people lear cotiuously, thereby ehacig their capabilities to create ad iovate. 3 Learig orgaizatios uphold five priciples: team learig, shared visios ad goals, a shared metal model (that is, similar ways of thikig), idividual commitmet to lifelog learig, ad systems thikig. 3 I a learig orgaizatio, patiet safety evets are see as opportuities for learig ad improvemet. 4 Therefore, leaders i learig orgaizatios adopt a trasparet, opuitive approach to reportig so that the orgaizatio ca report to lear ad ca collectively lear from patiet safety evets. I order to become a learig orgaizatio, a hospital must have a fair ad just safety culture, a strog reportig system, ad a commitmet to put that data to work by drivig improvemet. Each of these require the support ad ecouragemet of hospital leaders. Leaders, staff, licesed idepedet practitioers, ad patiets i a learig orgaizatio realize that every patiet safety evet (from mior evets to evets that cause major harm to patiets) must be reported. 4-8 Whe patiet safety evets are cotiuously reported, experts withi the hospital ca defie the problem, idetify solutios, achieve sustaiable results, ad dissemiate the chages or lessos leared to the rest of the hospital. 4-8 I a learig orgaizatio, the hospital provides staff with iformatio regardig improvemets based o reported cocers. This helps foster trust that ecourages further reportig. PS 4 Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015

Patiet Safety Systems The Role of Hospital Leaders i Patiet Safety Hospital leaders provide the foudatio for a effective patiet safety system by doig the followig: 9 Promotig learig Motivatig staff to uphold a fair ad just safety culture Providig a trasparet eviromet i which quality measures ad patiet harms are freely shared with staff Modelig professioal behavior Removig itimidatig behavior that might prevet safe behaviors Providig the resources ad traiig ecessary to take o improvemet iitiatives For these reasos, may of the stadards that are focused o the hospital s patiet safety system appear i the Joit Commissio s Leadership (LD) stadards, icludig Stadard LD.04.04.05: The hospital has a orgaizatiowide, itegrated patiet safety program withi its performace improvemet activities. Without the support of hospital leaders, hospitalwide chages ad improvemet iitiatives are difficult to achieve. Leadership egagemet i patiet safety ad quality iitiatives is imperative because 75% to 80% of all iitiatives that require people to chage their behaviors fail i the absece of leadership maagig the chage. 4 Thus, leadership should take o a log-term commitmet to trasform the hospital. 10 Safety Culture A strog safety culture is a essetial compoet of a successful patiet safety system ad is a crucial startig poit for hospitals strivig to become learig orgaizatios. I a strog safety culture, the hospital has a ureletig commitmet to safety ad to do o harm. Amog the most critical resposibilities of hospital leaders is to establish ad maitai a strog safety culture withi their hospital. The Joit Commissio s stadards address safety culture i Stadard LD.03.01.01: Leaders create ad maitai a culture of safety ad quality throughout the hospital. The safety culture of a hospital is the product of idividual ad group beliefs, values, attitudes, perceptios, competecies, ad patters of behavior that determie the orgaizatio s commitmet to quality ad patiet safety. Hospitals that have a robust safety culture are characterized by commuicatios fouded o mutual trust, by shared Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 5

Comprehesive Accreditatio Maual for Hospitals perceptios of the importace of safety, ad by cofidece i the efficacy of prevetive measures. 11 Orgaizatios will have varyig levels of safety culture, but all should be workig toward a safety culture that has the followig qualities: Staff ad leaders that value trasparecy, accoutability, ad mutual respect. 4 Safety as everyoe s first priority. 4 Behaviors that udermie a culture of safety are ot acceptable, ad thus should be reported to orgaizatioal leadership by staff, patiets, ad families for the purpose of fosterig risk reductio. 4,10,12 Collective midfuless is preset, wherei staff realize that systems always have the potetial to fail ad staff are focused o fidig hazardous coditios or close calls at early stages before a patiet may be harmed. 10 Staff do ot view close calls as evidece that the system preveted a error but rather as evidece that the system eeds to be further improved to prevet ay defects. 10,13 Staff who do ot dey or cover up errors but rather wat to report errors to lear from mistakes ad improve the system flaws that cotribute to or eable patiet safety evets. 6 Staff kow that their leaders will focus ot o blamig providers ivolved i errors but o the systems issues that cotributed to or eabled the patiet safety evet. 6,14 By reportig ad learig from patiet safety evets, staff create a learig orgaizatio. A safety culture operates effectively whe the hospital fosters a cycle of trust, reportig, ad improvemet. 10,15 I hospitals that have a strog safety culture, health care providers trust their coworkers ad leaders to support them whe they idetify ad report a patiet safety evet. 10 Whe trust is established, staff are more likely to report patiet safety evets, ad hospitals ca use these reports to iform their improvemet efforts. I the trust-report-improve cycle, leaders foster trust, which eables staff to report, which eables the hospital to improve. 10 I tur, staff see that their reportig cotributes to actual improvemet, which bolsters their trust. Thus, the trust-report-improve cycle reiforces itself. 10 (See Figure 1 o page PS-7.) Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 6 CAMH Update 1, July 2015

Patiet Safety Systems RPI Leadership Trust High Reliability Improve Report Health Care Safety Culture Figure 1. The Trust-Report-Improve Cycle I the trust-report-improve cycle, trust promotes reportig, which leads to improvemet, which i tur fosters trust. Leaders eed to esure that itimidatig or uprofessioal behaviors withi the hospital are addressed, so as ot to ihibit others from reportig safety cocers. 16 Leaders should both educate staff ad hold them accoutable for professioal behavior. This icludes the adoptio ad promotio of a code of coduct that defies acceptable behavior as well as behaviors that udermie a culture of safety. The Joit Commissio s Stadard LD.03.01.01, EP 4, requires that leaders develop such a code. Itimidatig ad disrespectful behaviors disrupt the culture of safety ad prevet collaboratio, commuicatio, ad teamwork, which is required for safe ad highly reliable patiet care. 17 Disrespect is ot limited to outbursts of ager that humiliate a member of the health care team; it ca maifest i may forms, icludig the followig: 4,12,17 Iappropriate words (profae, isultig, itimidatig, demeaig, humiliatig, or abusive laguage) Shamig others for egative outcomes Ujustified egative commets or complaits about aother provider s care Refusal to comply with kow ad geerally accepted practice stadards, the refusal of which may prevet other providers from deliverig quality care Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 7

Comprehesive Accreditatio Maual for Hospitals Not workig collaboratively or cooperatively with other members of the iterdiscipliary team Creatig rigid or iflexible barriers to requests for assistace or cooperatio Not returig pages or calls promptly These issues are still occurrig i hospitals atiowide. Of 4,884 respodets to a 2013 survey by the Istitute for Safe Medicatio Practices (ISMP), 73% reported ecouterig egative commets about colleagues or leaders durig the previous year. I additio, 68% reported codescedig laguage or demeaig commets or isults; while 77% of respodets said they had ecoutered reluctace or refusal to aswer questios or retur calls. 18 Further, 69% report that they had ecoutered impatiece with questios or the hagig up of the phoe. Nearly 50% of the respodets idicated that itimidatig behaviors had affected the way they hadle medicatio order clarificatios or questios, icludig assumig that a order was correct i order to avoid iteractio with a itimidatig coworker. 18 Moreover, 11% said they were aware of a medicatio error durig the previous year i which behavior that udermies a culture of safety was a cotributig factor. The respodets icluded urses, physicias, pharmacists, ad quality/risk maagemet persoel. Oly 50% of respodets idicated that their orgaizatios had clearly defied a effective process for hadlig disagreemets with the safety of a order. This is dow from 60% of respodets to a similar ISMP survey coducted i 2003, which suggests that this problem is worseig. 18 While these data are specific to medicatio safety, their lessos are broadly applicable: Behaviors that udermie a culture of safety have a adverse effect o quality ad patiet safety. A Fair ad Just Safety Culture A fair ad just safety culture is eeded for staff to trust that they ca report patiet safety evets without beig treated puitively. 2, 8 I order to accomplish this, hospitals should provide ad ecourage the use of a stadardized reportig process for staff to report patiet safety evets. This is also built ito the Joit Commissio s Leadership stadards at LD.04.04.05, EP 6: The leaders provide ad ecourage the use of systems for blamefree reportig of a system or process failure, or the results of proactive risk assessmets. Reportig eables both proactive ad reactive risk reductio. Proactive risk reductio solves problems before patiets are harmed, ad reactive risk reductio attempts to prevet the recurrece of problems that have already caused patiet harm. 10,15 Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 8 CAMH Update 1, July 2015

Patiet Safety Systems A fair ad just culture takes ito accout that idividuals are huma, fallible, ad capable of mistakes, ad that they work i systems that are ofte flawed. I the most basic terms, a fair ad just culture holds idividuals accoutable for their actios but does ot puish idividuals for issues attributed to flawed systems or processes. 14,18,19 Refer to Stadard LD.04.01.05, EP 4: Staff are held accoutable for their resposibilities. It is importat to ote that for some actios for which a idividual is accoutable, the idividual should be held culpable ad some discipliary actio may the be ecessary. (See Sidebar 2, below, for a discussio of tools that ca help leaders determie a fair ad just respose to a patiet safety evet.) However, staff should ever be puished or ostracized for reportig the evet, close call, hazardous coditio, or cocer. Sidebar 2. Assessig Staff Accoutability The aim of a safety culture is ot a blame-free culture but oe that balaces learig with accoutability. To achieve this, it is essetial that leaders assess errors ad patters of behavior i a maer that is applied cosistetly, with the goal of elimiatig behaviors that udermie a culture of safety. There has to exist withi the hospital a clear, equitable, ad trasparet process for recogizig ad separatig the blameless errors that fallible humas make daily from the usafe or reckless acts that are blameworthy. 1 7 A appropriate model for this process is the Icidet Decisio Tree developed by the Uited Kigdom s Natioal Patiet Safety Agecy. The agecy adapted this from James Reaso s culpability matrix. 5 For a cosistet process, leaders ca adapt the followig questios to assess the idividual s culpability i the patiet safety evet: 5 Were the actios itetioal? (Deliberate harm test) o If the aswer to the above questio is yes, the were adverse cosequeces iteded? Does there appear to be evidece of poor health or substace abuse? (Icapacity test) o If yes, the does the idividual have a kow medical coditio? l l If yes, the is there evidece the idividual took a uacceptable risk? If yes, the were there sigificat mitigatig circumstaces? Did the idividual depart from agreed protocols or safe procedures? (Foresight test) o If yes, the were the protocols ad safe procedures available, workable, itelligible, correct, ad i routie use? Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 9

Comprehesive Accreditatio Maual for Hospitals l l If yes, the is there evidece the idividual took a uacceptable risk? If yes, the were there sigificat mitigatig circumstaces? Would aother idividual comig from the same professioal group, possessig comparable qualificatios ad experiece, behave i the same way i similar circumstaces? (Substitutio test) o If yes, were there ay deficiecies i traiig, experiece, or supervisio? l l If yes, the is there evidece the idividual took a uacceptable risk? If yes, the were there sigificat mitigatig circumstaces? Reachig aswers to these questios requires a iitial ivestigatio ito the patiet safety evet to idetify cotributig factors. The use of the Icidet Decisio Tree or other formal decisio process ca help make determiatios of culpability more trasparet ad fair. 5 Refereces 1. The Joit Commissio. Behaviors that udermie a culture of safety. Setiel Evet Alert, No. 40, Jul 9, 2009. Accessed Sep 3, 2013. http:// www.joitcommissio.org/setiel_evet_alert_issue_40_behaviors_ that_udermie_a_culture_of_safety/ 2. The Joit Commissio. Leadership committed to safety. Setiel Evet Alert. Aug 27, 2009. Accessed Sep 8, 2013. http://www.joitcommissio.org/ setiel_evet_alert_issue_43_leadership_committed_to_safety 3. Marx D. How buildig a just culture helps a orgaizatio lear from errors. OR Maager. 2003 May;19(5):1, 14 15, 20. 4. Reaso J; Hobbs A. Maagig Maiteace Error. Farham, Surrey, Uited Kigdom: Ashgate Publishig, 2003. 5. Vicet C. Patiet Safety, 2d ed. Hoboke, NJ: Wiley-Blackwell, 2010. 6. Natioal Patiet Safety Agecy. Icidet Decisio Tree. Accessed Sep 7, 2013. http://www.rls.psa.hs.uk/resources/?etryid45=59900 7. Bagia JP, et al. Developig ad deployig a patiet safety program i a large health care delivery system: You ca t fix what you do t kow about. Jt Com J Qual Patiet Saf. 2001 Oct;27(10):522 532. Data Use ad Reportig Systems A effective culture of safety is evideced by a robust reportig system ad use of measuremet to improve. Whe hospitals adopt a trasparet, opuitive approach to reports of patiet safety evets or other cocers, the hospital begis reportig to lear ad to lear collectively from adverse evets, close calls, ad hazardous Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 10 CAMH Update 1, July 2015

Patiet Safety Systems coditios. This sectio focuses o data from reported patiet safety evets. Hospitals should ote that this is but oe type of data amog may that should be collected ad used to drive improvemet. Whe there is cotiuous reportig for adverse evets, close calls, ad hazardous coditios, the hospital ca aalyze the patiet safety evets, chage the process or system to improve safety, ad dissemiate the chages or lessos leared to the rest of theorgaizatio. 21-24 I additio to those metioed earlier i this chapter, a umber of stadards relate to the reportig of safety iformatio, icludig Performace Improvemet (PI) Stadard PI.01.01.01: The hospital collects data to moitor its performace; ad LD.03.02.01: The hospital uses data ad iformatio to guide decisios ad to uderstad variatio i the performace of processes supportig safety ad quality. Hospitals ca egage frotlie staff i iteral reportig i a umber of ways, icludig the followig: Create a opuitive approach to patiet safety evet reportig Educate staff o idetifyig patiet safety evets that should be reported Provide timely feedback regardig actios take o patiet safety evets Effective Use of Data Collectig Data Whe hospitals collect data or measure staff compliace with evidece-based care processes or patiet outcomes, they ca maage ad improve those processes or outcomes ad, ultimately, improve patiet safety. 25 The effective use of data eables hospitals to idetify problems, prioritize issues, develop solutios, ad track success. 9 Objective data ca be used to support decisios, ifluece people to chage their behaviors, ad to comply with evidece-based care guidelies. 9,26 The Joit Commissio ad the Ceters for Medicare ad Medicaid Services (CMS) both require hospitals to collect ad use data related to certai patiet care outcomes ad patiet harms. Some key Joit Commissio stadards related to data collectio ad use iclude the followig: EC.04.01.01: The hospital collects iformatio to moitor coditios i the eviromet. IC.01.03.01: The hospital idetifies risks for acquirig ad trasmittig ifectios. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 11

Comprehesive Accreditatio Maual for Hospitals LD.03.02.01: The hospital uses data ad iformatio to guide decisios ad to uderstad variatio i the performace of processes supportig safety ad quality. LD.04.04.05: The hospital has a orgaizatiowide, itegrated patiet safety program withi its performace improvemet activities. MM.08.01.01: The hospital evaluates the effectiveess of its medicatio maagemet system. PC.03.05.19: For hospitals that use Joit Commissio accreditatio for deemed status purposes: The hospital reports deaths associated with the use of restrait ad seclusio. PI.01.01.01: The hospital collects data to moitor its performace. PI.03.01.01: The hospital improves performace o a ogoig basis. Aalyzig Data Effective data aalysis ca eable a hospital to diagose problems withi its system similar to the way oe would diagose a patiet s illess based o symptoms, health history, ad other factors. Turig data ito iformatio is a critical competecy of a learig orgaizatio ad of effective maagemet of chage. Whe the right data are collected ad appropriate aalytic techiques are applied, it eables the hospital to moitor the performace of a system, detect variatio, ad idetify opportuities to improve. This ca help the hospital ot oly uderstad the curret performace of hospital systems but also ca help it predict its performace goig forward. 23 Aalyzig data with tools such as ru charts, statistical process cotrol (SPC) charts, ad capability charts helps a hospital determie what has occurred i a system ad provides clues as to why the system respoded as it did. 23 Table 1, followig, describes ad compares examples of these tools. Please ote that several types of SPC charts exist; this discussio focuses o the XmR chart, which is the most commoly used. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 12 CAMH Update 1, July 2015

Patiet Safety Systems Table 1. Defiig ad Comparig Aalytical Tools Tool Whe to Use Example Ru Chart 1 Whe the hospital eeds to idetify variatio withi a system Whe the hospital eeds a simple ad straightforward aalysis of a system As a precursor to a SPC chart Statistical Process Cotrol Chart Whe the hospital eeds to idetify variatio withi a system ad fid idicators of why the variatio occurred Whe the hospital eeds a more detailed ad idepth aalysis of a system Capability Chart 2 Whe the hospital eeds to determie whether a process will fuctio as expected, accordig to requiremets or specificatios I the example above, the curve at the top of the chart idicates a process that is oly partly capable of meetig requiremets. The curve at the bottom of the chart shows a process that is fully capable. Sources: 1. US Agecy for Healthcare Research ad Quality. Advaced Methods i Delivery System Research: Plaig, Executig, Aalyzig, ad Reportig Research o Delivery System Improvemet, Webiar #2: Statistical Process Cotrol. 2013 14 May. Accessed Apr 21, 2014. http://www.ahrq.gov/professioals/prevetio-chroic-care/improve/coordiatio/webiar02/ spc_slides.pptx. (Example 2, above). 2. George M, Rowlads D, et al. The LEAN-Six Sigma Pocket Tool Book. New York: McGraw-Hill, 2005. Used with permissio. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 13

Comprehesive Accreditatio Maual for Hospitals Usig Data to Drive Improvemet After data has bee tured ito iformatio, leadership should esure the followig: 27-29 Iformatio is preseted i a clear maer (LD.03.04.01, EP 3) Iformatio is shared with the appropriate groups throughout the orgaizatio (frotlie to the board) (LD.03.04.01, LD.04.04.05) Opportuities for improvemet ad actios to be take are clearly articulated (LD.03.05.01, EP 4; LD.04.04.01) Leadership provides staff with the time, resources, ad opportuities to participate i improvemet efforts as part of daily work (LD.03.01.01, EP 3) Improvemets are celebrated or recogized A Proactive Approach to Prevetig Harm Proactive risk reductio prevets harm before it reaches the patiet. By egagig i proactive risk reductio, a hospital ca correct process problems i order to reduce the likelihood of experiecig adverse evets. I a proactive risk assessmet the hospital evaluates a process to see how it could potetially fail, to uderstad the cosequeces of such a failure, ad to idetify parts of the process that eed improvemet. A proactive risk assessmet icreases uderstadig withi the orgaizatio about the complexities of process desig ad maagemet ad what could happe if the process fails. Whe coductig a proactive risk assessmet, orgaizatios should prioritize high-risk, high-volume areas. Areas of risk are idetified from iteral sources such as ogoig moitorig of the eviromet, results of previous proactive risk assessmets, from results of data collectio activities. Risk assessmet tools should be accessed from credible exteral sources such as a Setiel Evet Alert, atioally recogized risk assessmet tools, ad peer review literature. Beefits of a proactive approach to patiet safety icludes icreased likelihood of the followig: Idetificatio of actioable commo causes Avoidace of uiteded cosequeces Idetificatio of commoalities across departmets/services/uits Idetificatio of system solutios Hazardous (or usafe) coditios provide a opportuity for a hospital to take a proactive approach to reduce harm. Hospitals also beefit from idetifyig hazardous coditios while desigig ay ew process that could impact patiet safety. A hazardous coditio is defied as ay circumstace that icreases the probability of a Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 14 CAMH Update 1, July 2015

Patiet Safety Systems patiet safety evet. A hazardous coditio may be the result of a huma error or violatio, may be a desig flaw i a system or process, or may arise i a system or process i chagig circumstaces. A proactive approach to such coditios should iclude a aalysis of the systems ad processes i which the hazardous coditio is foud, with a focus o coditios that preceded the hazardous coditio. (See Sidebar 3, below.) A proactive approach to hazardous coditios should iclude a aalysis of the related systems ad processes, icludig the followig aspects: 30 Precoditios. Examples iclude hazardous (or usafe) coditios i the eviromet of care (such as oise, clutter, wet floors ad so forth), iadequate staffig levels, a operator who is impaired or iadequately traied. Supervisory iflueces. Examples iclude iadequate supervisio, plaed iappropriate operatios, failure to address a kow problem, authorizatio of activities that are kow to be hazardous. Orgaizatioal iflueces. Examples iclude iadequate staffig, iadequate policies, lack of strategic risk assessmet. The Joit Commissio requires proactive risk assessmets at Stadard LD.04.04.05, EP 10: At least every 18 moths, the hospital selects oe high-risk process ad coducts a proactive risk assessmet. Hospitals should recogize that this stadard represets a miimum requiremet. Hospitals workig to become learig orgaizatios are ecouraged to exceed this requiremet by costatly workig to proactively idetify risk. Sidebar 3. Strategies for a Effective Risk Assessmet Although several methods could be used to coduct a proactive risk assessmet, the followig steps comprise oe approach: Describe the chose process (for example, through the use of a flowchart). Huma errors are typically skills based, decisio based, or kowledge based; whereas violatios could be either routie or exceptioal (itetioal or egliget). Routie violatios ted to iclude habitual bedig of the rules, ofte eabled by maagemet. A routie violatio may break established rules or policies, ad yet be a commo practice withi a orgaizatio. A exceptioal violatio is a willful behavior outside the orm that is ot codoed by maagemet, egaged i by others, ad ot part of the idividual s usual behavior. Source: Diller T, Helmrich G, Duig S, et al. The Huma Factors Aalysis Classificatio System (HFACS) applied to health care. Am J Med Qual. 2013 Ju 27;29(3)181 190. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 15

Comprehesive Accreditatio Maual for Hospitals Idetify ways i which the process could break dow or fail to perform its desired fuctio, which are ofte referred to as failure modes. Idetify the possible effects that a breakdow or failure of the process could have o patiets ad the seriousess of the possible effects. Prioritize the potetial process breakdows or failures. Determie why the prioritized breakdows or failures could occur, which may ivolve performig a hypothetical root cause aalysis. Desig or redesig the process ad/or uderlyig systems to miimize the risk of the effects o patiets. Test ad implemet the ewly desiged or redesiged process. Moitor the effectiveess of the ewly desiged or redesiged process. Tools for Coductig a Proactive Risk Assessmet A umber of tools are available to help orgaizatios coduct a proactive risk assessmet. Oe of the best kow of these tools is the Failure Modes ad Effects Aalysis (FMEA). A FMEA is used to prospectively examie how failures could occur durig high-risk processes ad, ultimately, how to prevet them. The FMEA asks What if? to explore what could happe if a failure occurs at particular steps i a process. 31 Hospitals have other tools they ca cosider usig i their proactive risk assessmet. Some examples iclude the followig: Istitute for Safe Medicatio Practices Medicatio Safety Risk Assessmet: This tool is desiged to help reduce medicatio errors. Visit https://www.ismp.org/ selfassessmets/default.asp for more iformatio. Cotigecy diagram: The cotigecy diagram uses braistormig to geerate a list of problems that could arise from a process. Visit http://healthit.ahrq.gov/ health-it-tools-ad-resources/workflow-assessmet-health-it-toolkit/all-workflowtools/cotigecy-diagram for more iformatio. Potetial problem aalysis (PPA) is a systematic method for determiig what could go wrog i a pla uder developmet. The problem causes are rated accordig to their likelihood of occurrece ad the severity of their cosequeces. Visit http://healthit.ahrq.gov/health-it-tools-ad-resources/workflow-assessmethealth-it-toolkit/all-workflow-tools/potetial-problem-aalysis for more iformatio. Process decisio program chart (PDPC) provides a systematic meas of fidig errors with a pla while it is beig created. After potetial issues are foud, prevetive measures are developed, allowig the problems to either be avoided or a Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 16 CAMH Update 1, July 2015

Patiet Safety Systems cotigecy pla to be i place should the error occur. Visit http://healthit.ahrq.gov/health-it-tools-ad-resources/workflow-assessmet-health-it-toolkit/ all-workflow-tools/process-decisio-program-chart. Ecouragig Patiet Activatio To achieve the best outcomes, patiets ad families must be more actively egaged i decisios about their health care ad must have broader access to iformatio ad support. Patiet activatio is iextricably itertwied with patiet safety. Activated patiets are less likely to experiece harm ad uecessary hospital readmissios. Patiets who are less activated suffer poorer health outcomes ad are less likely to follow their provider s advice. 32,33 A patiet-cetered approach to care ca help hospitals assess ad ehace patiet activatio. Achievig this requires leadership egagemet i the effort to establish patiet-cetered care as a top priority throughout the hospital. This icludes adoptig the followig priciples: 34 Patiet safety guides all decisio makig. Patiets ad families are parters at every level of care. Patiet- ad family-cetered care is verifiable, rewarded, ad celebrated. The licesed idepedet practitioer resposible for the patiet s care, or his or her desigee, discloses to the patiet ad family ay uaticipated outcomes of care, treatmet, ad services. Though Joit Commissio stadards do ot require apology, evidece suggests that patiets beefit ad are less likely to pursue litigatio whe physicias disclose harm, express sympathy, ad apologize. Staffig levels are sufficiet, ad staff has the ecessary tools ad skills. The hospital has a focus o measuremet, learig, ad improvemet. Staff ad licesed idepedet practitioers must be fully egaged i patiet- ad family-cetered care as demostrated by their skills, kowledge, ad competece i compassioate commuicatio. Hospitals ca adopt a umber of strategies to support ad improve patiet activatio, icludig promotig culture chage, adoptig trasitioal care models, ad leveragig health iformatio techology capabilities. 34 A umber of Joit Commissio stadards address patiet rights ad provide a excellet startig poit for hospitals seekig to improve patiet activatio. These iclude the followig: Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 17

Comprehesive Accreditatio Maual for Hospitals Stadard RI.01.01.01: The hospital respects, protects, ad promotes patiet rights. Stadard RI.01.01.03: The hospital respects the patiet s right to receive iformatio i a maer he or she uderstads. Stadard RI.01.02.01: The hospital respects the patiet s right to participate i decisios about his or her care, treatmet, ad services. Stadard RI.01.03.01: The hospital hoors the patiet s right to give or withhold iformed coset. Stadard RI.01.05.01: The hospital addresses patiet decisios about care, treatmet, ad services received at the ed of life. Stadard RI.02.01.01: The hospital iforms the patiet about his or her resposibilities related to his or her care, treatmet, ad services. Beyod Accreditatio: The Joit Commissio Is Your Patiet Safety Parter To assist hospitals o their jourey toward creatig highly reliable patiet safety systems, The Joit Commissio provides may resources, icludig the followig: Setiel Evet Uit: A iteral Joit Commissio departmet that offers hospitals guidace ad support whe they experiece a setiel evet. Orgaizatios ca call the Setiel Evet Hotlie (630-792-3700) to clarify whether a patiet safety evet is cosidered to be a setiel evet ad is reviewable or to discuss ay aspect of the Setiel Evet Policy. The Setiel Evet Uit assesses the thoroughess ad credibility of a hospital s comprehesive systematic aalysis as well as the actio pla to help the hospital prevet the hazardous or usafe coditios from occurrig agai. Joit Commissio Ceter for Trasformig Healthcare: A Joit Commissio ot-forprofit affiliate that offers highly effective, durable solutios to health care s most critical safety ad quality problems to help hospitals trasform ito high reliability orgaizatios. For specific quality ad patiet problems, the Ceter s Targeted Solutios Tool (TST ) guides health care orgaizatios through a step-by-step process to measure their orgaizatio s performace, idetify barriers to excellece, ad direct them to prove solutios. To date, a TST has bee developed for each of the followig: had hygiee, had-off commuicatios, ad wrog-site surgery. For more iformatio, visit http://www.ceterfortrasformighealthcare.org. Stadards Iterpretatio Group: A iteral Joit Commissio departmet that helps orgaizatios with their questios about Joit Commissio stadards. First, orgaizatios ca see if other orgaizatios have asked the same questio by Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 18 CAMH Update 1, July 2015

Patiet Safety Systems accessig the Stadards FAQs at http://www.joitcommissio.org/ stadards_iformatio/jcfaq.aspx. Thereafter, orgaizatios ca submit questios about stadards to the Stadards Iterpretatio Group by completig a olie form at https://web.joitcommissio.org/sigsubmissio/sigolieform.aspx. Natioal Patiet Safety Goals: The Joit Commissio s yearly patiet safety requiremets based o data obtaied from the Joit Commissio s Setiel Evet Database ad recommeded by a pael of patiet safety experts. (For a list of the curret Natioal Patiet Safety Goals, go to http://www.joitcommissio.org/ stadards_iformatio/psgs.) Setiel Evet Alert: The Joit Commissio s periodic alerts with timely iformatio about similar, frequetly reported setiel evets, icludig root causes, applicable Joit Commissio requiremets, ad suggested actios to prevet a particular setiel evet. (For archives of previously published Setiel Evet Alert, go to http://www.joitcommissio.org/setiel_evet.) Quick Safety: Quick Safety is a mothly ewsletter that outlies a icidet, topic, or tred i health care that could compromise patiet safety. http:// www.joitcommissio.org/quick_safety.aspx?archieve=y Core Measure Solutio Exchage : Available for accredited or certified orgaizatios through the Joit Commissio Coect extraet, orgaizatios ca search a database of over two hudred success stories from accredited hospitals that have attaied excellet performace o core measures, icludig accoutability measures. Joit Commissio Resources: A Joit Commissio ot-for-profit affiliate that produces books ad periodicals, holds cofereces, provides cosultig services, ad develops software products (icludig AMP, Tracers with AMP, E-ditio, ECM Plus, CMSAccess, ad JCAccess ) for accreditatio ad survey readiess. (For more iformatio, visit http://www.jcric.com.) Webiars ad podcasts: The Joit Commissio ad its affiliate, Joit Commissio Resources, offer free webiars ad podcasts o various accreditatio ad patiet safety topics. Speak Up program: The Joit Commissio s campaig to educate patiets about health care processes ad potetial safety issues ad ecourage them to speak up wheever they have questios or cocers about their safety. (For more iformatio ad patiet educatio resources, go to http://www.joitcommissio.org/speakup.) Stadards BoosterPaks : Available for accredited or certified orgaizatios through Joit Commissio Coect, orgaizatios ca access BoosterPaks that provide detailed iformatio about a sigle stadard or topic area that has bee associated with a high volume of iquiries or ocompliace scores. Recet stadards Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 19

Comprehesive Accreditatio Maual for Hospitals BoosterPak topics iclude credetialig ad privilegig i ohospital settigs, waived testig, restrait ad seclusio, maagemet of hazardous waste, eviromet of care (icludig Stadards EC.04.01.01, EC.04.01.03, ad EC.04.01.05), ad sample collectio. Leadig Practice Library: Available for accredited or certified orgaizatios through Joit Commissio Coect, orgaizatios ca access a olie library of solutios to help improve safety. The searchable documets i the library are actual solutios that have bee successfully implemeted by hospitals ad reviewed by Joit Commissio stadards experts. Joit Commissio Web Portals: Through the Joit Commissio website, orgaizatios ca access web portals that provide a repository of resources from The Joit Commissio, the Ceter for Trasformig Healthcare, Joit Commissio Resources, ad Joit Commissio Iteratioal o the followig topics: o Trasitios of care: http://www.joitcommissio.org/toc.aspx o High reliability: http://www.joitcommissio.org/highreliability.aspx o Ifectio prevetio ad health care associated ifectios (HAI): http:// www.joitcommissio.org/hai.aspx o Emergecy maagemet: http://www.joitcommissio.org/ emergecy_maagemet.aspx Appedix. Key Patiet Safety Requiremets A umber of Joit Commissio stadards have bee discussed i the Patiet Safety Systems (PS) chapter. However, may Joit Commissio requiremets address issues related to the desig ad maagemet of patiet safety systems, icludig the followig examples: APR.09.01.01: The hospital otifies the public it serves about how to cotact its hospital maagemet ad The Joit Commissio to report cocers about patiet safety ad quality of care. APR.09.02.01: Ay idividual who provides care, treatmet, ad services ca report cocers about safety or the quality of care to The Joit Commissio without retaliatory actio from the hospital. HR.01.05.03: Staff participate i ogoig educatio ad traiig. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 20 CAMH Update 1, July 2015

Patiet Safety Systems EP 7. Staff participate i educatio ad traiig that icludes iformatio about the eed to report uaticipated adverse evets ad how to report these evets. Staff participatio is documeted. EP 8. Staff participate i educatio ad traiig o fall reductio activities. Staff participatio is documeted. EP 13. The hospital provides educatio ad traiig that addresses how to idetify early warig sigs of a chage i a patiet's coditio ad how to respod to a deterioratig patiet, icludig how ad whe to cotact resposible cliicias. Educatio is provided to staff ad licesed idepedet practitioers who may request assistace ad those who may respod to those requests. Participatio i this educatio is documeted. LD.02.01.01: The missio, visio, ad goals of the hospital support the safety ad quality of care, treatmet, ad services. LD.02.03.01: The goverig body, seior maagers, ad leaders of the orgaized medical staff regularly commuicate with oe aother o issues of safety ad quality. LD.02.04.01: The hospital maages coflict betwee leadership groups to protect the quality ad safety of care. LD.03.01.01: Leaders create ad maitai a culture of safety ad quality throughout the hospital. EP 1. Leaders regularly evaluate the culture of safety ad quality usig valid ad reliable tools. EP 2. Leaders prioritize ad implemet chages idetified by the evaluatio. EP 3. Leaders provide opportuities for all idividuals who work i the hospital to participate i safety ad quality iitiatives. EP 4. Leaders develop a code of coduct that defies acceptable behavior ad behaviors that udermie a culture of safety. EP 5. Leaders create ad implemet a process for maagig behaviors that udermie a culture of safety. EP 6. Leaders provide educatio that focuses o safety ad quality for all idividuals. EP 7. Leaders establish a team approach amog all staff at all levels. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 21

Comprehesive Accreditatio Maual for Hospitals EP 8. All idividuals who work i the hospital, icludig staff ad licesed idepedet practitioers, are able to opely discuss issues of safety ad quality. EP 9. Literature ad advisories relevat to patiet safety are available to all idividuals who work i the hospital. EP 10. Leaders defie how members of the populatio(s) served ca help idetify ad maage issues of safety ad quality withi the hospital. LD.03.02.01: The hospital uses data ad iformatio to guide decisios ad to uderstad variatio i the performace of processes supportig safety ad quality. LD.03.03.01: Leaders use hospitalwide plaig to establish structures ad processes that focus o safety ad quality. LD.03.04.01: The hospital commuicates iformatio related to safety ad quality to those who eed it, icludig staff, licesed idepedet practitioers, patiets, families, ad exteral iterested parties. LD.03.05.01: Leaders implemet chages i existig processes to improve the performace of the hospital. LD.03.06.01: Those who work i the hospital are focused o improvig safety ad quality. LD.04.01.01: The hospital complies with law ad regulatio. LD.04.04.05: The hospital has a orgaizatiowide, itegrated patiet safety program withi its performace improvemet activities. EP 1. The leaders implemet a hospitalwide patiet safety program. EP 2. Oe or more qualified idividuals or a iterdiscipliary group maages the safety program. EP 3. The scope of the safety program icludes the full rage of safety issues, from potetial or o-harm errors (sometimes referred to as ear misses, close calls, or good catches) to hazardous coditios ad setiel evets. EP 4. All departmets, programs, ad services withi the hospital participate i the safety program. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 22 CAMH Update 1, July 2015

Patiet Safety Systems EP 5. As part of the safety program, the leaders create procedures for respodig to system or process failures. EP 6. The leaders provide ad ecourage the use of systems for blame-free iteral reportig of a system or process failure, or the results of a proactive risk assessmet. EP 7. The leaders defie patiet safety evet ad commuicate this defiitio throughout the orgaizatio. EP 8. The hospital coducts thorough ad credible comprehesive systematic aalyses (for example, root cause aalyses) i respose to setiel evets as described i the Setiel Evets (SE) chapter of this maual. EP 9. The leaders make support systems available for staff who have bee ivolved i a adverse or setiel evet. Note: Support systems recogize that coscietious health care workers who are ivolved i setiel evets are themselves victims of the evet ad require support. Support systems provide staff with additioal help ad support as well as additioal resources through the huma resources fuctio or a employee assistace program. Support systems also focus o the process rather tha blamig the ivolved idividuals. EP 10. At least every 18 moths, the hospital selects oe high-risk process ad coducts a proactive risk assessmet. EP 11. To improve safety ad to reduce the risk of medical errors, the hospital aalyzes ad uses iformatio about system or process failures ad the results of proactive risk assessmets. EP 12. The leaders dissemiate lessos leared from comprehesive systematic aalyses (for example, root cause aalyses), system or process failures, ad the results of proactive risk assessmets to all staff who provide services for the specific situatio. EP 13. At least oce a year, the leaders provide goverace with writte reports o the followig: All system or process failures The umber ad type of setiel evets Whether the patiets ad the families were iformed of the evet All actios take to improve safety, both proactively ad i respose to actual occurreces Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 23

Comprehesive Accreditatio Maual for Hospitals For hospitals that use Joit Commissio accreditatio for deemed status purposes: The determied umber of distict improvemet projects to be coducted aually All results of the aalyses related to the adequacy of staffig EP 14. The leaders ecourage exteral reportig of sigificat adverse evets, icludig volutary reportig programs i additio to madatory programs. Note: Examples of volutary programs iclude The Joit Commissio Setiel Evet Database ad the US Food ad Drug Admiistratio (FDA) MedWatch. Madatory programs are ofte state iitiated. MM.07.01.03: The hospital respods to actual or potetial adverse drug evets, sigificat adverse drug reactios, ad medicatio errors. EP 3. The hospital complies with iteral ad exteral reportig requiremets for actual or potetial adverse drug evets, sigificat adverse drug reactios, ad medicatio errors. MS.08.01.01: The orgaized medical staff defies the circumstaces requirig moitorig ad evaluatio of a practitioer s professioal performace. MS.09.01.01: The orgaized medical staff, pursuat to the medical staff bylaws, evaluates ad acts o reported cocers regardig a privileged practitioer s cliical practice ad/or competece. NR.01.01.01: The urse executive directs the delivery of ursig care, treatmet, ad services. EP 2. The urse executive has the authority to speak o behalf of ursig to the same extet that other hospital leaders speak for their respective disciplies, departmets, or service lies. NR.02.01.01: The urse executive directs the hospital s ursig services. EP 3. The urse executive coordiates: The developmet of a effective, ogoig program to measure, aalyze, ad improve the quality of ursig care, treatmet, ad services. EP 5. The urse executive directs: The implemetatio of hospitalwide programs, policies, ad procedures that address how ursig care eeds of the patiet populatio are assessed, met, ad evaluated. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 24 CAMH Update 1, July 2015

Patiet Safety Systems EP 6. The urse executive directs: The implemetatio of a effective, ogoig program to measure, aalyze, ad improve the quality of ursig care, treatmet, ad services. NR.02.02.01: The urse executive establishes guidelies for the delivery of ursig care, treatmet, ad services. EP 5. The urse executive, registered urses, ad other desigated ursig staff write: Stadards to measure, assess, ad improve patiet outcomes. PI.01.01.01: The hospital collects data to moitor its performace. PI.02.01.01: The hospital compiles ad aalyzes data. PI.03.01.01: The hospital improves performace o a ogoig basis. RI.01.01.01: The hospital respects, protects, ad promotes patiet rights. EP 29. The hospital prohibits discrimiatio based o age, race, ethicity, religio, culture, laguage, physical or metal disability, socioecoomic status, sex, sexual orietatio, ad geder idetity or expressio. RI.01.02.01: The hospital respects the patiet s right to participate i decisios about his or her care, treatmet, ad services. EP 21. The hospital iforms the patiet or surrogate decisio-maker about uaticipated outcomes of care, treatmet, ad services that relate to setiel evets as defied by The Joit Commissio. (Refer to the Glossary for a defiitio of setiel evet.) EP 22. The licesed idepedet practitioer resposible for maagig the patiet s care, treatmet, ad services, or his or her desigee, iforms the patiet about uaticipated outcomes of care, treatmet, ad services related to setiel evets whe the patiet is ot already aware of the occurrece or whe further discussio is eeded. Note: I settigs where there is o licesed idepedet practitioer, the staff member resposible for maagig the care of the patiet is resposible for sharig iformatio about such outcomes. Refereces 1. Jura J, Godfey A. Quality Cotrol Hadbook, 6th ed. New York: McGraw-Hill, 2010. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 25

Comprehesive Accreditatio Maual for Hospitals 2. America Society for Quality. Glossary ad Tables for Statistical Quality Cotrol, 4th ed. Milwaukee: America Society for Quality Press, 2004. 3. Sege PM. The Fifth Disciplie: The Art ad Practice of the Learig Orgaizatio, 2d ed. New York: Doubleday, 2006. 4. Leape L, et al. A culture of respect, part 2: Creatig a culture of respect. Academic Medicie. 2012 Jul. 87(7):853 858. 5. Wu A, ed. The Value of Close Calls i Improvig Patiet Safety: Learig How to Avoid ad Mitigate Patiet Harm. Oak Brook, IL: Joit Commissio Resources, 2011. 6. Agecy for Healthcare Research ad Quality (AHRQ). Becomig a High Reliability Orgaizatio: Operatioal Advice for Hospital Leaders. Rockville, MD: AHRQ, 2008. 7. Fei K, Vlasses FR: Creatig a safety culture through the applicatio of reliability sciece. J Healthc Qual. 2008 Nov-Dec; 30(6):37 43. 8. Massachusetts Coalitio of the Prevetio of Medical Errors: Whe Thigs Go Wrog: Respodig to Adverse Evets. 2006 Mar. Accessed Sep 30, 2013. http:// www.macoalitio.org/documets/respodigtoadverseevets.pdf. 9. The Joit Commissio. The Joit Commissio Leadership Stadards. Oak Brook, IL: Joit Commissio Resources, 2009. 10. Chassi MR, Loeb JM. High-reliability healthcare: Gettig there from here. Milbak Q. 2013 Sep; 91(3):459 490. 11. Advisory Committee o the Safety of Nuclear Istallatios. Study Group o Huma Factors. Third Report of the ACSNI Health ad Safety Commissio. Sudbury, Eglad: HSE Books, 1993. 12. Leape L, et al. A culture of respect, part 1: The ature ad causes of disrepectful behavior by physicias. Academic Medicie. 2012 Jul; 87(7):1 8. 13. Weick, K.E. ad Sutcliffe K.M.. Maagig the Uexpected, Secod Editio. Sa Fracisco: Jossey-Bass, 2007. 14. Reaso J, Hobbs A. Maagig Maiteace Error: A Practical Guide. Aldershot (UK): Ashgate; 2003. 15. Associatio for the Advacemet of Medical Istrumetatio. Risk ad Reliability i Healthcare ad Nuclear Power: Learig from Each Other. Arligto, VA: Associatio for the Advacemet of Medical Istrumetatio, 2013. 16. Reaso J. Huma error: Models ad maagemet. BMJ. 2000 Mar 13; 320(3):768-770. 17. The Joit Commissio: Behaviors that udermie a culture of safety. Setiel Evet Alert. 2009 Jul 9. Accessed Sep. 3, 2013. http://www.joitcommissio.org/ setiel_evet_alert_issue_40_behaviors_that_udermie_a_culture_of_safety/. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 26 CAMH Update 1, July 2015

Patiet Safety Systems 18. Istitute for Safe Medicatio Practices. Uresolved disrespectful behavior i health care: Practitioers speak up (agai)-part I. ISMP Medicatio Safety Alert. Oct 3, 2013. Accessed Sep 18, 2014. http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=60. 19. Chassi M, Loeb L. The ogoig quality jourey: Next stop high reliability. Health Affairs. 2011 Apr 7; 30(4):559 568. 20. Heifetz R, Liksy M. A survival guide for leaders. Harvard Busiess Review. 2002 Ju; 1-11. 21. Otario Hospital Associatio. A Guidebook to Patiet Safety Leadig Practices: 2010. Toroto: Otario Hospital Associatio, 2010. 22. The Joit Commissio. Leadership committed to safety. Setiel Evet Alert. 2009 Aug 27. Accessed Aug 26, 2013. http://www.joitcommissio.org/setiel_evet_alert_issue_43_leadership_committed_to_safety/ 23. Ogric G, Headrick L, et al. Fudametals of Health Care Improvemet: A Guide to Improvig Your Patiet s Care, 2d ed. Oak Brook, IL: Joit Commissio Resources/ Istitute for Healthcare Improvemet, 2012. 24. US Agecy for Healthcare Research ad Quality. Becomig a High Reliability Orgaizatio: Operatioal Advice for Hospital Leaders. Rockville, MD: AHRQ, 2008. 25. Joit Commissio Resources. Patiet Safety Iitiative: Hospital Executive ad Physicia Leadership Strategies. Hospital Egagemet Network. Oak Brook, IL: Joit Commissio Resources, 2013. Accessed Sep 12, 2013. https://www.jcr-he.org/pub/ Home/CaledarEvet00312/JCR_He_Leadership_Chage_Package-FINAL.pdf. 26. The Joit Commissio. Leadership committed to safety. Setiel Evet Alert. 2009 Aug. 27. Accessed Sep. 8, 2013. http://www.joitcommissio.org/ setiel_evet_alert_issue_43_leadership_committed_to_safety. 27. Nelso E, Batalde P, et al. Microsystems i health care, part 2: Creatig a rich iformatio eviromet. Jt Comm J Qual Patiet Saf. 2003 Ja; 29(1):5 15. 28. Nelso E, Godfrey M, et al. Cliical microsystems, part 1: The buildig blocks of health systems. Jt Comm J Qual Patiet Saf. 2008 Jul; 34(7):367 378. 29. Pardii-Kiely K, Greelee E, et al: Improvig ad sustaiig core measure performace through effective accoutability of cliical microsystems i a academic medical ceter. Jt Comm J Qual Patiet Saf. 2010 Sep; 36(9):387 398. 30. Diller T, Helmrich G, Duig S, et al. The Huma Factors Aalysis Classificatio System (HFACS) applied to health care. Am J Med Qual. 2013 Ju 27. Accessed Apr 22, 2014. http://ajm.sagepub.com/cotet/early/2013/06/27/ 1062860613491623.full.pdf+html. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. CAMH Update 1, July 2015 PS 27

Comprehesive Accreditatio Maual for Hospitals 31. Croteau R, ed. Root Cause Aalysis i Health Care: Tools ad Techiques, fourth editio. Oak Brook, IL: Joit Commissio Resources, 2010. 32. AARP Public Policy Istitute. Beyod 50.09 chroic care: A call to actio for health reform. 2009 May. Accessed Ju 6, 2014. http://www.aarp.org/health/medicareisurace/ifo-03-2009/beyod_50_hcr.html. 33. Godolphi W, Towle A. Framework for teachig ad learig iformed shared decisio makig. BMJ. Sep 18, 1999; 319(7212):766 771. 34. Hibbard J, et al. Developmet of the patiet activatio measure (PAM): Coceptualizig ad measurig activatio i patiets ad cosumers. Health Serv Res. Aug 2004; 39(4 Pt 1):1005 1026. Shadig idicates a chage effective July 1, 2015, uless otherwise oted i the What's New. PS 28 CAMH Update 1, July 2015