Catalog Number : ncd1969
Title : Joint Commission Safety Chapter, Sentinel Event Policy and CMS RCA Requirements
Speaker : Sue Dill
Duration : 120 minutes
Webplay Recording Date : 1-11-2016
Webplay Price : $ 150 for two weeks viewing
Webinar Overview:
This webinar will cover the Joint Commission sentinel event policy changes and how to help hospitals ensure compliance. The Joint Commission (TJC) Patient Safety System will also be covered which was a new chapter effective January 1, 2015 along with the July 2015 changes. The patient safety system chapter and the sentinel event policy are designed to be used together.
Target Audience
Patient Safety Officers, Senior Leadership (CEO, COO, CNO, CMO, etc.), Risk Managers and staff, TJC Accreditation Director, Compliance Officers, CMS Regulatory Compliance staff, Department Directors, Nurses, Nurse Educators, Nurse Managers and Supervisors, Consumer Advocates, Quality Improvement Director and Staff, In-house Legal Counsel and anyone responsible to ensure quality and safety of patients and to ensure compliance with CMS or TJC standards
Webinar Objectives:
- Recall that CMS has a final worksheet on QAPI that includes a section on patient safety, adverse events, and medical errors
- Discuss that TJC has a patient safety system chapter with a goal to help hospitals improve quality of care and patient safety
- Describe that the Joint Commission has a sentinel event policy and procedure that hospitals should be familiar with
Webinar Agenda/Outline:
CMS QAPI Worksheet on Patient Safety, Adverse Events (AE) and Medical Errors
CMS finalized the worksheets
Section on Patient Safety, AE, and medical error
Staff training or communication related to expectations for patient safety
P&P on non-punitive environment
Staff role in promoting patient safety
Training required regarding if staff feel unsafe
What constitutes a medical error or near miss?
Required reporting
RCA done on all serious preventable AEs
RCA tracer
Surveyor will select 3 RCAs to review
TJC Sentinel Event Policy and Procedure
Sentinel Event Alerts (SEA) and importance
Rewritten in 2015
Sentinel Events (SE)
Revised Definition
Death, permanent, suicide of inpatient, unanticipated death of full term infant, discharge of infant to wrong family, etc.
Required review of sentinel events and process
Patient safety event, close calls, etc.
Goals of SE policy
Responding to SE
Leadership standards
Medical Staff standards
Patient Rights standards
System Analysis Approach
Action Plan
Reporting a SE and 4 options
Through and credible RCA requirements
Follow Up
TJC Patient Safety Systems
New chapter in 2015 and updated July 2015
No new standard requirements but framework
Process to improve quality and patient safety
LD.04.04.05 Hospital Patient Safety Program requirements
Becoming a learning institution
Role of hospital leaders in patient safety
Data use and reporting systems
Key patient safety requirements
Safety culture
Fair and just culture
Holding staff accountable
Proactive approach to preventing harm in healthcare
FMEA
Encouraging patients to become active partners in healthcare
Contact Hours:
- Nursing participants: Instruct-online has approved this program for
2.4 contact hours, Iowa Board of Nursing Approved Provider Number 339.
-
All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a
2 Hour Attendance Certificate for each program.
Refund Policy:
Full tuition is refunded immediately on request if the participant has not been
sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program
.