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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.