PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure of Unanticipated Outcomes Medical Devices MISSION: Shore Health System will foster a just culture committed to reducing medical/healthcare errors through a nonpunitive reporting process, education, systems redesign, and performance improvement initiatives consistent with the Shore Health System philosophy of Exceptional Care, Every Day. VISION: The vision of Shore Health System is to focus proactively on patient safety using a team approach that consistently monitors and evaluates patient outcomes to support the organization s strategic plan. Identified medical/healthcare errors will be analyzed in a process that maintains the respect and dignity of all individuals involved. Shore Health System leadership will ensure appropriate resources are provided to maintain the safest possible environment for the delivery of patient care. GOALS: Embrace a culture of safety that emphasizes system s thinking and process redesign while encouraging individual accountability and responsibility rather than culpability. Support proactive strategies to reduce the potential for medical/healthcare errors by prioritizing patient safety when assessing, implementing or redesigning the organization s processes, functions, and services. Encourage open, honest, and respectful communication to foster trust in our relationships with each other as healthcare providers and with our patients. OBJECTIVES: Encourage identification and reporting of medical/healthcare errors and patient safety risks without fear of judgment or placement of blame. Involve patients in decisions about their health care and promote open, honest communication about medical/healthcare errors and the associated consequences, which may occur. Incorporate patient safety into job specific competencies and recognize patient safety as an integral job responsibility. Facilitate organizational education on all levels about prevention, identification and reporting of actual or potential patient safety issues. 1
PAGE #: 2 of 6 Analyze patient care data using a multidisciplinary team approach to identify opportunities to reduce the potential for medical/healthcare errors. Share knowledge of medical/healthcare errors, including near misses, sentinel events and other related issues, with a focus on improving process and system designs. 1.0 SHORE HEALTH SYSTEM CULTURE OF SAFETY 1.1 Individual Employee Responsibility 1.1.1 Know and follow policies and procedures applicable to assigned duties. 1.1.2 Use sound judgment and awareness of potential hazards before taking action. 1.1.3 Promptly report actual or potential errors/events to the immediate manager/supervisor, or designee. 1.2 Management/Director Responsibility 1.2.1 Establish a just culture that encourages error/event reporting. 1.2.2 Educate staff regarding error event reporting, error prevention strategies, and continuous safety improvement. 1.2.3 Encourage and involve staff at the department level to identify system flaws and potential corrective actions to foster a safe work environment. 1.2.4 Focus on the how of an error/event how did it occur, etc. rather than who may have contributed to it. 1.2.5 Maintain compliance with all licensing/regulatory bodies by taking appropriate actions on any identified violations. 1.2.6 Implement appropriate systems to monitor and evaluate safe care delivery. 1.2.7 Quickly respond to identify safety issues by implementing corrective measures and plans and educate all staff accordingly. 1.2.8 Monitor and evaluate corrective measures to show sustained improvement in patient outcomes. 1.3 Administrative and Medical Staff Responsibilities 1.3.1 Promote improvements in patient safety outcomes by encouraging reporting, avoiding blaming, and emphasizing the how of system elements impacting patient safety. 2
PAGE #: 3 of 6 1.3.2 Engage staff members in identifying real or potential hazards. 1.3.3 Implement evidence-based patient safety strategies throughout all clinical services. 1.3.4 Provide for continual education of physicians and employees regarding safety issues and practices. 1.3.5 Promptly report events/errors or situations of actual or potential harm to responsible stakeholders and Senior Leadership Team. 1.4 Governing Body 2.0 REPORTING 1.4.1 Review program results and support ongoing safety efforts. 1.4.2 Allocate adequate resources to support a comprehensive safety program. 2.1 Risk Identification Occurrence Reporting An occurrence is defined as any adverse event not consistent with the routine operation of Shore Health System. All employees and medical staff members are required to participate in the system-wide occurrence-reporting program. 2.2 Shore Health System supports a non-punitive process for all employees, medical staff, and volunteers to report errors and near misses, including the option of anonymous reporting through the Corporate Compliance/Safety Hotline at 1-877-300-3889. 2.2.1 We recognize that competent and caring professionals can make mistakes and we cannot instill fear of punitive action for reporting these errors. 2.2.2 Errors most often result from inadequate or complex processes and/or systems. 2.3 Reported errors and accidents will be evaluated in an attempt to identify opportunities for improvement, thus improving patient outcomes. 2.4 In the process of evaluating errors and near misses, healthcare providers will participate in developing improved processes. 2.5 Error and near miss reporting are a critical component of the Shore Health System patient safety program. 2.6 Employees are not subject to disciplinary action within the reporting process EXCEPT as follows: 3
PAGE #: 4 of 6 2.6.1 Event is not reported in a timely fashion. 2.6.2 Event involves patient neglect/abandonment, sabotage, malicious behavior, chemical impairment, or criminal activity. 2.6.3 False information is provided on the Occurrence Report or in the follow up investigation. 2.6.4 The employee fails to respond to educational efforts and/or fails to participate in the education or other corrective/preventative plan. 2.6.5 Employees who meet any of the above will be subject to disciplinary action in accordance with Human Resource policies and procedures. 3.0 The focus of the Root Cause Analysis process is to identify underlying causal factors that result in performance variation. The preponderance of identified causative issues typically relate to deficiencies in system design or system capability. Resolution of these factors requires system-level changes such as new processes, protocols, equipment or environmental alterations. System-level changes will be addressed by the most relevant and appropriate group, including, but not limited to: Senior Leadership, the Patient Safety committee, the Performance Management Committee, the Shore Health System Quality and Safety Committee, and/or the Medical Staff Quality Committee. In the event it becomes clear that staff competency is the root cause for a pattern of errors, management will make every reasonable effort to ensure staff can reliably deliver safe care. If it becomes clear that a staff member cannot practice in a reliably safe manner in spite of education and counseling, this situation will be treated as a staff competency issue through Human Resource disciplinary procedures. 3.1 Any occurrence should be reported to the Department Manager/Designee as described in the Occurrence Report guidelines. The attending physician should also be notified immediately as appropriate. The initial investigation of the incident is the responsibility of the Manager/Designee who has seventy-two (72) hours to complete the investigation. The Director of Risk Management will be notified of the event as described within the Occurrence Report guidelines. 3.2 It is the responsibility of the Director of Risk Management to evaluate all Occurrence Reports and identify those which present potential liability situations within seventy-two (72) hours. The Director of Risk Management will notify the CEO as well as the respective insurance carrier and legal counsel of any potentially litigious situations, as appropriate. 4.0 ANALYSIS The Director of Risk Management and the Director of Patient Safety and Advocacy will analyze the Occurrence Report data for trends that may require a corrective plan of action by department managers. 4.1 Annually, a Failure Mode Effect Analysis (FMEA) will be conducted on a high-risk process, selected in part through JCAHO sentinel event summaries. The FMEA will help identify the 4
PAGE #: 5 of 6 potential or an actual undesirable variance. The results will be used to guide efforts to redesign of processes or systems to minimize or prevent risk to patients. The redesigned process will be tested, implemented and monitored for effectiveness. 4.2 Error-prone or high-risk processes will be measured and analyzed through a team approach with responsible stakeholders. Corrective action is taken to rectify significant deviations. At any given time, the critical steps of at least one high-risk process is the subject of measurement and analysis to determine degree of variation from intended performance. 4.3 Processes for FMEA or other error-prone/high risk processes may be identified by Risk Management, Patient Safety Committee, the Shore Health System Quality and Safety Committee, the Medical Staff Quality Committee or the any other concerned stakeholder. 4.4 Patient/family and staff opinions, perceptions of risk and suggestions for improving safety will be obtained and aggregated to identify opportunities for improvement. 5.0 The implementation of new processes or the redesign of current processes will incorporate patient safety principles and an emphasis on the following hospital and patient care functions. 5.1 Patient Rights 5.2 Patient Assessment 5.3 Care of the Patient 5.4 Patient Family Education 5.5 Continuum of Care 5.6 Leadership 5.7 Management of the Environment of Care 5.8 Improving Organizational Performance 5.9 Management of Infection Control 5.10 Management of Human Resources 6.0 COMMUNICATION 7.0 REVIEW 6.1 Communication regarding medical/healthcare errors. See Administrative Policy RI-20: Guidelines For Disclosure Of Unanticipated Outcomes. 6.2 See Administrative Policy PI-01: Sentinel Events. This Patient Safety Plan will be reviewed annually by the Patient Safety Committee. 5
PAGE #: 6 of 6 Effective 05/02 Approved SHS Board of Directors: 05/22/02 Revised 08/03 Approved SHS Board of Directors: 08/27/03 Revised 10/05 Approved SHS Board of Directors: 02/22/06 Revised 10/10 Approved SHS Board of Directors: 01/26/11 Submitted Kim Billingslea, Director Patient Safety and Advocacy/Patient Safety Officer 6