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This program will cover The Joint Commission Sentinel Event (SE) policy and Patient Safety Systems chapter, which are designed to be used together to help hospitals ensure compliance and improve patient safety. The program will discuss Sentinel Event policy amendment made in January 2016.
Our expert will also discuss CMS Root Cause Analysis (RCA) tracer, which lists many questions that a surveyor will ask a hospital during a validation or certification survey. Knowing TJC standards on creating a thorough and credible root cause analysis (systematic analysis) will help hospitals address a surveyor’s questions.
CMS QAPI Worksheet on Patient Safety, Adverse Events & Medication Errors
|- Policies & procedures on non-punitive environment||- What constitutes a medical error?|
|- Staff role in promoting patient safety||- Section on patient safety, AE, & medical errors|
|- RCA performed on all preventable AEs||- CMS-finalized worksheets|
TJC Sentinel Event Policy & Procedure
|- Sentinel Event Alerts||- Goals of SE policy|
|- Patient safety event, close calls, etc.||- Systematic analysis approach|
|- Reporting a SE and 4 options||- Action plan & follow up|
TJC Patient Safety Systems
|- Key patient safety requirements||- Proactive approach to preventing harm|
|- LD.04.04.05 Hospital Safety Program requirements||- Becoming a learning institution|
|- Process to improve quality and patient safety||- Role of hospital leaders in patient safety|
|- Data use and reporting systems||- Fair & just culture|
Anyone involved with or interested in compliance regulations and standards, including but not limited to: CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Quality Improvement Staff, Physicians, Nurses (all levels), OR Nurse Directors, ICU Nurse Directors, CCU Nurse Directors, Board Members, Clinic Managers, Outpatient Directors, Lab Directors, Compliance Officers, CMS Liaisons, TJC Liaisons, Registration Staff, Safety Officers and Staff, Pharmacy Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Legal Counsel, Behavioral Health Staff, Psychiatry Staff, Social Workers, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.