In the ever-evolving landscape of healthcare, the importance of robust policies and procedures cannot be overstated. These frameworks are essential in ensuring that healthcare delivery is safe, efficient, and patient-centered. While foundational healthcare policies and procedures have long been established to address regulatory compliance and operational efficiency, advancements in the field have emphasized the critical role of patient safety evaluation systems (PSES) and patient safety policies. This shift is driven by the need to create a culture of safety that fosters continuous improvement and transparent communication among healthcare professionals.
In this article, we delve into the intricacies of clinical policies and procedures, highlighting the integration of patient safety evaluation systems and their impact on enhancing the quality of care. By understanding these elements, healthcare organizations can better navigate the complexities of delivering top-notch care in an increasingly demanding environment.
The CDC defines policy as a “law, regulation, procedure, administrative action, incentive, or voluntary practice.” Policies often come from governing or oversight bodies but may also be implemented by individual healthcare organizations. For example, healthcare policies may address patient care, legal and safety regulations, or security and privacy matters.
In contrast, a healthcare procedure (not to be confused with a medical procedure) describes the steps undertaken to adhere to a policy. Think of procedures as the roadmap for showing how a policy should be implemented internally, describing the goals, actions, resources, and boundaries of the service. Both policies and procedures are data-backed and crafted by hospital administration and operations teams, with patient safety and quality of care as the top priorities.
Most crucially, neither healthcare policies nor procedures are static. Policies are often living documents, and procedures can and should be adjusted periodically to ensure adherence and compliance. These must be routinely reviewed and updated to evolve with clinical evidence, technology advancements, and more.
For example, The Joint Commission releases new National Patient Safety Goals each year based on qualitative and quantitative data from experts in the field. Organizations seeking accreditation frequently adjust their policies and procedures to adhere to current best practices as defined by these reputable organizations.
In addition to providing a structured framework and guidance on best practices, policies and procedures are essential to ensuring consistent standards of care and mitigating potential risks and adverse events.
The benefits of enacting strong, evidence-based policies and procedures in the hospital setting include:
Many policies and procedures in healthcare are essentially endemic in healthcare settings. For example, facilities have procedures in place to protect PHI according to HIPAA regulations. Likewise, hand hygiene policies and infection control procedures are put in place to protect both patients and staff from pathogens and infection.
Other examples of effective clinical policies and procedures include:
The United States Congress showed its commitment to a culture of safety within our nation’s healthcare system in 2005 when it passed the Patient Safety and Quality Improvement Act. The Act, as it is commonly called, acknowledges that system failures are often best addressed when experiences, good and bad, are shared within an industry. The Act encourages open, honest discussion in a protected environment and promotes the development of a safer health system.
The protected environments referred to in The Act are Patient Safety Organizations or PSOs. As a byproduct of their daily work, healthcare organizations create a considerable amount of sensitive quality, safety, and risk-related information. Therefore, an organization’s participation in a PSO plays an important role in being able to use this information and conduct improvement activities in a protected space.
Part of the government’s rationale for establishing federal protections stemmed from the limited and inconsistent protections across states, which only fueled fear of legal liability and sanctions among physicians and healthcare organizations. So, unlike some state-specific protections that may only apply to certain circumstances or particular types of data, the PSO federal privilege and confidentiality protections apply to anything meeting the definition of Patient Safety Work Product or PSWP, including event details and associated deliberations.
Patient Safety Work Product (PSWP) includes any data, reports, records, memoranda, analyses (such as root cause analyses) and written or oral statements (or copies of any of this material), which could improve patient safety, healthcare quality or healthcare outcomes, that are assembled or developed by a provider for reporting to a PSO and are reported to a PSO. PSWP also includes information developed by a PSO for the conduct of patient safety activities.
It’s just as important to define what PSWP is not. PSWP is NOT:
A Patient Safety Evaluation System or PSES is the process that manages the collection, management, and analysis of information for reporting to a Patient Safety Organization (PSO). It’s characterized as the secure physical and/or electronic space for the conduct of patient safety activities. A PSES provides a protected environment for the candid consideration of quality and safety information. A facility’s PSES Policy is an important part of ensuring the full protection of PSWP under the law. While not required, it is considered best practice to document the mechanisms, staff, equipment, activities, and communication avenues your organization formally uses to manage PSWP.
In general, PSES policies should address the following:
The PSES could include information from event reporting systems, root cause analyses, safety huddles, committee meetings/minutes, reports/dashboards/scorecards, and more. Given the importance of a PSES Policy in optimizing federal protections of privilege and confidentiality, patient safety organizations often assist members in designing and documenting the scope and function of their system.
To download a free copy of ADNPSO’s Patient Safety Evaluation System Checklist, click here.
Source: AHRQ – Working with a PSO: One Approach
Becoming a PSO was a natural extension of ADN’s work, and we were federally listed by the Agency for Healthcare Research & Quality (AHRQ) in 2009. Shortly after, ADN launched its QAC event reporting application as a means for collecting and analyzing event data to help its members identify underlying causes, pinpoint and redesign faulty processes, and ultimately minimize the risk and recurrence of safety errors.
As detailed below, the benefits of PSO membership include federal protections and confidentiality, support with Patient Safety Evaluation Systems (PSES), analyses and deep dives, access to experts and initiatives, and much more.
Federal Protections & Confidentiality: Healthcare providers who report adverse events to a PSO are federally protected from legal discovery and can use the information to improve patient safety without fear of it being used against them in legal proceedings. This safe harbor encourages more reporting of adverse events, which can lead to a better understanding of the root causes of these events and help identify opportunities for improvement.
PSES Policy Support: ADNPSO provides its members with a comprehensive PSES Policy Template. Facilities are encouraged to consider the template in conjunction with other existing internal policies and then further tailor the template to their unique processes and workflows.
Analyses & Deep Dives: By collecting and analyzing data on adverse events, PSOs can identify patterns and trends that can help healthcare providers identify areas for improvement and implement strategies to reduce the incidence of adverse events. For example, in a deep-dive analysis by ADNPSO of all participant data, the event type “Other” revealed a death rate 3 times higher than ALL remaining patient safety event categories combined.
Access to Experts & Initiatives: ADNPSO conducts patient safety activities with transmitted PSWP from our members to develop and disseminate best practices for improving quality and reducing adverse patient outcomes. Our most recent initiative focused on enhancing the safety culture within ambulatory care settings. This 18-month initiative not only benefited ADN’s clinic facilities but our acute care facilities as well. ADNPSO took the lessons learned from our work and developed resources applicable to the acute care setting. These resources were combined into a toolkit for PSO members.
Network of Patient Safety Databases (NPSD): The NPSD is a data source implemented by AHRQ that contains non-identifiable data derived from PSWP submitted to PSOs across the country. ADNPSO regularly contributes to the NPSD to support the learning of mitigating patient risk across healthcare settings, nationally. PSOs have the potential to promote rapid learning and widespread sharing of best practices, thereby increasing the pace of improvement for patient safety.
Leveraging the Network: ADNPSO encourages members to proactively communicate with us about what they are focusing on, struggling with, or successfully improving. ADNPSO is always happy to share insights, as well as poll members or our AHRQ network. This dialogue can lead to productive email exchanges, virtual safe tables, or even larger PSO analyses or initiatives.
High-reliability organizations tend to follow best practices for implementing policies and procedures.
First, ensure all relevant stakeholders are involved, especially your frontline care staff. They typically have the strongest understanding of what works and what does not and where improvements can be made. Their insights are critical when crafting or reforming policies and procedures.
Next, ensure policies and procedures are up-to-date and based on the latest evidence. Your policies and procedures should be specific to your facility and patient population. Ideally, they will be based on data you gather, such as patient safety data, near-miss data, and SOPS data.
Communication is also essential. Education and training for staff at all levels should be comprehensive and ongoing. Ideally, communication will be two-way between administration and care staff and should be non-punitive. Improvement depends on honest feedback from those in patient-facing roles.
With transparency and a data-driven mindset, acute care facilities can implement effective policies and procedures that elevate quality care.
Join a Patient Safety Organization
The integration of comprehensive healthcare policies and procedures with patient safety evaluation systems marks a significant advancement in the pursuit of quality care. These frameworks not only ensure compliance with regulatory standards but also foster an environment of continuous improvement and patient safety. By adopting evidence-based practices and encouraging open communication through Patient Safety Organizations (PSOs), healthcare providers can significantly reduce medical errors and enhance patient outcomes. The proactive engagement of frontline staff, combined with robust data analysis and support from PSOs, creates a resilient healthcare system capable of adapting to new challenges. As healthcare continues to evolve, the commitment to maintaining and refining these policies and procedures will remain crucial in achieving excellence in patient care.
4 Tips to Reach Your National Patient Safety Goals