We have at BCMCH, a risk management plan, which is reviewed and revised annually.

We consistently communicate and model the BCMCH’s values, mission and vision, especially as they relate to patient safety.

We conduct Patient Safety rounds on a regular basis and provide feedback to staff about the concerns presented during the rounds.

We uphold the idea of a fair and just culture and seek to propagate this concept throughout BCMCH.

We have a process in place to hold individuals accountable for their actions and performance, and to evaluate compliance with designated responsibilities, scope of practice and organizational values.

We perform daily safety briefings or huddles, if any, in the MS office meetings

We embrace patient- and family-centered care practices, and commit adequate resources and effort to implement these practices.

We have a formal process to identify and respond to serious adverse events and medical errors.

We are honest and transparent with patients and families when serious adverse events and medical errors occur.

We have an established process for disclosing errors to patients and family members, and we specify who should participate in these discussions.

We monitor patient satisfaction survey results and take prompt action when we become aware of adverse trends and issues.

We provide the governing board with quarterly reports on patient safety and risk management initiatives.

We have a thorough, well-documented process for credentialing, privileging and reappointing members of the medical staff.

We involve the Administrative Committee in overseeing the credentialing process.

We have a process in place for verifying the education, training and credentials of advanced practice nurses and mid-level providers.

We conduct employee surveys to assess attitudes and reveal potential problems regarding patient safety.

We actively encourage communication and collaboration among risk management,quality and patient safety departments.

We have a formalized Audit process, which is governed by hospital and medical staff by laws.

Our Audit process is in accordance with the requirements of relevant statutory and accrediting organizations.

We collect and systemically analyze provider performance data, including morbidity and mortality rates, patient satisfaction results, complaints, Audit recommendations and practice patterns (e.g., length of stay, readmissions, prescribing patterns).

We follow Medical Council for Graduate Medical Education requirements regarding the supervision of residents.

We have a formalized process in place addressing disruptive, abusive and/orimpaired providers

We include police verification and feedback checks from previous employer in our outsourced hiring process.

We have anti-discriminatory hiring, promotion and termination policies in place.

We evaluate core competencies upon hire, at the end of the probationary period and atleast annually thereafter.

We do not tolerate intimidating, disrespectful or disruptive behavior at any level, and respond to incidents swiftly and consistently.

We watch staff for signs of substance abuse or other impairments that could affect job performance.

We promote use of our employee assistance program and sastisfaction survey.

We have a social media policy that complies with privacy/confidentiality requirements and is designed to maintain professional boundaries.

We have a telephone log and formal process for replying to patients who call the labor and delivery unit for medical advice.

We follow a protocol that provides for timely triage of patients who present to the labor and delivery unit.

We have on-call schedules for obstetric and anesthesia providers to ensure that one is always available if needed.

We have a departmental chain of command, and we are accountable to use it.

We utilize structured communication tactics, such as SBAR (Situation, Background, Assessment and Recommendations).

We require that all staff who interpret electronic fetal monitoring (EFM) demonstrate competence on an annual basis.

We require nursing and medical staff to utilize standardized terminology for fetal monitoring tracing interpretation.

We follow relevant guidelines for the identification, storage and retention of EFM tracings.

We follow a protocol regarding elective inductions before 39 weeks gestational age.

We follow a protocol for induction of labor that is consistent with current national/international clinical guidelines.

We follow monitoring guidelines for patients who receive epidural infusions.

We have a process and train staff for emergency deliveries prior to the arrival of a physician.

We follow a protocol for operative vaginal deliveries.

We follow a protocol for vaginal birth after previous Cesarean delivery that is in accordance with current national/international clinical guidelines.

We monitor for compliance with “decision-to-incision” timeliness for emergent Cesarean sections.

We follow a shoulder dystocia protocol that is in accordance with current national/international clinical guidelines.

We have emergency obstetric medications readily available on the unit.

We have written maternal and neonatal resuscitation guidelines and the necessary equipment on hand.

We routinely conduct obstetrical emergency drills and simulations.

We have an infant identification policy.

We have a written infant abduction prevention and response plan (CODE PINK), and we conduct regular drills.

We follow a hyperbilirubinemia protocol that addresses assessment, laboratory testing and reporting of results.

We assess the skills and competency of all perinatal staff and providers at least annually.

We have a process in place for situations where a provider may be acting outside of his/her scope of practice.

We utilize perinatal quality metrics that are consistent with industry standards.

We monitor for compliance with established perinatal protocols, guidelines, and policies and procedures.

We have multidisciplinary perinatal patient safety meetings to evaluate trends and opportunities for improvement.

We perform root cause analyses (RCA) on sentinel and/or serious reportable events.

We follow a screening checklist for all procedures performed in ambulatory surgical centers.

We participate in training and exercises to improve teamwork and communication within the perioperative and ambulatory surgical care settings.

We institute and enforce a policy regarding the presence of healthcare industry representatives and/or observers.

We utilize a pre-operative checklist covering such areas as patient identification, informed consent, current history and physical, site/side marking, review of diagnostic test results and administration of pre-operative medications.

We require that anesthesia providers complete a pre-operative equipment safety checklist.

We follow a protocol for managing unexpectedly difficult intubations and/or airway emergencies.

We require staff to document critical information – such as pre- and post-surgery skin assessments; skin preparation; patient positioning; and use of any padding, supports or restraints – in a specific section of the perioperative record.

We implement the Universal Protocol, which includes a pre-operative verification process, operative site marking and a final time-out.

We implement the same assessments, treatment and monitoring protocols wherever anesthesia is administered, including locations other than the operating room.

We follow industry standards for labeling medicines in syringes, cups and basins.

We have emergency medications readily available and properly secured on the unit.

We have a departmental chain of command, and we are accountable to use it.

We comply with industry guidelines for the prevention and detection of unintended retained foreign objects.

We have a surgical fire prevention and response program in place, which includes staff training and the performance of drills on a regular basis.

We have a protocol addressing clinical alarm management in the perioperative setting, which ensures that alarms remain on, are audible at all times, and undergo preventive and routine maintenance.

We follow protocols for the assessment and management of patients with sleep apnea.

We have a malignant hyperthermia rapid response protocol.

We require all providers to comply with an established process for obtaining approval of new technology or revised procedures.

We train staff and verify their ability to safely use all relevant equipment and technology.

We have specific equipment sterilization guidelines, and regularly monitor staff compliance.

We follow an established process for credentialing physicians who perform laparoscopic or robotic procedures.

We comply with manufacturer guidelines regarding the use of equipment with bariatric patients.

We utilize established perioperative quality metrics, and confirm that they are consistent with industry standards.

We monitor for compliance with established perioperative protocols, guidelines, and policies and procedures.

We have multidisciplinary perioperative patient safety meetings to evaluate trends and opportunities for improvement.

We perform RCA on sentinel and/or serious reportable events.

We maintain a secure environment of care and utilize products that are safe for behavioral health patients.

We respect and safeguard patient rights.

We follow a formalized process for conducting searches of patients, belongings and rooms.

We conduct a comprehensive suicide risk assessment on every patient upon admission and comply with protocols regarding reassessment, intervention and monitoring.

We have policies and procedures for the safe use of seclusion, restraints and one-to-one observation.

We have a policy concerning assessment and management of patients who have comorbidities or are medically unstable.

We have a fall prevention program reflecting the specific risk factors and needs of the patient population (e.g., geriatric behavioral health).

We conduct elopement drills and debrief as a team.

We train staff in crisis intervention and de-escalation, using established programs and techniques.

We comply with applicable statutes and regulations for the investigation and reporting of violence, abuse, harassment and assault.

We monitor for compliance with established behavioral health protocols, guidelines, and policies and procedures.