The Joint Commission 2015 Patient Safety Systems Chapter Survey
Have you made any changes to your patient safety program as a result of the new Patient Safety Systems Chapter in the 2015 Joint Commission Hospital Accreditation Standards?
If yes, have you
Can your hospital show that your program has a measurable positive impact on patient safety over the last three years?
If no, what are you planning to do to comply with the PS chapter standards?
Your answer
How often does your hospital leadership and managers use continuous improvement projects to effectively address patient safety issues?
If so, are they continuously tracked and documented?
Does your hospital use data in its decision making process?
If so, what are the data sources?
Your answer
Have these data sources been validated?
How often does your hospital maintain and update significant measures of performance?
If so, are there individuals specifically assigned and accountable to maintain and update data?
How often does your hospital respond to drops in performance?
Do you have regular measure reviews?
Do these reviews result in formal projects?
Is your hospital presenting data in standardized easy to read and actionable format?
If Yes, is data presented in control charts?
Do you train your personnel to read and interpret control charts?
How often is your hospital’s performance information shared appropriately?
Is it communicated in a manner that promotes and supports change?
Is process improvement part of your learning organizations?
Does your hospital prioritize and address patient safety opportunities and concerns?
How is data used to prioritize patient safety opportunities and concerns?
Your answer
Is your hospital’s entire staff involved in continuous improvement efforts?
Are all staff accountable for implementing and sustaining improvements?
Are staff given opportunities to work as team members in Process Improvement projects?
How does leadership support continuous improvement efforts?
Does leadership provide resources in terms of time and materials needed to participate in and complete projects and initiatives?
What process improvement method do you use most frequently?
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