Patient Safety Friendly Hospital Intiative Purpose Implementation of a set of patient safety...

Patient Safety Patient Safety Friendly Hospital Friendly Hospital

IntiativeIntiative

PurposePurpose Implementation of a set of patient Implementation of a set of patient

safety standards in hospitalssafety standards in hospitals

Providing a framework for hospitals to Providing a framework for hospitals to enable them to deliver safer patient enable them to deliver safer patient care by assessing hospitals from a care by assessing hospitals from a patient safety perspective, building patient safety perspective, building capacity of staff regarding patient capacity of staff regarding patient safety and involving consumers in safety and involving consumers in improving health and safetyimproving health and safety

StandardsStandards

5 Domains5 Domains 24 subdomains24 subdomains

A set of standardA set of standard Critical standards (20 in Total)Critical standards (20 in Total) Core (90 in total)Core (90 in total) Development standards (30 in total)Development standards (30 in total)

Domains Subdomains

Critical

Core Developmental

Leadership and Management

6 9 20 7

Patient and Public Involvement

7 2 16 10

Safe Evidence based Clinical Practices

6 7 29 8

Safe Environment 2 2 19 0

Lifelong Learning 3 0 6 5

24 20 90 30

StandardsStandards Critical: Critical: compulsory for enrolment for compulsory for enrolment for

PSFHIPSFHI

Core: Core: a minimum set of standards as a a minimum set of standards as a safe place for patients (not compulsory safe place for patients (not compulsory to meet 100% for enrolment as PSFHI)to meet 100% for enrolment as PSFHI) % shows the level of hospital attains% shows the level of hospital attains

Developmental: Developmental: requirements for requirements for enhancement of patient safetyenhancement of patient safety

Format of patient safety Format of patient safety standardsstandards

Title: Title: the area it coversthe area it covers

Measurement statement: Measurement statement: details of details of the standardthe standard

Rationale: Rationale: explaining why the explaining why the specific standard was selectedspecific standard was selected

Standard: Standard: requirements to comply requirements to comply with the WHO patient safety standards with the WHO patient safety standards

Level of compliance with patient Level of compliance with patient safety standardssafety standards

Hospital level

Critical Core Developmental

Level 1 100% Any Any

Level 2 100% 60-89% Any

Level 3 100% % =or > 90 Any

Level 4 100% % =or > 90 % =or > 80

Domain ADomain A

Leadership and ManagementLeadership and Management

A. Leadership and Management A. Leadership and Management StandardsStandards

A.1. A.1. Leadership and Governance Commitment Leadership and Governance Commitment to patient safetyto patient safety

A.2. A.2. Hospitals’ Patient Safety ProgramHospitals’ Patient Safety Program

A.3. A.3. Use of data for Safety Performance Use of data for Safety Performance ImprovementImprovement

A.4. A.4. The hospital has essential functioning The hospital has essential functioning equipment and supplies to deliver its equipment and supplies to deliver its servicesservices

A.5. A.5. Safer Staff for safer patients around the Safer Staff for safer patients around the clock to deliver safe careclock to deliver safe care

A.6. A.6. Policies, guidelines and standard Policies, guidelines and standard operation procedure (SOP) for all operation procedure (SOP) for all departments and supporting servicesdepartments and supporting services

A.A. Critical Core DevelopmentalCritical Core Developmental

Criteria Criteria CriteriaCriteria Criteria Criteria

A.1. 3 3 2A.1. 3 3 2

A.2. 2 5 2A.2. 2 5 2

A.3. 0 2 2A.3. 0 2 2

A.4. 3 3 1A.4. 3 3 1

A.5. 1 5 0A.5. 1 5 0

A.6. 0 2 0A.6. 0 2 0

99 2020 77

A.1. Leadership and A.1. Leadership and GovernanceGovernance

Measurement Statement: The Measurement Statement: The Leadership and Governance are Leadership and Governance are

committed to patient safety.committed to patient safety.

A.1. Rationale:A.1. Rationale:

The hospital’s governance is The hospital’s governance is accountable for assuring the safety accountable for assuring the safety of its patients. The necessary of its patients. The necessary processes are in place and a non-processes are in place and a non-blaming learning culture is blaming learning culture is established and maintained.established and maintained.

A.1. Critical CriteriaA.1. Critical Criteria

A.1.1.1. The hospital has Patient Safety as a A.1.1.1. The hospital has Patient Safety as a strategic priority. This patient safety strategy is strategic priority. This patient safety strategy is being implemented through a detailed action being implemented through a detailed action plan.plan.

A.1.1.2. Hospital has designated a senior staff A.1.1.2. Hospital has designated a senior staff member with responsibility, accountability and member with responsibility, accountability and authority for patient safety.authority for patient safety.

A.1.1.3. The leadership conducts regular Patient A.1.1.3. The leadership conducts regular Patient Safety Executive Walk to promote patient safety Safety Executive Walk to promote patient safety culture, learn about risks in the system, and act culture, learn about risks in the system, and act on patient safety improvement opportunities. on patient safety improvement opportunities.

A.1. Core CriteriaA.1. Core Criteria

A.1.2.1. The hospital has an annual budget for A.1.2.1. The hospital has an annual budget for patient safety activities based on a detailed patient safety activities based on a detailed action plan.action plan.

A.1.2.2. The leadership supports staff involved A.1.2.2. The leadership supports staff involved in patient safety incidents as long as there is in patient safety incidents as long as there is no intentional harm or negligence.no intentional harm or negligence.

A.1.2.3. The hospital follows a code of ethics, A.1.2.3. The hospital follows a code of ethics, for example in relationship to research, for example in relationship to research, resuscitation, consent, confidentiality, resuscitation, consent, confidentiality, relations to industry. relations to industry.

A.1. Developmental A.1. Developmental CriteriaCriteria

A.1.3.1. There is an open, non A.1.3.1. There is an open, non punitive, none blaming, learning and punitive, none blaming, learning and continuous improvement patient continuous improvement patient safety culture at all levels of the safety culture at all levels of the hospital.hospital.

A.1.3.2. The leadership assesses staff A.1.3.2. The leadership assesses staff attitudes towards patient safety attitudes towards patient safety culture regularly.culture regularly.

A.2. Patient Safety A.2. Patient Safety ProgramProgram

Measurement Statement: The Measurement Statement: The hospital has a Patient Safety hospital has a Patient Safety

Program.Program.

A.2. RationaleA.2. Rationale

The hospital has systems to identify The hospital has systems to identify and manage safety issues that can and manage safety issues that can cause harm to patients. cause harm to patients.


A.2.1.1. A designated person should A.2.1.1. A designated person should co-ordinate patient safety and risk co-ordinate patient safety and risk management activities. (middle management activities. (middle management)management)

A.2.1.2. The hospital conducts regular A.2.1.2. The hospital conducts regular monthly morbidity and mortality monthly morbidity and mortality meetings.meetings.

A.2. Core CriteriaA.2. Core CriteriaA.2.2.1. Patient Safety is reflected in A.2.2.1. Patient Safety is reflected in

hospital’s organizational structure.hospital’s organizational structure.A.2.2.2. Risk is managed reactively.A.2.2.2. Risk is managed reactively.A.2.2.3. The hospital audits its safety A.2.2.3. The hospital audits its safety

practices on a regular basis.practices on a regular basis.A.2.2.4. The hospital has multidisciplinary A.2.2.4. The hospital has multidisciplinary

Patient Safety Internal Body Patient Safety Internal Body (PSIB)which meet regularly to ensure an (PSIB)which meet regularly to ensure an overarching patient safety program. overarching patient safety program.

A.2.2.5. The hospital regularly develops A.2.2.5. The hospital regularly develops reports on different patient safety reports on different patient safety activities and disseminates it internally.activities and disseminates it internally.


A.2.3.1. The hospital regularly A.2.3.1. The hospital regularly develops reports on different patient develops reports on different patient safety activities and disseminates it safety activities and disseminates it externally.externally.

A.2.3.2. Risk is managed proactively.A.2.3.2. Risk is managed proactively.

A.3. Data to improve Safety A.3. Data to improve Safety PerformancePerformance

Measurement Statement: The Measurement Statement: The hospital uses data to improve hospital uses data to improve

safety performance.safety performance.


The hospital insures valid and reliable The hospital insures valid and reliable data to compare its safety data to compare its safety performance to internal and external performance to internal and external benchmarks.benchmarks.


A.3.2.1. The hospital sets and reviews A.3.2.1. The hospital sets and reviews targets related to patient safety targets related to patient safety goals.goals.

A.3.2.2. The hospital has a set of A.3.2.2. The hospital has a set of process and output measures that process and output measures that assess performance with a special assess performance with a special focus on patient safety.focus on patient safety.


A.3.3.1. Hospitals should seek to A.3.3.1. Hospitals should seek to compare their process and outcome compare their process and outcome indicator data with other PSFHs.indicator data with other PSFHs.

A.3.3.2. The hospital acts on A.3.3.2. The hospital acts on benchmarking results through action benchmarking results through action plan and patient safety improvement plan and patient safety improvement projects. projects.

A.4. Equipment and A.4. Equipment and SuppliesSupplies

Measurement Statement: The Measurement Statement: The hospital has essential hospital has essential

functioning equipment and functioning equipment and supplies to deliver its services.supplies to deliver its services.


The hospital ensures continuous The hospital ensures continuous availability of essential functioning availability of essential functioning equipment and supplies to ensure equipment and supplies to ensure the delivery of safe, quality service.the delivery of safe, quality service.


A.4.1.1. The hospital ensures A.4.1.1. The hospital ensures availability of essential equipment.availability of essential equipment.

A.4.1.2. The hospital ensures that all A.4.1.2. The hospital ensures that all reusable medical devices are reusable medical devices are properly decontaminated prior to properly decontaminated prior to use.use.

A.4.1.3. The hospital has sufficient A.4.1.3. The hospital has sufficient supplies to ensure prompt supplies to ensure prompt decontamination and sterilization. decontamination and sterilization.


A.4.2.1. The hospital undertakes A.4.2.1. The hospital undertakes regular preventative maintenance regular preventative maintenance for equipment including calibration.for equipment including calibration.

A.4.2.2. The hospital undertakes A.4.2.2. The hospital undertakes regular repair or replacement of regular repair or replacement of broken (malfunctioning) equipment.broken (malfunctioning) equipment.

A.4.2.3. The hospital ensures staff A.4.2.3. The hospital ensures staff receive appropriate training for receive appropriate training for available equipment.available equipment.


A.4.3.1. The hospital makes A.4.3.1. The hospital makes appropriate and safe use of smart appropriate and safe use of smart pumps for fluid and drug delivery.pumps for fluid and drug delivery.

A.5. Technically competent staff for A.5. Technically competent staff for safer patientssafer patients

Measurement Statement: The Measurement Statement: The hospital has technically hospital has technically

competent staff for safer patients competent staff for safer patients round the clock to deliver safe round the clock to deliver safe

care.care.


A.5.1.1. Qualified clinical staff, both A.5.1.1. Qualified clinical staff, both permanent and temporary, are permanent and temporary, are registered to practice with an registered to practice with an appropriate body.appropriate body.

A.5. Core CriteriaA.5. Core CriteriaA.5.2.1. Clinical staffing levels should A.5.2.1. Clinical staffing levels should

reflect patient needs at all times.reflect patient needs at all times.A.5.2.2. Sufficient, trained and appropriate A.5.2.2. Sufficient, trained and appropriate

non-clinical support staff should be non-clinical support staff should be available to meet patient needs.available to meet patient needs.

A.5.2.3. Staff should be allowed sufficient A.5.2.3. Staff should be allowed sufficient rest breaks to practice safely and adhere rest breaks to practice safely and adhere to national labor laws.to national labor laws.

A.5.2.4. Students and trainees should work A.5.2.4. Students and trainees should work within their competencies and under within their competencies and under appropriate supervision.appropriate supervision.

A.5.2.5. An occupational health program is A.5.2.5. An occupational health program is implemented for all staff.implemented for all staff.

A.6. Policies, Guidelines, A.6. Policies, Guidelines, Standard Operating Procedure Standard Operating Procedure

(SOP)(SOP)

Measurement Statement: Hospital Measurement Statement: Hospital has policies, guidelines, and has policies, guidelines, and

standard operating procedure standard operating procedure (SOP) for all departments and (SOP) for all departments and

supporting services.supporting services.


The hospital has policies and standard The hospital has policies and standard operating procedures to ensure operating procedures to ensure delivery of standardized safe care.delivery of standardized safe care.


A.6.2.1. The hospital has policies and A.6.2.1. The hospital has policies and procedures for all departments and procedures for all departments and services.services.

A.6.2.2. The hospital provides A.6.2.2. The hospital provides evidence of implementation of evidence of implementation of policies, guidelines and SOPs.policies, guidelines and SOPs.

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