November 6, 2007 | Mark Paradies

The Joint Commission Revises Leadership Standard – Includes Elements Related to Investigations and Root Cause Analysis

One of the elements of the revised standard that I thought would interest readers of this blog is  LD.4.260. It states that:

The organization implements an integrated resident safety program throughout the organization.

LD.4.260 includes 13 specific elements:

1. There is an organization-wide, integrated resident safety program.

2. One or more qualified individuals or an interdisciplinary group manages the organization-wide safety program.

3. The scope of the program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events, which have serious adverse outcomes.

4. All departments, programs, and services within the organization participate in the safety program.

5. The organization creates procedures for responding to system or process failures, such as continuing  to provide care, treatment, and services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.

6. The organization: Defines responses to various types of potential adverse events. 

7. The organization: Conducts proactive risk assessments.

8. The organization: Makes support systems6 available for staff members who have been involved in a sentinel event.

9. The organization: Analyzes and uses information about a system or process failure to improve safety.

10. The organization: Provides systems for the internal and external reporting of a system or process failure.

11. The organization: Provides governance at least once a year, with written reports on all system or process failures, on the number and type of sentinel events, on whether the residents and the families were informed of the adverse events, and on all actions taken to improve safety, both proactively and in response to actual occurrences.

12.  The organization: Disseminates lessons learned from root cause analyses to staff who provide services or are affected by the situation.

13. The organization: Encourages external reporting of significant adverse events, including voluntary reporting programs in addition to mandatory programs.
To review the revised program see:

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