April 2002

JCAHO Compliments Market-based Organizations on Patient Safety Plans


Patients who are knowledgeable about their medications are a strong link to preventing medication errors.

While concern for patient safety is a hallmark of Catholic Health Initiatives and the entire Catholic health care ministry, regulations from the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) now require health providers to formalize their patient safety processes. "Every Catholic Health Initiatives market-based organization has the elements of a safety program," said Joanie Cox, director of performance improvement for Catholic Health Initiatives. "Many things they already do, such as the use of preprinted orders and protocols, contribute to patient safety. JCAHO simply wants these elements formalized into comprehensive patient safety plans with oversight bodies and leadership accountability."

Two market-based organizations have already been noted by JCAHO surveyors for their patient safety plans: St. Elizabeth Regional Medical Center, Lincoln, Neb., and St. Vincent Health System, Little Rock, Ark.

"We started our patient safety initiative a few months before our JCAHO survey in July 2001," said Carolyn Yarbrough, senior project analyst and patient safety officer for St. Vincent. "We already had a lot of leadership support, which is key."

St. Vincent formed a patient safety oversight committee that includes representatives from administration, quality management, medical affairs, risk management, pharmacy, epidemiology, laboratory and radiology, nursing and facilities management. Glenn Davis, MD, the chief of the St. Vincent medical staff and a patient safety enthusiast, is also on the committee.

St. Vincent’s committee defined what it will measure and monitor to assess the system’s safety performance. "We drew up a list of 15 measures, then decided which were most crucial," said Marilyn Jones, director of quality and resource management and corporate responsibility officer for St. Vincent. The system now monitors six measures of patient safety, including surgical site infections and adverse drug reactions, and reports them to the St. Vincent Board of Directors every two months.

St. Elizabeth’s patient safety plan, instituted in June 2001, added structure and accountability to the medical center’s patient safety fforts. "Everyone here has a role in assuring patient safety, but we structured our Performance Improvement Council to take the lead responsibility for our patient safety initiatives and results," said Lori Burkett, director of performance improvement for St. Elizabeth.

St. Elizabeth’s plan involves patients and their families in safety efforts. "We believe in talking about safety issues among ourselves and with our patients," said Burkett. "For example, patients who are knowledgeable about their medications are a strong link to preventing medication errors. They need to understand the medications they receive and feel comfortable speaking up if they are unfamiliar with a new or different medication."

St. Elizabeth is now conducting a survey of patients to monitor safety processes and capture suggestions for safety improvements. "We want patients to know that we are committed to identifying potential risks, which will help to eliminate root causes," said Burkett. A survey that will reveal patient perceptions of safety issues is also in development at St. Vincent. "A safety program is always a work in progress," said Yarbrough. "It’s really a tool to improve patient care, which is a continuous process."

For more information, contact Carolyn Yarbrough at cyarbrough@stvincenthealth.com, or Lori Burkett at lburkett@stez.org.