2015 regulatory training - techknowledge - techknowledge• slips, trips and falls • u.s....

• 18 Customizable Modules

• 44 Topics Discussed

• User-friendly Format That Tracks Progress Online

• Content Is Updated Annually

• Helps meet The Joint Commission International’s 2015 Requirements

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2015 Regulatory Training

Safety Storm 2015 was created by Health.edu, a division of Texas Tech University Health Sciences Center. Health.edu is a producer of current, essential educational courses for health care professionals.

The 3-part program includes a variety of topics, which cover many of the fundamental components of key Safety concerns common in healthcare organizations. Safety Storm is designed to assist employers in their efforts to help train staff on meeting The Joint Commision International’s 2015 requirements included in occupational and patient safety standards. The need for additional training on topics included in Safety Storm as well as other safety concerns should be identified by each organization.

The Swank HealthCare Learning Management System makes it easy to customize Safety Storm for your organization. Simply select the modules most suitable to the facility’s needs and customize the content to include facility- specific instructions and/or content.

On the following pages, the standards related to the Safety Storm modules are listed for reference. The cited regulations do not suggest that the modules are fully sufficient to meet the standards but are offered as a resource to determine the degree to which training staff on the content of each module assists in complying with related standards.

Contact your Swank HealthCare Representative for more information on Safety Storm today!

2015 Safety Storm will premiere January 1, 2015.

COURSES AND MODULES

ALPHAFOR GENERAL STAFF

Personal Workplace Safety

• Back Safety• Slips, Trips and Falls

Environmental Workplace Safety• Fire Safety• Electrical Safety/LOTO• Emergency Management

Workplace Hazards• Hazardous Materials/SDS• Bloodborne Pathogens• Latex Allergies

Organizational Workplace Safety• Workplace Violence• Sexual Harassment• Recognizing the Impaired

Healthcare Worker

Information Technology• Protected Health Information (PHI) • Computer Security

BETAFOR GENERAL STAFF

Patient Rights• Patient Bill of Rights• Informed Consent• Advance Directives

Maintaining Patient Privacy• Patient Information Privacy:

HIPAA and HITECH

Patient Safety: Adverse Medical Events• Causes of Adverse Medical Events

and Medical Errors• Reducing Adverse Medical Events

and Medical Errors• Handoff Communication

Infection Control: Standard Precautions• Hand Hygiene, PPE, Care of the

Environment, Patient Placement and Care

• Elements of Respiratory Hygiene, Cough Etiquette and Safe Injection Practices

• Transmission-based Precautions

Influenza/Tuberculosis• Influenza• Tuberculosis

GAMMAFOR CLINICAL STAFF

Ethical Aspects of Care

• Ethics• Religion/Spirituality• End of Life - Compassionate Care

Identifying and Reporting Abuse• Mandatory Reportable Incidents• Recognizing Abuse

Assessment/Management of Pain• Pain Assessment Techniques• Pain Management Responsibilities

Patient Safety (Clinical)• Kinds and Causes of Adverse Medical Events

and Medical Errors• Wrong Site, Wrong Procedure, Wrong Person

Surgery Errors• Strategies for Reducing and Reporting Adverse

Medical Events and Medical Errors

Restraint, Seclusion and Sedation• Restraint and Seclusion• Sedation

Recognizing and Responding to a Patient’s Worsening Condition

• Rapid Response Teams

Preventing Healthcare-Associated Infections Due to Multidrug-Resistant Organisms (MDROs)

• Magnitude of the Problem of MDROs• Prevention and Control of MDROs

Preventing Patient Infections: CAUTI, CLABSIs, SSIs

• CAUTI• Magnitude of Problem of CLABSIs• Placement and Care of CVCs• SSI

Safety Storm 2015



Safety Storm AlphaMODULE TOPICS REGULATIONS ADDRESSED*

1 Personal Workplace Safety

• Back Safety • U.S. Occupational Safety & Health Act 29 USC §654, 5(a)1 - Each employer shall furnish to each of [their] employees employment/place of employment which are free from recognized hazards that are causing or are likely to cause death or serious harm; Occupational Safety and Health Act, Sec. 5, (a)(1)&(a)(2).

• Slips, Trips and Falls • U.S. Occupational Safety & Health Act 29 USC §654, 5(a)1 - Each employer shall furnish to each of [their] employees employment/place of employment which are free from recognized hazards that are causing or are likely to cause death or serious harm; Occupational Safety and Health Act, OSHA 29 CFR §1910 Subpart D A66; PC 01.02.08 - The hospital assesses the patient’s risk for falls based on the patient population and setting. The hospital implements interventions to reduce falls based on the patient’s assessed risk.

2 Environmental Workplace Safety

• Fire Safety • U.S. Occupational Safety & Health Act 29 USC §654, 5(a)1 - Each employer shall furnish to each of [their] employees employment/place of employment which are free from recognized hazards that are causing or are likely to cause death or serious harm; 29 CFR §1910 (e); CFR §482.41(b) Standard: Life Safety from Fire - The hospital must ensure that the life safety from fire requirements are met; LS.02.01.10 - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat; LS.02.02.20 (EP3) - The hospital maintains the integrity of the means of egress; LS.02.01.70 - The hospital provides and maintains operating features that conform to fire and smoke prevention requirements; EC.02.03.01 - The hospital manages fire risks; EC.02.03.03 - The hospital conducts fire drills; EC.02.03.05 - The hospital maintains fire safety equipment and fire safety building features; NFPA 25, (1998); NPFA 72(1999); NFPA 1600(2010); NFPA 101(2000).

• Electrical Safety / LOTO • OSHA 29 CFR §1910.147; Electrical Safety 29 CFR §1910 Subpart S (Electrical Safety Requirements); U.S. Occupational Safety & Health Act 29 USC §654, 5(a)1 - Each employer shall furnish to each of [their] employees employment/place of employment which are free from recognized hazards that are causing or are likely to cause death or serious harm.

• Emergency Management • EM.01.01.01 - The hospital engages in planning activities prior to developing its written Emergency Operations Plan; EM.02.01.01 - The hospital has an Emergency Operations Plan; EM.02.02.09 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency; EM.03.01.03 - The hospital evaluates the effectiveness of its Emergency Operations Plan; LD.04.04.05 - The hospital has an organization-wide, integrated patient safety program within its performance improvement activities.

3 Workplace Hazards • Hazardous Materials/SDS • OSHA 29 CFR 1910.1200(a); EC.02.02.01 - The hospital manages risks related to hazardous materials and waste U.S. Occupational Safety & Health Act 29 USC §654, 5(a)1 - Each employer shall furnish to each of [their] employees employment/place of employment which are free from recognized hazards that are causing or are likely to cause death or serious harm;

• Bloodborne Pathogens • Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health Universal Precautions for Prevention of Transmission of HIV/Other Bloodborne Infections; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.

• Latex Allergies • OSHA 29 CFR §1910.138(b)- Hand Protection, Selection. Employers shall base the selection of the appropriate hand protection on an evaluation of the performance characteristics of the hand protection relative to the task(s) to be performed, conditions present, duration of use, and the hazards and potential hazards identified.


Safety Storm Alpha Safety Storm AlphaMODULE TOPICS REGULATIONS ADDRESSED*

4 Organizational Workplace Safety

• Workplace Violence • Occupational Safety and Health Act, Sec. 5, (a)(1)&(a)(2); RI.01.06.03 - The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse; LD.03.01.01, EP4 - Leaders create and maintain a culture of safety and quality throughout the hospital (leaders create and implement a process for managing disruptive and inappropriate behaviors; RI.01.06.03 - The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse; EC.01.01.01 - Hospital plans activities to minimize risks in the environment of care.

• Sexual Harassment • RI.01.06.03 - The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse; E.E.O.C. Guidelines; §29 C.F.R Part 1604.11; Title VII of the Civil Rights Act of 1964.

• Recognizing the Impaired Healthcare Worker

• Health Insurance Portability and Accountability Act (HIPAA) of 1996; Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.

5 Information Technology • Protected Health Information (PHI) • Health Insurance Portability and Accountability Act (HIPAA) of 1996; Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009; lM.01.01.03 - The hospital plans for continuity of its information management processes; IM.02.01.01 - The hospital protects the privacy of health information; IM.02.01.03 - The hospital maintains the security and integrity of health information; IM.02.02.01 - The hospital effectively manages the collection of health information; IM.02.02.03 - The hospital retrieves, disseminates, and transmits health information in useful formats; IM.03.01.01 - Knowledge-based information resources are available, current, and authoritative; IM.04.01.01 - The hospital maintains accurate health information.

• Computer Security • Health Insurance Portability and Accountability Act (HIPAA) of 1996; Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009; lM.01.01.03 - The hospital plans for continuity of its information management processes; IM.02.01.01 - The hospital protects the privacy of health information; IM.02.01.03 - The hospital maintains the security and integrity of health information; IM.02.02.01 - The hospital effectively manages the collection of health information; IM.02.02.03 - The hospital retrieves, disseminates, and transmits health information in useful formats; IM.03.01.01 - Knowledge-based information resources are available, current, and authoritative; IM.04.01.01 - The hospital maintains accurate health information.


Safety Storm BetaMODULE TOPICS REGULATIONS ADDRESSED*

1 Patient Rights • Patient Bill of Rights • HR.01.04.01 - The hospital provides orientation to staff; HR.01.05.03: - Staff participates in ongoing education and training; RI.01.01.01 - The hospital respects, protects, and promotes patient rights; RI.01.01.03 - The hospital respects the patient’s right to receive information in a manner he or she understands; RI.01.02.01 - The hospital respects the patient’s right to participate in decisions about his or her care, treatment, and services. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate; RI.01.03.01 - The hospital honors the patient’s right to give or withhold informed consent; RI.01.03.03 - The hospital honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care; R1.01.03.05 - The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials; R1.01.04.01 - The hospital respects the patient’s right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services; R1.01.05.01 - The hospital addresses patient decisions about care, treatment, and services received at the end of life. R1.01.06.03: The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse; R1.01.06.05 - The patient has the right to an environment that preserves dignity and contributes to a positive self-image; R1.01.07.01 - The patient and his or her family have the right to have complaints reviewed by the hospital; R1.01.07.03 - The patient has the right to access protective and advocacy services; R1.01.07.07 - For psychiatric hospital settings that provide longer term care (more than 30 days): The hospital protects the rights of the patients who work for or on behalf of the hospital; R1.02.01.01 - The hospital informs the patient about his or her responsibilities related to his or her care, treatment, and services.

• Informed Consent • RI.01.01.01 - The hospital respects, protects, and promotes patient rights.

• Advance Directives • RI.01.01.01 - The hospital respects, protects, and promotes patient rights.

2 Maintaining Patient Privacy • Patient Information Privacy: HIPAA and HITECH

• Health Insurance Portability and Accountability Act (HIPAA) of 1996; Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.

3 Patient Safety: Adverse Medical Events

• Causes of Adverse Medical Events and Medical Errors

• NPSG.03.06.01: The hospital will maintain and communicate accurate patient medication information.

• Reducing Adverse Medical Events and Medical Errors

• NPSG.03.06.01: The hospital will maintain and communicate accurate patient medication information.

• Handoff Communication • NPSG.03.06.01: The hospital will maintain and communicate accurate patient medication information.



4 Infection Control: Standard Precautions

• Hand Hygiene, PPE, Care of the Environment, Patient Placement and Care

• IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; EP 1 When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or, in the absence of such guidelines, expert consensus. IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.

• Elements of Respiratory Hygiene, Cough Etiquette and Safe Injections Practices

• IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.



• Transmission-based Precautions • IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.

5 Influenza/Tuberculosis • Influenza • IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.


Safety Storm Beta Safety Storm BetaMODULE TOPICS REGULATIONS ADDRESSED*

• Tuberculosis • IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.

• IC.01.01.01 - The hospital identifies the individual(s) responsible for the infection prevention and control program; IC.01.02.01 - Hospital leaders allocate needed resources for the infection prevention and control program; IC.01.03.01 - The hospital identifies risks for acquiring and transmitting infections; IC.01.04.01 - Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections (Note: See NPSG.07.01.01 for hand hygiene guidelines); IC.01.05.01 - The hospital has an infection prevention and control plan; IC.01.06.01 - The hospital prepares to respond to an influx of potentially infectious patients; IC.02.01.01 - The hospital implements its infection prevention and control plan; IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies; IC.02.03.01 - The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff; IC.02.04.01 - The hospital offers vaccination against influenza to licensed independent practitioners and staff; IC.03.01.01 - The hospital evaluates the effectiveness of its infection prevention and control plan; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); OSHA Standards: Personal Protective Equipment, 29 CFR Part 1910.132; OSHA Standards: Respiratory Protection for Tuberculosis, 29, CFR Par 1910.139; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances.


Safety Storm GammaMODULE TOPICS REGULATIONS ADDRESSED*

1 Ethical Aspects of Care • Ethics • RI.01.01.01 - The hospital [organization] respects, protects, and promotes patients’ rights; PC.02.01.01 - The hospital [organization] provides care, treatment, and services for each patient; LD.04.02.05 - When internal or external review results in the denial of care, treatment, and services, or payment, the hospital [facility] makes decisions regarding the ongoing provision of care, treatment, and services, and discharge or transfer, based on the assessed needs of the patient; HR.01.04.01 - The organization provides orientation to staff, EP 6 - The hospital orients staff on the following: Patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented; RI.01.01.03: The hospital respects the patient’s right to receive information in a manner he or she understands.

• Religion/Spirituality • PC.02.02.03: The hospital makes food and nutrition products available to its patients; RI.01.01.01 - The hospital respects, protects, and promotes patients’ rights, EP 9 - The hospital accommodates the patient’s right to religious and other spiritual services; RI.01.01.03: The hospital respects the patient’s right to receive information in a manner he or she understands; TS.01.01.01 - The hospital, with the medical staff’s participation, develops, and implements policies and procedures for donating and procuring organs and tissue, EP 5 - Staff education includes training in the use of discretion and sensitivity to the circumstances, beliefs, and desires of the families of potential organ, tissue, or eye donors.

• End of Life - Compassionate Care • PC.02.02.03: The hospital makes food and nutrition products available to its patients; R1.01.05.01 - The hospital addresses patient decisions about care, treatment, and services received at the end of life; RI.01.01.03: The hospital respects the patient’s right to receive information in a manner he or she understands; PC.02.02.13 - The patient’s comfort and dignity receive priority during end-of-life care, EP 1 - To the extent possible, the hospital provides care and services that accommodate the patient’s and his or her family’s comfort, dignity, psychosocial, emotional, and spiritual end-of-life needs, EP 2 - The hospital provides staff with education about the unique needs of dying patients and their families.

2 Identifying and Reporting Abuse

• Mandatory Reportable Incidents • PC.01.02.09 - The hospital assesses the patient who may be a victim of possible abuse and neglect, EP 3 - The hospital educates staff about how to recognize signs of possible abuse and neglect and about their roles in follow-up; CoP §482.13 Patient Rights (c) Privacy and Safety (3) The patient has the right to be free from all forms of abuse and harassment.

• Recognizing Abuse • PC.01.02.09 - The hospital assesses the patient who may be a victim of possible abuse and neglect, EP 3 - The hospital educates staff about how to recognize signs of possible abuse and neglect and about their roles in follow-up; CoP §482.13 Patient Rights (c) Privacy and Safety (3) The patient has the right to be free from all forms of abuse and harassment.

3 Assessment and Management of Pain

• Pain Assessment Techniques • PC.01.02.07 - The hospital assesses and manages the patient’s pain; RI.01.01.01 - The hospital respects, protects, and promotes patient’s rights, EP 8 - The hospital respects the patient’s rights to pain management; HR.01.04.01 - The hospital provides orientation to staff, EP 4 - The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented.


Safety Storm Gamma Safety Storm GammaMODULE TOPICS REGULATIONS ADDRESSED*

• Pain Management Responsibilities • PC.01.02.07 - The hospital assesses and manages the patient’s or resident’s pain; [APPLICABLE TO NURSING AND REHABILITATION CENTERS] The organization conducts a comprehensive pain assessment of the patient or resident that is consistent with the patient’s or resident’s condition. The organization uses methods to assess pain that are consistent with the patient’s or resident’s age, condition, and cognitive ability. The organization reassesses the patient’s or resident’s pain, based on its reassessment criteria. (PC.02.03.01 The hospital provides patient education and training based on each patient’s needs and abilities. The organization either treats the patient’s or resident’s pain or refers the patient or resident for treatment. Note: Treatment of pain includes interventions for breakthrough pain.PC 10. Based on the patient’s condition and assessed needs,the education and training provided to the patient by the hospital include any of the following: Discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management.PC.02.03.01 The organization provides patient and resident education and training based on each patient’s or resident’s needs and abilities. The organization respects the patient’s or resident’s right to pain management. RI.01.01.01 A 1.The hospital has written policies on patient rights. A 8. The hospital respects the patient’s right to pain management. RI.01.01.01 - The hospital respects, protects, and promotes patient’s rights, EP 8 - The hospital respects the patient’s rights to pain management; The organization respects the patient’s or resident’s right to pain management. (See also HR.01.04.01, EP 4; HR.02.02.01, EP 4; PC.01.02.07, EP 1; PC.02.03.01, EP 10) HR.01.04.01 - The hospital provides orientation to staff, EP 4 - The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented. The organization orients staff on the following: Their specific job duties and responsibilities, including those related to infection prevention and control and, if applicable to their role, assessing and managing pain. Completion of this orientation is documented. HR.02.02.01 The organization provides orientation to licensed independent practitioners.The organization orients licensed independent practitioners on the following: Their specific responsibilities, including those related to infection prevention and control, and assessing and managing pain. The organization defines, in writing, the information to be gathered during the initial assessment(s), including the following: The patient’s or resident’s pain status, including recent pain history, origin, location, severity, alleviating, and exacerbating factors; current treatment for pain; and response to treatment.

4 Patient Safety (Clinical) • Kinds and Causes of Adverse Medical Events and Medical Errors

• LD.03.06.01 - All hospital employees and medical staff have a focus on quality improvement and patient safety; LD.04.04.05 The hospital has an organization-wide, integrated patient safety program within its performance improvement activities, EP 11 To improve safety and to reduce the risk of medical errors, the hospital analyzes and uses information about system or process failures and the results of proactive risk assessments; CoP §482.21 - Quality Assessment and Performance Improvement Program which must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

• Wrong Site, Wrong Procedure, Wrong Person Surgery Errors

• UP.01.01.01 - Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site; UP.01.02.01 - Mark the procedure site; UP.01.03.01 - A time-out is performed before the procedure; LD.03.06.01 - All hospital employees and medical staff have a focus on quality improvement and patient safety.



• Strategies for Reducing and Reporting Adverse Medical Events and Medical Errors

• NPSG.03.06.01 - The hospital will maintain and communicate accurate patient medication information; OSHA 29 CFR §1910.1030 - Bloodborne Pathogens, Toxic and Hazardous Substances; NPSG.07.01.01 - Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines; NPSG.07.03.01 - Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria); NPSG.07.04.01 - Implement evidence-based practices to prevent central line–associated bloodstream infections. Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines; NPSG.07.05.01 - Implement evidence-based practices for preventing surgical site infections; Element of Performance for NPSG.07.05.01 A 5. Measure surgical site infection rates for the first 30 or 90 days following surgical procedures; The [organization’s] measurement strategies follow evidence-based guidelines. Note 1: Surveillance may be targeted to certain procedures based on the [organization’s] risk assessment..NPSG 07.06.01 - Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI); LD.03.06.01 - All hospital employees and medical staff have a focus on quality improvement and patient safety; LD.04.04.05 The hospital has an organization-wide, integrated patient safety program within its performance improvement activities, EP 11 To improve safety and to reduce the risk of medical errors, the hospital analyzes and uses information about system or process failures and the results of proactive risk assessments; CoP §482.21 - Quality Assessment and Performance Improvement Program which must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

5 Restraint, Seclusion and Sedation

• Restraint and Seclusion • PC.01.02.01: The organization assesses and reassesses its patients and residents; PC.03.05.17 The hospital trains staff to safely implement the use of restraint or seclusion; 29 CFR § 482.13 Patient Rights (12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within one hour after the initiation of the intervention. (e) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

• Sedation • PC.01.02.01: The hospital assesses and reassesses its patients; PC.03.01.01 The hospital plans operative and other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia. Standard PC.03.01.01 requires a sufficient number of staff, in addition to the person performing the procedure, be present to perform the procedure, monitor and recover the patient. The person administering the medication must be qualified to manage the patient at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. There may be a need for additional monitoring personnel, but the person administering the sedation must be qualified to monitor the patient.


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6 Recognizing and Responding to a Patient’s Worsening Condition

• Rapid Response Teams • NPSG.16.01.01 Improve recognition and response to changes in a patient’s condition. The hospital selects a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual when the patient’s condition appears to be worsening. Standard PC.02.01.09 The organization plans for and responds to life-threatening emergencies. EP 1 The organization has written policies and procedures for responding to life-threatening emergencies. EP 3 The organization responds to life-threatening emergencies according to its policies and procedures. EP 9 For ambulatory surgical centers that elect to use The Joint Commission deemed status option: Emergency equipment is immediately available for use when needed to respond to emergencies. EP 10 For ambulatory surgical centers that elect to use The Joint Commission deemed status option: The types of emergency equipment available are appropriate for the organization’s patient population and types of procedures performed.

7 Preventing Healthcare- Associated Infections Due to Multidrug-Resistant Organisms (MDROs)

• Magnitude of the Problem of MDROs

• NPSG.16.01.01 Improve recognition and response to changes in a patient’s condition. The hospital selects a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual when the patient’s condition appears to be worsening. Standard PC.02.01.09 The organization plans for and responds to life-threatening emergencies. EP 1 The organization has written policies and procedures for responding to life-threatening emergencies. EP 3 The organization responds to life-threatening emergencies according to its policies and procedures. EP 9 For ambulatory surgical centers that elect to use The Joint Commission deemed status option: Emergency equipment is immediately available for use when needed to respond to emergencies. EP 10 For ambulatory surgical centers that elect to use The Joint Commission deemed status option: The types of emergency equipment available are appropriate for the organization’s patient population and types of procedures performed.

• Prevention and Control of MDROs • NPSG.07.03.01 - Implement evidence-based practices to prevent healthcare-associated infections due to multidrug-resistant organisms in acute care hospitals, incl EP3, Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistent organism about healthcare-associated infection prevention strategies; NPSG.07.04.01 - Implement evidence-based practices to prevent central line–associated bloodstream infections. Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines; NPSG.07.05.01 - Implement evidence-based practices for preventing surgical site infections; Element of Performance for NPSG.07.05.01 A 5. Measure surgical site infection rates for the first 30 or 90 days following surgical procedures, based on National Healthcare Safety Network (NHSN) procedural codes. The [organization’s] measurement strategies follow evidence-based guidelines. NPSG.07.06.01 - Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

8 Preventing Patient Infections: CAUTI, CLABSIs, SSIs

• CAUTI • NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).* Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children., EP 2 -Insert indwelling urinary catheters according to established evidence-based guidelines that address the following: Limiting use and duration to situations necessary for patient care - Using aseptic techniques for site preparation, equipment and supplies. EP 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following: Securing catheters for unobstructed urine flow and drainage; maintaining the sterility of the urine collection system; replacing the urine collection system when required; collecting urine samples. EP 4 Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following: Selecting measures using evidence-based guidelines or best practices; monitoring compliance with evidence-based guidelines or best practices; evaluating the effectiveness of prevention efforts. Note: Surveillance may be targeted to areas with a high volume of patients using indwelling catheters. High-volume areas are identified through the hospital’s risk assessment as required in IC.01.03.01, EP 2.



• Magnitude of Problem of CLABSIs • NPSG.07.04.01 - Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations; NPSG.07.05.01 EP 1 - The hospital educates healthcare workers who are involved in these procedures about healthcare-associated infections, central line-associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities. EP 5: Provide central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. IC.02.01.01, EP 1: The organization implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.

• Placement and Care of CVCs • NPSG.07.04.01 - Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations, EP5 - The hospital educates healthcare workers who are involved in these procedures about healthcare-associated infections, central line-associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities.

• SSI • NPSG.07.05.01 - Implement evidence-based practices for preventing surgical site infections, Element of Performance for NPSG.07.05.01: EP 1 Educate staff and licensed independent practitioners involved in surgical procedures about surgical site infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities. EP 2 Educate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.EP 3 Implement policies and procedures aimed at reducing the risk of surgical site infections: These policies and procedures meet regulatory requirements and are aligned with evidence-based guidelines (for example, The Centers for Disease Control and Prevention (CDC) and/or other professional organizational guidelines). EP 4 As part of the effort to reduce surgical site infections:- Conduct periodic risk assessments for surgical site infections in a time frame determined by the hospital. Select surgical site infection measures using best practices or evidence-based guidelines. Monitor compliance with best practices or evidence-based guidelines. Evaluate the effectiveness of prevention efforts. Note: Surveillance may be targeted to certain procedures based on the hospital’s risk assessment. EP 5. Measure surgical site infection rates for the first 30 or 90 days following surgical procedures based on National Healthcare Safety Network (NHSN) procedural codes. The [organization’s] measurement strategies follow evidence-based guidelines.EP 6 Provide process and outcome (for example, surgical site infection rate) measure results to key stakeholders. EP 7 - Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to evidence-based practices. EP 8 - When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations,

*Regulations listed for reference. Additional training may be required to meet the standards.

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