Posted in: Triangle Times Today

Volume 2 | Issue 5 | May 2023

Four essential components of a total systems approach to safety

National Safety Month is held in June with an aim to reduce workplace injuries. This year AAAHC focuses on examining your culture of safety beyond patient care to a total systems approach.

Patients are often at the forefront of quality improvement initiatives that drive safety. Through AAAHC Standards, ambulatory care settings have established safety programs, such as quality and risk management, that are reviewed by the governing body at least annually. Propelled by the focus on clinical risk management and medical error prevention, progressive health care providers embrace an organizational culture that actively supports a total systems approach to safety.

According to the Institute for Healthcare Improvement (IHI), four foundational interdependent areas are essential to create total systems safety. These include Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning System.

  1. Culture, Leadership, and Governance. Leaders greatly influence organizational culture by defining and demonstrating set values and norms that guide behavior and activity within the organization. Assessing organizational culture is one way to feel its pulse and identify what and if changes are needed. The Centers for Disease Control and Prevention (CDC) and Agency for Healthcare Research and Quality (AHRQ) provide tools and resources available to assess and monitor safety culture. However, assessing organizational culture is just the beginning. Establishing priorities for action, identifying and implementing resources, and communicating with staff are key to enabling a true culture of workplace safety.
  2. Patient and Family Engagement. Facilitating equitable engagement of patients and their support persons in the coproduction of care has proven to improve overall care outcomes and perceived value of care to the consumer.
  3. Workforce Safety. At the end of a long pandemic, our workforce is tired, they are burnt out, and retention is at an all-time low. Never has it been so critical to build a healthy work environment that fosters joy and a genuine concern and accountability for the physical and psychological wellbeing of staff. More recently there have been advancements in the development of resources to support workforce health and safety. (See National Plan for health workforce well-being published by the National Academy of Medicine and Total Worker Health approach developed by the National Institute for Occupational Safety
    and Health).
  4. Learning Systems. Shifting from a reporting system to a system that fosters a continuous learning approach. According to the IHI, “Learning Systems are organizational processes that integrate information, such as adverse events, clinical data, staff and patient feedback, and best practice to strengthen internal processes and promote safety.”

AAAHC encourages all accredited health care organizations to embrace a total systems approach to safety, starting with a self-assessment and developing a plan of action. Resources can be accessed through hyperlinks in this article.


v42 Q&A, Part IV

This month our series of articles on v42 Standards focuses on safety. The article provides actionable information about what can be done to improve and implement your safety program.

What is the purpose of a safety program?

The purpose of a safety program is to provide patients, staff, and visitors with a safe and healthy environment that seeks to prevent injury and illness and minimize risks. AAAHC Standards require a written safety program that addresses the environment of care, the safety of patients, staff, and others and meets or exceeds local, state, or federal safety requirements. The safety program should include processes for managing identified hazards, potential threats, near misses, and other safety concerns and be approved by the governing body.

What should be included in a facility’s written safety program?

The written safety program requires the following:

  • Processes for managing identified hazards, potential threats, near misses, and other safety concerns
  • Processes to reduce and avoid medication errors
  • Practices employed to prevent falls and other physical injuries and to ensure the accurate and timely reporting of such events
  • Practices employed to prevent skin and tissue injury from chemicals, cleaning solutions, and other hazardous exposure
  • Methods of ensuring that food and drink for patient use is stored, prepared, served,
    and disposed of in compliance with local, state, and federal guidelines

What are some examples of processes for identifying hazards, potential threats, near misses, and other safety concerns?

Documentation should be available that demonstrates that a risk assessment was conducted or is underway in accordance with the requirements of the organization’s safety program. Examples include operational, clinical, life safety, hazard vulnerability, cyber security, emergency preparedness, and workforce risks.

Who can approve policies that address occupational health and safety regulations?

The governing body approves and implements policies that comply with all applicable occupational health and safety regulations for health care workers designed to eliminate and/or minimize exposures.

Are facilities required to document work injury and illness records?

Yes, according to Occupational Safety and Health Administration (OSHA) employers with more than 10 employees are required to keep a record of serious workplace injuries and illnesses. All records should be maintained in accordance with state and federal reporting requirements and any other insurance requirements.

What information is included in work injury and illness records?

According to OSHA, records are to include information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. Such records should be maintained for at least five years.

Conferences & Exhibits

  • American College Health Association (ACHA)
    May 31–Jun 3
  • National Association of Community Health Centers (NACHC)
    Aug 27–29
  • California Ambulatory Surgery Association (CASA)
    Sep 13–15
  • Ohio Association of Ambulatory Surgery Centers (OAASC)
    Sep 19–20
  • Becker’s ASC Business and Operations of ASCs
    Oct 26–28
  • IHI Forum — Institute for Healthcare Improvement
    Dec 10–13

1095 Learn

Achieving Accreditation, Jun 22–23 Chicago, IL

Join us lakeside in Chicago this summer to learn about the accreditation journey or refresh your memory for an upcoming survey. All attendees will come away with new understanding, fresh perspectives, and the feeling of time well spent.

Learn more and register.


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