Domain 1:
A. Hospital senior governing boards prioritize safety as a core value, hold hospital leadership accountable for patient safety, and include patient safety metrics to inform annual leadership performance reviews and compensation.
B. Hospital leaders, including C-suite executives, place patient safety as a core institutional value. One or more C-suite leaders oversee a system-wide assessment on safety (examples provided in the Attestation Guide), and the execution of patient safety initiatives and operations, with specific improvement plans and metrics. These plans and metrics are widely shared across the hospital and governing board.
C. Hospital governing boards, in collaboration with leadership, ensure adequate resources to support patient safety (such as equipment, training, systems, personnel, and technology).
D. Reporting on patient and workforce safety events and initiatives (such as safety outcomes, improvement work, risk assessments, event cause analysis, infection outbreak, culture of safety, or other patient safety topics) accounts for at least 20% of the regular board agenda and discussion time for senior governing board meetings.
E. C-suite executives and individuals on the governing board are notified within 3 business days of any confirmed serious safety events resulting in significant morbidity, mortality, or other harm.
Domain 2:
A. Hospitals need to create a strategic plan that publicly shares its commitment to patient safety as a core value and outlines specific safety goals and associated metrics, including the goal of ‘zero’ preventable harm.
B. Hospital safety goals must include the use of metrics to identify and address disparities in safety outcomes based on the patient characteristics determined by the hospital to be most important to health care outcomes for the specific populations served.
C. Implement written policies and protocols to cultivate a just culture that balances no-blame and appropriate accountability and reflects the distinction between human error, at risk behavior, and reckless behavior.
D. Hospital are required to implement a patient safety curriculum and competencies for all clinical and non-clinical hospital staff, including C-suite executives and individuals on the governing board, regular assessments of these competencies for all roles, and action plans for advancing safety skills and behaviors.
E. Hospitals must create an action plan for workforce safety with improvement activities, metrics and trends that address issues such as slips/trips/falls prevention, safe patient handling, exposures, sharps injuries, violence prevention, fire/electrical safety, and psychological safety.
Domain 3:
A. Hospitals must conduct a hospital-wide culture of safety survey using a validated instrument annually, or every 2 years with pulse surveys on target units during non-survey years. Results are shared with the governing board and hospital staff and used to inform unit-based interventions to reduce harm.
B. Hospitals must assign a dedicated team that conducts event analysis of serious safety events using an evidence-based approach, such as the National Patient Safety Foundation’s Root Cause Analysis and Action (RCA2).
C. Hospitals must employ a patient safety metrics dashboard that uses external benchmarks (such as CMS Star Ratings or other national databases) to monitor performance and inform improvement activities on safety events (such as: medication errors, surgical/procedural harm, falls, pressure injuries, diagnostic errors, and healthcare-associated infections).
D. Hospitals must implement a minimum of 4 of the following high reliability practices:
- Tiered and escalating (for example, unit, department, facility, system) safety huddles should be conducted at least 5 days a week, with 1 day being a weekend, that include key clinical and non-clinical (for example, lab, housekeeping, security) units and leaders, with a method in place for follow-up on issues identified.
- Hospital leaders should participate in monthly rounding for safety on all units, with Csuite executives rounding at least quarterly, with a method in place for follow-up on issues identified.
- A data infrastructure to measure safety, based on patient safety evidence (for example, systematic reviews, national guidelines) and data from the electronic medical record that enables identification and tracking of serious safety events and precursor events. These data are shared with C-suite executives at least monthly, and the governing board at every regularly scheduled meeting.
- Technologies, including a computerized physician order entry system and a barcode medication administration system, that promote safety and standardization of care using evidence-based practices.
- The use of a defined improvement method (or hybrid of proven methods), such as Lean, Six Sigma, Plan-Do-Study-Act (PDSA), and/or high reliability frameworks.
- Team communication and collaboration training of all staff.
- The use of human factors engineering principles in selection and design of devices, equipment, and processes.
E. Hospitals should participate in large-scale learning network(s) for patient safety improvement (such as national or state safety improvement collaboratives), share data on safety events and outcomes with these network(s) and have implemented at least one best practice from the network or collaborative that enables identification and tracking of serious safety events.
Domain 4:
A. Hospitals must enable a confidential safety reporting system that allows staff to report patient safety events, near misses, precursor events, unsafe conditions, and other concerns, and prompts a feedback loop to those who report.
B. Hospitals should voluntarily works with a Patient Safety Organization listed by the Agency for Healthcare Research and Quality (AHRQ) to carry out patient safety activities as described in 42 CFR 3.20, such as, but not limited to, the collection and analysis of patient safety work product, dissemination of information such as best practices, encouraging a culture of safety, or activities related to the operation of a patient safety evaluation system.
C. Patient safety metrics must be tracked and reported to all clinical and non-clinical staff and made public in hospital units (for example, displayed on units so that staff, patients, families, and visitors can see).
D. Hospitals must have defined, evidence-based communication and resolution program reliably implemented after harm events, such as AHRQ’s Communication and Optimal Resolution (CANDOR) toolkit, that contains the following elements:
- Harm event identification
- Open and ongoing communication with patients and families about the harm event
- Event investigation, prevention, and learning
- Care-for-the-caregiver
- Financial and non-financial reconciliation
E. Hospitals should use standard measures to track the performance of communication and a resolution program and report those measures to the governing board at least quarterly.
Domain 5:
A. Creating a Patient and Family Advisory Council ensures patient, family, caregiver, and community input to safety related activities, including representation at board meetings, consultation on safety goal-setting and metrics, and participation in safety improvement initiatives.
B. Patient and Family Advisory Council should include patients and caregivers of patients who are diverse and representative of the patient population.
C. Patients have comprehensive access to and are encouraged to view their own medical records and clinician notes via patient portals and other options, and the hospital provides support to help patients interpret information that is culturally and linguistically appropriate as well as submit comments for potential correction to their record.
D. Hospital incorporates patient and caregiver input about patient safety events or issues (such as patient submission of safety events, safety signals from patient complaints or other patient safety experience data, patient reports of discrimination).
E. Hospital supports the presence of family and other designated persons (as defined by the patient) as essential members of a safe care team and encourages engagement in activities such as bedside rounding and shift reporting, discharge planning, and visitation 24 hours a day, as feasible.
