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Patient Safety Tool Applicator Tool Three Levels

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Patient Safety Tool Applicator Tool Three Levels

 

TABLE 1. Patient Safety Applicator Tool – Beginners
Item Area to address: Critical Process Performance Measure
Category 1: Leadership
1.1. Institutional Leadership Senior Leadership Direction: How senior leaders communicate the priority of patient safety to all stakeholders. Functioning institutional systems for communicating patient safety policies, issues and activities to all stakeholders, actively seeking feedback and use of the information for improvement and creating a culture of safety.
1.2. Social Responsibility Ethical Behavior: How the institution ensures ethical communication with stakeholders in regard to patient safety issues. Ongoing monitoring of quality issues and appropriate procedures are in place for reporting and analysis of adverse events and improvement of institution's patient safety systems.
Category 2: Strategic Planning
2.1. Strategy Development Strategic Objectives: How patient safety practices are identified and translated to institution's goals. Data from national databanks and practice guidelines from professional organizations are incorporated in institution's patient safety goals, plans and patient care practices.
2.2. Strategy Deployment Action Plan Development and Deployment: How the institution develops, monitors and improves action plans to ensure patient safety. Institutional and unit patient safety action plans and systems for sustaining achieved improvements are in place and are revised and improved on a regular basis.
Category 3: Focus on Patients, Other Customers and Markets
3.1. Patient, Other Customer and Healthcare Market Knowledge Patient Safety Market Knowledge: How the healthcare institution determines patients' expectations and appropriate knowledge in regard to patient safety. Planned, coordinated and aligned institutional activities to ensure patient education and providing of useful information to the intended audiences in regard to patient safety issues, institutional policies and practices.
3.2. Patient and Other Customer Relationships and Satisfaction Satisfaction Determination: How the institution obtains information and feedback from patients on patient safety issues to improve the delivery of healthcare. Design and implementation of comprehensive and accessible systems for adverse events reporting from patients and their families, and continuous analysis of the obtained data.
Category 4: Measurement, Analysis and Knowledge Management
4.1. Measurement and Analysis of Institutional Performance Performance Measurement: How the institution collects, tracks and analyzes patient safety data. Non-punitive reporting systems are in place for recording, monitoring, tracking and analysis of adverse events and near misses and the results from this analysis are used in institution's improvement plans.
4.2. Information and Knowledge Management Data and Information Availability: How the institution ensures that its clinical information technology (Computerized Physician's Order Entry – CPOE, infusion pumps, alarm systems, etc) is reliable, secure and user-friendly. A planned, aligned and monitored institution-wide process of clinical technology use facilitates information transfer and clear communication.
Item Area to address: Critical Process Performance Measure
Category 5: Staff Focus
5.1. Work Systems Staff Performance Management System: How the institution supports high clinical performance standards and alignment with national clinical performance measures and best case- management practices. Best patient safety practices and clinical guidelines are adopted, monitored and clinician performance is evaluated for consistency with these adopted standards.
5.2. Staff Learning and Motivation Staff Education, Training and Development: How the institution structures and promotes effective education and training of professionals in developing and improving patient safety systems. Institutional mechanism for determining of and acting on patient safety educational and training needs for individuals, teams, departments and different categories of professional caregivers.
5.3.Staff Well-being and Satisfaction Work Environment: How the institution maintains conductive environment in regard to patient safety. Institution's patient safety goals are integrated in institution's everyday healthcare delivery functions, regularly reviewed and improved and progress towards them is continuously monitored and evaluated.
Category 6: Process Management
Item Area to address: Critical Process Performance Measure
6.1. Patient Safety System Patient Safety System: How the institution ensures that patient safety requirements are met at the "sharp end" of the healthcare delivery system. An institutional mechanism exists for continuous monitoring, improvement and sustainability of patient safety outcomes in healthcare delivery.
6.2. Support Processes Patient Safety Support Processes: How the institution coordinates departmental and interdepartmental patient safety infrastructures to reduce variability in healthcare delivery and improve performance. Systems for departmental and interdepartmental communications, collaborations and aligned effort in regard to seamless implementation of best practices and clinical guidelines in patient identification, medication and continuous case management are assessed and improved on an ongoing basis.
Category 7: Institutional performance
7.1. Patient Safety Institutional Performance Patient Safety Results: How the institution ensures patient safety The institution monitors the administration of high-alert medications.
TABLE 2. Patient Safety Applicator Tool - Intermediate
Item Area to address: Critical Process Performance Measure
Category 1: Leadership
1.1. Institutional Leadership Senior Leadership Direction: How senior leaders communicate the priority of patient safety to all stakeholders. Functioning institutional systems for communicating patient safety policies, issues and activities to all stakeholders, actively seeking feedback and use of the information for improvement and creating a culture of safety.
Institutional Governance: How senior leaders create an environment for development and improvement of patient safety systems in the institution.  Systems are in place on different institutional levels for collection and analysis of relevant data used for institutional improvement of patient safety.
Institutional Performance Review: How patient safety findings are translated in institutional short- and long-term goals and priorities. There is an institutional structure that takes the lead in continuous internal assessment of patient safety, review of current patient safety research findings and translation of research and developed clinical guidelines in institution's clinical practices, strategic planning and priorities.
1.2. Social Responsibility Ethical Behavior: How the institution ensures ethical communication with stakeholders in regard to patient safety issues. Ongoing monitoring of quality issues and appropriate procedures are in place for reporting and analysis of adverse events and improvement of institution's patient safety systems.
Category 2: Strategic Planning
2.1. Strategy Development Strategic Objectives: How patient safety practices are identified and translated to institution's goals. Data from national databanks and practice guidelines from professional organizations are incorporated in institution's patient safety goals, plans and patient care practices.
2.2. Strategy Deployment Action Plan Development and Deployment: How the institution develops, monitors and improves action plans to ensure patient safety. Institutional and unit patient safety action plans and systems for sustaining achieved improvements are in place and are revised and improved on a regular basis.
Category 3: Focus on Patients, Other Customers and Markets
3.1. Patient, Other Customer and Healthcare Market Knowledge Patient Safety Market Knowledge: How the healthcare institution determines patients' expectations and appropriate knowledge in regard to patient safety. Planned, coordinated and aligned institutional activities to ensure patient education and providing of useful information to the intended audiences in regard to patient safety issues, institutional policies and practices.
3.2. Patient and Other Customer Relationships and Satisfaction Satisfaction Determination: How the institution obtains information and feedback from patients on patient safety issues to improve the delivery of healthcare. Design and implementation of comprehensive and accessible systems for adverse events reporting from patients and their families, and continuous analysis of the obtained data.
Item Area to address: Critical Process Performance Measure
Category 4: Measurement, Analysis and Knowledge Management
4.1. Measurement and Analysis of Institutional Performance Performance Measurement: How the institution collects, tracks and analyzes patient safety data. Non-punitive reporting systems are in place for recording, monitoring, tracking and analysis of adverse events and near misses and the results from this analysis are used in institution's improvement plans.
4.2. Information and Knowledge Management Data and Information Availability: How the institution ensures that its clinical information technology (Computerized Physician's Order Entry – CPOE, infusion pumps, alarm systems, etc) is reliable, secure and user-friendly. A planned, aligned and monitored institution-wide process of clinical technology use facilitates information transfer and clear communication.
Category 5: Staff Focus
5.1. Work Systems Staff Performance Management System: How the institution supports high clinical performance standards and alignment with national clinical performance measures and best case- management practices. Best patient safety practices and clinical guidelines are adopted, monitored and clinician performance is evaluated for consistency with these adopted standards.
5.2. Staff Learning and Motivation Staff Education, Training and Development: How the institution structures and promotes effective education and training of professionals in developing and improving patient safety systems. Institutional mechanism for determining of and acting on patient safety educational and training needs for individuals, teams, departments and different categories of professional caregivers.
5.3.Staff Well-being and Satisfaction Work Environment : How the institution maintains conductive environment in regard to patient safety. Institution's patient safety goals are integrated in institution's everyday healthcare delivery functions, regularly reviewed and improved and progress towards them is continuously monitored and evaluated.
Item Area to address: Critical Process Performance Measure
Category 6: Process Management
6.1. Patient Safety System Patient Safety System: How the institution ensures that patient safety requirements are met at the "sharp end" of the healthcare delivery system. An institutional mechanism exists for continuous monitoring, improvement and sustainability of patient safety outcomes in healthcare delivery.
6.2. Support Processes Patient Safety Support Processes: How the institution coordinates departmental and interdepartmental patient safety infrastructures to reduce variability in healthcare delivery and improve performance. Systems for departmental and interdepartmental communications, collaborations and aligned effort in regard to seamless implementation of best practices and clinical guidelines in patient identification, medication and continuous case management are assessed and improved on an ongoing basis.
Category 7: Institutional Performance
7.1. Patient Safety Institutional Performance Patient Safety Results: How the institution ensures patient safety A 2-identifier system for patient identification is in place and is consistent in the continuity of healthcare throughout the institution. The institution monitors the administration of high-alert medications.Proper marking of surgery sites is established as a precaution to decrease incidents of wrong-side surgery (where applicable). The institution ensures adequate professional staff preparation for proper and safe use of infusion pumps (where applicable). The institution ensures a non-punitive approach for reporting all adverse events and near misses.The institution ensures that an accessible, confidential and adequately functioning reporting system is in place for reporting all adverse events and near misses. The institution proactively works towards changing the traditional culture of "blame and shame."
TABLE 3. Patient Safety Applicator Tool: Advanced Level
Category 1: Leadership
Item Area to address: Critical Process Performance Measure
1.1. Institutional Leadership 1.1.1. Senior Leadership Direction: How senior leaders communicate the priority of patient safety to all stakeholders. 1.1.1.1. Functioning institutional systems for communicating patient safety policies, issues and activities to all stakeholders, actively seeking feedback and use of the information for improvement and creating a culture of safety.1.1.1.2. Provision and use of real time adverse event reporting tool that alerts leadership automatically to events as they happen, thereby improving real-time communication and stressing the importance of performance improvement in real time.
1.1.2. Institutional Governance: How senior leaders create an environment for development and improvement of patient safety systems in the institution.  1.1.2.1.  A patient safety plan and institutional policies support non-punitive reporting environment and disclosure of adverse events.1.1.2.2. Systems are in place on different institutional levels for collection and analysis of relevant data used for institutional improvement of patient safety.
1.1.3. Institutional Performance Review: How patient safety findings are translated in institutional short- and long-term goals and priorities. 1.1.3.1. There is an institutional structure that takes the lead in continuous internal assessment of patient safety, review of current patient safety research findings and translation of research and developed clinical guidelines in institution's clinical practices, strategic planning and priorities.
Category 1: Leadership
Item Area to address: Critical Process Performance Measure
1.2. Social Responsibility 1.2.1. Responsibilities to the public: How the institution incorporates patient safety accreditation and legal requirements as integral parts of its performance improvement. 1.2.1.1. Institutional patient safety plans and policies are developed, carried forward and improved in accordance with the regulations and recommendations of legislative bodies, patient safety agencies and accreditation bodies, such as but not limited to JCAHO, OSHA, NRA, IHI, NCQA, URAC, AAHP, AHA, etc.1.2.1.2. Requirements in the areas of patient identification, healthcare communications, administration of high-alert medications, wrong-site surgery, use of infusion pumps and clinical alarm systems are adequately addressed.    
1.2.2. Ethical Behavior: How the institution ensures ethical communication with stakeholders in regard to patient safety issues. 1.2.2.1. Ongoing monitoring of quality issues and appropriate procedures are in place for reporting and analysis of adverse events and improvement of institution's patient safety systems.1.2.2.2. Adopting guidelines and monitoring healthcare staff and professionals compliance with patient safety policies and procedures and effective communication of these policies and procedures to patients and their families.
1.2.3. Support of key communities: How the institution proactively responds to current and future public concerns in regard to patient safety. 1.2.3.1. Institutional plan and support systems are in place for proactive collecting and analysis of patient safety information and utilization of the review results for improvement of the patient safety systems.
1.2.4. Responsibilities to the public: How the institution monitors its medication error rate. 1.2.4.1. Independent medication error review team is identified and educated in regard to the medication usage cycle and is engaged in developing and monitoring medication safety system.
Category 2: Strategic Planning
Item Area to address: Critical Process Performance Measure
2.1. Strategy Development 2.1.1. Strategic Development Process: How the healthcare institution develops its view of the future and sets directions and policies to communicate, implement and monitor its patient safety systems. 2.1.1.1. Patient safety action plans and systems for sustaining achieved improvements are in accordance with national best practices and performance measures guidelines and provide for optimal matching of healthcare needs and service delivery capabilities.2.1.1.2. Ongoing, planned and regularly monitored effort in creation, adaptation and adoption of clinical guidelines and best practices based on clinical patient safety research.2.1.1.3. Comprehensive and ongoing proactive approach in seeking stakeholder expectations in setting goals for short- and long-term patient safety planning.2.1.1.4. The capabilities of modern technologies and database access are taken into consideration in setting goals for short- and long-term planning.
2.1.2. Strategic Objectives: How patient safety practices are identified and translated to institution's goals. 2.1.2.1. Data from national databanks and practice guidelines from professional organizations are incorporated in institution's patient safety goals, plans and patient care practices.
2.1.3. Strategic Objectives: How the institution achieves realistic evaluation of technology capability for improving safety (present and future). 2.1.3.1. Cost-benefit analysis of safety technology with accumulation of data to evaluate the accuracy of such estimates over time and life of safety technology projects.
2.2. Strategy Deployment 2.2.1. Action Plan Development and Deployment: How the institution develops, monitors and improves action plans to ensure patient safety. 2.2.1.1. Institutional and unit patient safety action plans and systems for sustaining achieved improvements are in place and are revised and improved on a regular basis.2.2.1.2. System-wide processes are used for communication and alignment of patient safety planned efforts.
2.2.2. Performance Projection: How leaders achieve consistency and improvement of healthcare delivery. 2.2.2.1. National, regional and specialty standards (best practices, clinical performance measures, etc.) are incorporated as benchmarks in institution's short- and long-term plans and are used in the assessment of institution's and individual's quality of healthcare delivery.
Category 3: Focus on Patients, Other Customers and Markets
Item Area to address: Critical Process Performance Measure
3.1. Patient, Other Customer and Healthcare Market Knowledge 3.1.1. Patient Safety Market Knowledge: How the healthcare institution determines patients' expectations and appropriate knowledge in regard to patient safety. 3.1.1.1. Coordinated and planned interdepartmental activities to ensure effective team effort for determining the requirements and expectations of culturally and linguistically diverse patient populations in regard to patient safety and use of this information for improvement of institution's patient safety systems.3.1.1.2. Planned, coordinated and aligned institutional activities to ensure patient education and providing of useful information to the intended audiences in regard to patient safety issues, institutional policies and practices.
3.1.2. Patient Safety Market Knowledge: How the institution helps set the expectations of patients and infuses realistic goals and expectations into the marketplace. 3.1.2.1. Outcome determination of patient expectations and efforts to influence the development of realistic expectations.
3.2. Patient and Other Customer Relationships and Satisfaction 3.2.1. Patient/Customer Relationship Building: How the healthcare institution gathers and analyses information about patients' and community's expectations in regard to safety of healthcare delivery, and how the results and interpretations are used for improvement of institution's patient safety systems. 3.2.1.1. Proactive alliance building with patient safety groups and local communities for continuous collection, analysis and interpretation of data about patient and other customers expectations.3.2.1.2. Designing, aligning, monitoring and improving of the procedures for inclusion of patients and their families as active team-players in the process of professional healthcare delivery.
3.2.2. Satisfaction Determination: How the institution obtains information and feedback from patients on patient safety issues to improve the delivery of healthcare. 3.2.2.1. Design and implementation of comprehensive and accessible systems for adverse events reporting from patients and their families, and continuous analysis of the obtained data.3.2.2.2. Proactive planned effort to enhance patients' knowledge and information in regard to patient safety issues.
Category 4: Measurement, Analysis and Knowledge Management
Item Area to address: Critical Process Performance Measure
4.1. Measurement and Analysis of Institutional Performance 4.1.1. Performance Measurement: How the institution selects and implements into its patient safety systems patient safety benchmarks. 4.1.1.1. Systematic, planned and aligned effort to monitor developments of patient safety standards and implement regional, national and specialty standards as benchmarks for institution's clinical practices.4.1.1.2. Clinical performance measures as developed by national, regional or professional institutions (as applicable) are implemented in the everyday clinical practice, i.e. at the "sharp end" of healthcare service delivery.
4.1.2. Performance Measurement: How the institution collects, tracks and analyzes patient safety data. 4.1.2.1. Root Cause Analysis (RCA) and Failure Modes and Effects Analysis (FMEA) training is available to healthcare providers.4.1.2.2. RCA and/or FMEA approach is used on a customary basis by the healthcare providers in analysis of patient safety issues and improvement of healthcare delivery and patient safety.4.1.2.3. Non-punitive reporting systems are in place for recording, monitoring, tracking and analysis of adverse events and near misses and the results from this analysis are used in institution's improvement plans.
4.1.3. How the institution monitors the occurrence of near misses and how uses this information for process improvement. 4.1.3.1. A process exists for recording, monitoring, tracking and analysis of near misses and feedback is used for process improvement.
4.2. Information and Knowledge Management 4.2.1. Data and Information Availability: How the institution ensures that its clinical information technology (Computerized Physician's Order Entry – CPOE, infusion pumps, alarm systems, etc) is reliable, secure and user-friendly. 4.2.1.1. A planned, aligned and monitored institution-wide process of clinical technology use facilitates information transfer and clear communication.4.2.1.2. A process is in place for assurance that technology implementation is in compliance with patient safety requirements.
4.2.2. Data and Information Availability: How stakeholders' satisfaction, dissatisfaction and expectations in regard to patient safety are determined and used for improvement of patient safety systems. 4.2.2.1. Data from comprehensive, accessible and user-friendly systems for tracking stakeholder reports, comments and complaints in regard to patient safety satisfaction, dissatisfaction and expectations is used to improve patient safety systems and update patient safety action plans.
4.2.3. Institutional Knowledge: How patient safety information is shared with all stakeholders in support of overall institution's goals and action plans for performance improvement. 4.2.3.1. Processes are in place to secure integrity, timeliness, reliability, security, accuracy and confidentiality of patient safety related data and analyses of such data, as it is shared with all stakeholders, are used to positively affect institution's performance improvement and action planning.
Category 5: Staff Focus
Item Area to address: Critical Process Performance Measure
5.1. Work Systems 5.1.1. Organization and Management of Work: How healthcare delivery is organized to promote patient safety systems establishment and innovation. 5.1.1.1. How patient safety issues are communicated, data are collected and analyzed, and existing processes are improved at different institutional levels to promote consistency in the safety of healthcare delivery.
5.1.2. Staff Performance Management System: How the institution supports high clinical performance standards and alignment with national clinical performance measures and best case- management practices. 5.1.2.1. Best patient safety practices and clinical guidelines are adopted, monitored and clinician performance is evaluated for consistency with these adopted standards.
5.1.3. Staff Performance Management System: How the institution identifies, deploys and monitors patient safety practices. 5.1.3.1. Interdepartmental systems for ensuring seamless healthcare delivery and patient safety are consistent with national, regional or specialty best practices and standards for patient safety and healthcare delivery.
5.1.4. Recruitment and Career Progression: How the institution identifies requirements and recognition for patient safety officers. 5.1.4.1. Development, implementation, revision and improvement of institution's plan for hiring, retaining and recognition of patient safety staff.
5.1.5. Recruitment and Career Progression: How the institution includes safety compliance and attitudes in staff recruitment, selection and promotion. 5.1.5.1. General staff knowledge and practice of safe activities is rewarded and taken into consideration for recruitment, selection and promotion.
5.2. Staff Learning and Motivation 5.2.1. Staff Education, Training and Development: How the institution structures and promotes effective education and training of professionals in developing and improving patient safety systems. 5.2.1.1. Institutional mechanism for determining of and acting on patient safety educational and training needs for individuals, teams, departments and different categories of professional caregivers.
5.2.2. Motivation and Career Development: How the institution supports the role of the patient safety officer and the patient safety role of the whole workforce. 5.2.2.1. Development, implementation and improvement of internal patient safety policies, practices and activities.
Category 5: Staff Focus
Item Area to address: Critical Process Performance Measure
5.3.Staff Well-being and Satisfaction 5.3.1. Work Environment: How the institution maintains conductive environment in regard to patient safety. 5.3.1.1. Institution's patient safety goals are integrated in institution's everyday healthcare delivery functions, regularly reviewed and improved and progress towards them is continuously monitored and evaluated.
5.3.2. Staff Support and Satisfaction: How the institution determines staff satisfaction in implementation of patient safety systems. 5.3.2.1. Institutional mechanisms for periodic gathering of information on healthcare providers' opinions and expectations in regard to factors enhancing or inhibiting communication of sentinel events and using the results of the analysis of all collected data for institutional patient safety improvement. 5.3.2.2. Staff satisfaction is promoted by actively providing feedback on patient safety system implementation.
5.3.3. Staff Support and Satisfaction: How the institution includes medical staff attitudes and satisfaction in implementation of patient safety systems. 5.3.3.1. Medical staff participation and support of safety environment within the institution.
Category 6: Process Management
Item Area to address: Critical Process Performance Measure
6.1. Patient Safety System 6.1.1. Patient Safety System: How the institution determines patient safety process requirements and involves patients and other stakeholders in design and redesign of patient safety processes. 6.1.1.1. Accreditation, professional and legal requirements as well as improvements resulting from stakeholder surveys and reporting systems results analyses are incorporated in institution's patient safety systems and processes on a regular basis.
6.1.2. Patient Safety System: How the institution designs patient safety systems. 6.1.2.1. Evidence that Quality Improvement (QI) methodology, including but not limited to RCA, FMEA, Plan-Do-Study-Act Cycle (PDSA, Rapid Cycle Change), clinical performance measures and best practices are used to decrease variability of healthcare delivery and improve patient safety outcomes.
6.1.3. Patient Safety System: How the institution ensures that patient safety requirements are met at the "sharp end" of the healthcare delivery system. 6.1.3.1. An institutional mechanism exists for continuous monitoring, improvement and sustainability of patient safety outcomes in healthcare delivery.
6.1.4. Campus security: How the institution ensures that patients feel secure arriving for and leaving appointments for care. 6.1.4.1. An institutional mechanism exists for continuous monitoring, improvement and sustainability of a campus environment that promotes a feeling of safety and security, and supports the healing process without adding stress regarding personal safety.
6.2. Support Processes 6.2.1. Patient Safety Support Processes: How the institution coordinates departmental and interdepartmental patient safety infrastructures to reduce variability in healthcare delivery and improve performance. 6.2.1.1. Systems for departmental and interdepartmental communications, collaborations and aligned effort in regard to seamless implementation of best practices and clinical guidelines in patient identification, medication and continuous case management are assessed and improved on an ongoing basis.
6.2.2. Patient Safety Support Process: How the institution includes suppliers and partners in safety initiatives and process development. 6.2.2.1. Safety compliance evaluations of suppliers and partners (including medical staff).
Category 7: Institutional Performance
Item Area to address: Critical Process Performance Measure
7.1. Patient Safety Institutional Performance 7.1.1. Patient Safety Results: How the institution ensures patient safety 7.1.1. A 2-identifier system for patient identification is in place and is consistent in the continuity of healthcare throughout the institution.
7.1.2. Healthcare departmental and interdepartmental communications are accurate and reliable at different institutional levels.
7.1.3. The institution monitors the administration of high-alert medications.
7.1.4. Proper marking of surgery sites is established as a precaution to decrease incidents of wrong-side surgery (where applicable).
7.1.5. The institution ensures adequate professional staff preparation for proper and safe use of infusion pumps (where applicable).
7.1.6. The institution ensures adequate professional staff preparation for proper and safe use of clinical alarm systems (where applicable).
7.1.7. The institution ensures a non-punitive approach for reporting all adverse events and near misses.
7.1.8. The institution ensures proper staff is dedicated to support and conduct RCA, FMEA, and implement QI methodology in analyzing multidimensional patient safety practices at different institutional levels.
7.1.9. The institution ensures that an accessible, confidential and adequately functioning reporting system is in place for reporting all adverse events and near misses.
7.1.10. The institution ensures that a uniform, unambiguous and comprehensive nomenclature for reporting of adverse events and near misses is adopted throughout the healthcare institution.
7.1.11. The institution proactively works towards changing the traditional culture of "blame and shame."
7.1.12. The institution ensures safe healthcare delivery through utilization of modern technology.
7.1.13. The institution ensures that professional, accreditation and legal requirements in the area of patient safety are adequately addressed.
7.1.14. The institution ensures that national benchmarks in healthcare delivery (best practices, clinical performance measures, etc.) are used to decrease variability of healthcare delivery and improve patient safety outcomes.
7.1.15. The institution assures that appropriate leadership development and education in the area of patient safety is provided on an ongoing basis.
7.1.16. The institution assures that appropriate staff development and education in the area of patient safety is provided on an ongoing basis.