Accountability & Transparency-FREE No CME Option-Building a Culture of Safety - Accountability and Transparency (720p HD)

Video Transcription

Video Summary

This webinar in the “Building a Culture of Safety” series focused on Domain 4 of the CMS Patient Safety Structural Measure (PSSM): accountability and transparency. The presenter, clinical improvement consultant Amanda Donlan, reviewed how hospitals will attest to statements across five PSSM domains via the Hospital Quality Reporting (HQR) system, with public reporting on CMS Care Compare and scoring based on domains fully met.  <br /><br />Domain 4 emphasizes open discussion of safety events, non-punitive reporting, learning from harm, and sharing safety data across the organization. Key elements include: (1) maintaining a confidential safety reporting system for staff (and ideally patients) with a feedback loop; (2) reporting serious safety events, near misses, and precursors to an AHRQ-listed Patient Safety Organization (PSO); (3) tracking and visibly sharing patient safety metrics with clinical/non-clinical staff and publicly on units; (4) implementing an evidence-based Communication and Resolution Program after harm events (e.g., AHRQ’s CANDOR), including caregiver support and reconciliation; and (5) using standard measures to track that program and reporting results to the governing board at least quarterly.  <br /><br />Participants discussed current practices (dashboards, newsletters, leadership rounding, board reporting) and barriers to public transparency (data understanding, liability concerns). The session closed with resources and upcoming events.

Keywords

CMS Patient Safety Structural Measure (PSSM)

Domain 4 accountability and transparency

Hospital Quality Reporting (HQR) system

CMS Care Compare public reporting

confidential safety event reporting system

AHRQ Patient Safety Organization (PSO) reporting

patient safety metrics dashboards and unit transparency

Communication and Resolution Program (CANDOR)