By
Abdalla Ibrahim Healthcare Surveyor
Accreditation Specialist
May, 2013
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Required Organizational Practices
(ROPs)
Essential practice that organization must
have in place to:
enhance patient/client safety
minimize risk.
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The Required Organizational Practices
The ROP
Statement defines the practice that is expected.
Guidelines
Context and motivation on why ROP is important to patient
safety and risk management.
Tests for Compliance (major and minor)
Expectations of surveyors during on-site assessment to
determine compliances with ROP.
Categorized as major or minor.
Reference Material
Sources of evidence, tools and resources to assist
organizations in meeting tests for compliance.
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Pathway of Development
Developed in 2004 by Patient Safety Advisory Committee
Developing:
National and international literature reviews
Analysis of survey results and compliance rates
Research with regard to other accrediting bodies
ROPs Extensive testing and national consultation
Feedback from expert advisory committees, client organizations,
surveyors and stakeholders
ROPs reviewed and updated
New ROPs are developed as recommended by advisory
committees and field-specific consultation.
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ROPs categories
ROPs are categorized into six patient safety areas:
1. Safety culture
2. Communication
3. Medication use
4. Worklife/workforce
5. Infection control
6. Risk assessment
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SAFETY AREAS, GOAL AND ROPs
SAFETY CULTURE:
Create a culture of safety within the organization
• Adverse events
disclosure
• Adverse events reporting
• Client safety quarterly
reports
• Client safety-related
prospective analysis
e.g.
Failure Modes and Effects
Analysis (FMEA)
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SAFETY AREAS, GOAL AND ROPs
Organizational culture
The collective behavior of humans who are part of an organization.
The organization values, visions, norms, working language, systems, symbols, beliefs and habits.
The pattern that are taught to new organizational members as a way of perceiving, and even thinking and feeling.
Organizational culture affects the way people and groups interact with each other, with clients, and with stakeholders.
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SAFETY AREAS, GOAL AND ROPs
COMMUNICATION
Improve effective and coordinated communication among service providers and recipients of care
• Two client identifiers
• Safe surgery Practices (Sign in, Time out, Sign out)
• Dangerous abbreviations (Do not Do List)
• Medication reconciliation:
• at admission
• at transfer or discharge
• Transfer of Client information at a transition point:
(SBAR: Situation, Background, assessment and recommendation)
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SAFETY AREAS, GOAL AND ROPs
MEDICATION USE:
Ensure the safe use of high-risk medications
• Concentrated electrolytes (Ca >10%, Mg> 20%, K >2 mEq/ml,
Na > 0.9%)
• High alert medication: eg.
adrenergic agent,
narcotics, insulin,
chemotherapy, sedatives,
neuromascular blockaing,
heparine,
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SAFETY AREAS, GOAL AND ROPs
WORKLIFE/ WORKFORCE: Create a worklife and physical environment that supports safe delivery of care and service
• Workplace violence
prevention
• Client safety plan
• Client safety: Education
and training
• Preventive maintenance
program
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SAFETY AREAS, GOAL AND ROPs
INFECTION CONTROL:
Reduce risk of health care-associated infections and their impact across the continuum of care/service
• Hand-hygiene education
and training
• Hand-hygiene audit
• Infection rates
• Pneumococcal vaccine
• Sterilization processes
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SAFETY AREAS, GOAL AND ROPs
RISK ASSESSMENT:
Identify safety risks inherent in the client population
• Falls prevention
strategy
• Home safety risk
assessment
• Pressure ulcer
prevention
• Suicide prevention
• Venous
thromboembolism
(VTE) prophylaxis
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