The required organizational practices (ROPs)

By

Abdalla Ibrahim Healthcare Surveyor

Accreditation Specialist

May, 2013

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mailto:[email protected]

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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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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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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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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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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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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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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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Health & Medicine

The required organizational practices (ROPs)