CPHRM Review Course - Patient Safety - Feb 2025 PDF

CPHRM course Dr. Sahar Khalil Alhajrassi Consultant prosthodontic SB-Prosth, CPHQ, CPHRM, EFQM, HMP mini-MBA, strategic planning and KPI practitioner, 1 Certified Professional Healthcare Risk Management (CPHRM) Review Course - F...

CPHRM course Dr. Sahar Khalil Alhajrassi Consultant prosthodontic SB-Prosth, CPHQ, CPHRM, EFQM, HMP mini-MBA, strategic planning and KPI practitioner, 1 Certified Professional Healthcare Risk Management (CPHRM) Review Course - Feb 2025 2  AGENDA The CPHRM Examination. Exam Answering Strategies. Patient Safety domain. Risk Financing domain. Claims Management domain. Legal & Regulatory domain. Healthcare Operations domain. 3  The CPHRM Examination A credential not a certificate. 110 MCQs (100 scored & 10 pre-test) 5 content domains Answered in 2 hours. AMP/PSI administers the exam www.GoAMP.com 4  Risk Manager Duties…….. Prevention, reduction, and control of loss to healthcare organization, patients, visitors, volunteers, physicians, and other colleagues. Interfacing with a number of healthcare professionals in incident investigation and analysis, tracking, trending and evaluation, risk financing and claims management. 5  Exam Eligibility Must fulfill ONE of the following requirements for education/healthcare experience AND meet the requirement for risk management experience: Education/Healthcare Experience ❑ BA degree or higher from an accredited college or university plus 5 years of experience in a healthcare setting or with a provider of services to the healthcare industry. ❑ Associate degree or equivalent from an accredited college plus 7 years of experience in a healthcare setting or with a provider of services to the healthcare industry. ❑ High school diploma or equivalent plus 9 years of experience in a healthcare setting or with a provider of services to the healthcare industry. Risk Management Experience 3000 hours or 50% of full-time job duties within the last 3 years dedicated to healthcare risk management in a healthcare setting or with a provider of to the healthcare industry. 6 Exam Content (1)Recall: The ability to recall or recognize specific information. (2)Application: The ability to apply knowledge to new or changing situations. (3)Analysis: The ability to analyze and synthesize information, determine solutions and/or evaluate the usefulness of a solution. 7 Studying Material 8  Exam Application Process AMP/PSI administers the exam. Submit an online application and pay fee: $ 275 ASHRM members (1,000 SAR) $ 425 Non-member (1,600 SAR) A candidate must make an appointment to take the CPHRM Examination within 90 days from confirmation of eligibility from PSI. [email protected] 9 10 11 12 13 14 15 16 17 18 19 20  Renewal Requirement Successful re-examination: To renew this way, successfully pass the CPHRM Certification Examination no more than one year prior to expiration of your CPHRM. NO Renewal fee required. OR Completion of 45 contact hours of eligible continuing professional education: over the 3 year period and payment of the renewal fee: $ 135 ASHRM Member (500 SAR). $ 225 non-member (850 SAR). 21  Exam Answering The Answer is 1.Make Predictions: as you read guess what the answerStrategies will be. the only correct answer. 2.Eliminate Answers: getting down to not subject to opinion. just two remaining possible choices represents what is correct in actual (50/50 chance). practice. 3. Hedge & extreme phrases: “likely, may, can, will often, The Distractors are sometimes, often, almost, mostly, defensibly incorrect. usually, generally, rarely, sometimes” (cover every possibility). not partially correct. “exactly, only , never and always” not incredibly obvious. (definite answer). plausible to those who don’t 4.Time management: (minute per question). know the correct answer. 5.Use your common sense and often reflect misconceptions and relate to work experience. errors. 22 CPHRM EXAM 23 24 Clinical / Patient Safety 25 objectives 26  Outlines Looking for risks in all the right places – High Risk Areas. Patient Safety. Sentinel Events. RCA. FMEA. Patient Safety Challenges. Critical Incident Debriefing. Patient Safety Disclosure. Measuring A culture of Safety. 27 History 28  High risk clinical areas Need interpreter Res Ipsa loquitor Privilege for intubation Limited interruption Anthologist 24H SBAR, CRM Sequester equipment and sedation during handoffs 29 Care bunddle  High risk clinical areas Renal patient 1st place patient visit Assessment for competence contraindicated for No duty to emergency treatment 1St action sitter Duty to worn contrast material EMETAL Mandatory reporting Restrain need reassessment after 1hour FDA,SMDA Vulnerable patient If pt died mandatory reporting to CMS OSHA radiation Separate authorization 30 31 32 33 34 35 36 Patient Safety infrastructure 37 38 39 Stages of maturity in a safety culture 40  Just Culture: No punishment for human error. - Leadership seeks to learn from mistakes Punishment for : Willful misconduct. Reckless Behavior. Unjustified deliberate violation of rules. 41  42 42 43  Just Culture: Mental Processing Errors Reliance on short-term memory. Write down –read back Interruption during task execution. Poor design of tasks and devices. 44 44  In a Just Culture accountability Model: Individuals are held accountable for their own individual performance. Leadership Acknowledges the unintentional nature of human error. Leadership Seeks to learn. 45 45  Just Culture: Why We Need It - Only 2-3% of errors reported - Most hospitals unaware of the extent of error - Health care workers would report only what they could not hide - Errors, as viewed by hospital workers and the public, are indicators of carelessness 46 46 47  AHRQ Suggestions for Just Culture Walk-rounds. (Leadership Rounding) Open book management and biweekly huddles. Hotline for reporting and anonymous reporting. Involve staff directly in problemsolving. Educate hospital leaders about making error reporting anonymous, easy, convenient and non-punitive Charge leadership with developing annual plans, hold them accountable and require periodic progress reports. Re-evaluate disciplinary policies. Congratulate for their contribution. AHRQ common format: 48 Walk-rounds. (Leadership Rounding) Leading by example Demonstrates support for making safety a high priority Increase awareness of safety issues - Educate staff about safety concerns - Identify barriers to safety - Evens the playing field Follow-Up - Record the data - Initiate PI project - Inform the front line of trends/actions 49 49 A Just Culture Encourages and Supports Reporting (near miss – PCE- SE) Help to prevent future patient harm Guide performance Provide an improvement indication of human and Provide an system opportunity to performance identify risks 50 50 51 52 53 54 55  More Reporting Less Blame One’ Own Violation of One’s Own Policy Errors of Other Human Error Individuals Equipment 56 57 58 59 60 b. Real time quality assurance 61 b. Real time quality assurance 62 63 64 HRO-High Reliable Organization 65  Organizations that operate in complex system without mistakes over long period of time 66 1. Sensitivity to operations. Preserving constant awareness and vigilance by leaders and staff about the state of the systems and processes affecting patient care. This awareness is central to noting risks and preventing them. 2. Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work, or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential to understand the true reasons patients are placed at risk. 3. Preoccupation with failure. When near misses occur, these are viewed as evidence of systems to improve for reduction of potential harm to patients. Rather than viewing near misses as proof the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention. 4. Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes work and the risks patients face, high reliability in the organization’s safety culture may not be possible. 5. Resilience. Leaders and staff need to be trained and prepared to know how to respond when system failures do occur. 67  Use of data in patient safety Data awareness Data analysis Data inventory Data trending. Event Categorization : Taxonomy. Trigger tools. RCAand FMEA. Near miss. Incidents data. Infection Control data. Pharmacy data. Equipment's data. Radiation safety data. Use data to meet RM goals 68  Confusion about the use of data Analysis of rare events rather than large number of events Multiple data steams without a defined process on how to view data No central repository Survey bias 69 70 71 72 73 74 75 76 77 Taxonomy: naming-defining and calcify the event according to severity of the outcome Necessary and important for patient safety: Provides common language to classify events. Provides known way for providers to communicate about specific events. Promotes comparison with other organizations. Example: NCCMERP Index for categorizing errors. National council coordination medical error reporting and privilege 78 79  D 80 81 82  Relation between human and enviroment “We can not change the human condition, but we can change the conditions under which humans work” James Reason. Factors that are Factors that directly Factors that directly present before action permit decision allow decision making takes place execution Fatigue, stress, Perception, boredom memory, Communication attention Reasoning, Ability to carry Dehydration, judgment out intended hunger action 83 83 84 85  Human and Fatigue : Fatigue can impact an individual’s performance and personality Reduce decision-making ability Prolong response time Increase lapses in attention Negatively affect short-term memory Lessen ability to multitask Increase irritability, moodiness, and depression Decrease ability to communicate 86 86 Cognitive – confirmation –hindsight (I know it) Using biases or what is known as “cognitive dispositions to respond”, such as: Jumping to conclusions Seeing what is already expected whether actually there or not Overconfidence bias Sunk costs Diagnostic errors responsible for preventable errors in hospitalized patients) missed, wrong or delay) Bias toward action 87  Human Factors – Mental Short Cuts: There are four categories of errors seen in healthcare: 1. Availability Heuristics (easily remembered) Diagnosis based on past experience. 2. Anchoring Heuristics (Premature closure) Diagnosis made from initial impression, not supported by subsequent data. 3. Framing effects (related to context) Diagnosis unduly influenced or prejudged by collateral information. E.g., Known drug addict diagnosed with overdose rather than stroke. 4. Blind obedience Diagnosis made from undue reliance on lab results. 88  There are four categories of errors seen in healthcare: 1. Availability Heuristics (easily remembered) Diagnosis based on past experience. 2. Anchoring Heuristics (Premature closure) Diagnosis made from initial impression, not supported by subsequent data. 3. Framing effects (related to context) Diagnosis unduly influenced or prejudged by collateral information. E.g., Known drug addict diagnosed with overdose rather than stroke. 4. Blind obedience Diagnosis made from undue reliance on lab results. 89 Human error – risk behavior – reckless behavior 1- Human error : Slips: tend to occur in situations that are so routine that they have become rote Lapses: generally not visible because reflective of a memory failure Mistakes: error in decision making ,in correct planning - complex than slips; go undetected for period of time Knowledge based :lack of knowledge, skill Rule based: good rule applied incorrectly or a bad rule applied solution : redesign the system ,console worker 90 Human error – risk behavior – reckless behavior 1- Human error : Slips: tend to occur in situations that are so routine that they have become rote Lapses: generally not visible because reflective of a memory failure Mistakes: error in decision making ,in correct planning - complex than slips; go undetected for period of time Knowledge based :lack of knowledge, skill Rule based: good rule applied incorrectly or a bad rule applied solution : redesign the system ,console worker 91 Human error – risk behavior – reckless behavior Active Failures Highly visible errors with immediate consequences Latent Failures May be hidden for years and generally rooted in organizational culture 92 The Anatomy of Errors in Health Care Blunt end of Organizational Factors – the system Culture, policies, procedures, regulations Environmental Factors – Equipment, staffing, resources, constraints Sharp end of the system Human Factors – Clinical competency, communication skills, problem solving skills 93 Human error – risk behavior – reckless behavior 2 -risk behavior : behavior choice , Intentional action but unintended outcome. - With repeated behavior, our sense of risk will be reduced solution : coaching (manger –staff) 94 Human error – risk behavior – reckless behavior 3- reckless behavior : putting yourself or others at risk. Solution :disciplinary action we need to design a safe care : 95 96 97 98 99 100  Disruptive and inappropriate behaviors Applies to employees, patients, families and visitors Physical and/or verbal behavior Address in entity policy & procedure Conduct education around application of policy & procedure Provide counseling/support for staff involved if needed 101  Human-error reduction strategies Communication and Teamwork. Interface must exist between patient safety and QI or PI departments. Use of technology in Patient Safety. Patient Safety Guiding Principles: Simplification. Standardization. Use of Constrains and Forcing Functions. Use of Protocols and Checklists. Avoidance or reduction of Stafffatigue. Heighten awareness and understanding of error reduction and prevention through communication and training. 102 103  All of the following are effective error prevention strategies except: 1. Decreasing the number of steps in a process 2. Reducing handoffs during a process 3. Adding multiple double checks 4. Providing adequate training to “front line” staff 104  All of the following are effective error prevention strategies except: 1. Decreasing the number of steps in a process 2. Reducing handoffs during a process 3. Adding multiple double checks 4. Providing adequate training to “front line” staff 105 105 106 107  D 108 109  A 110 111 112  The Institute of Medicine: “To Err is Human” Estimated that approximately 50,000 to 100,000 inpatients die each year because of medical errors Committee on Quality Health Care in America Project: “Crossing the Quality Chasm” Biggest challenge is to establish a “just culture” in the reporting of events STEEP 113  The Institute of Medicine: “To Err is Human” Estimated that approximately 50,000 to 100,000 inpatients die each year because of medical errors Committee on Quality Health Care in America Project: “Crossing the Quality Chasm” Biggest challenge is to establish a “just culture” in the reporting of events STEEP 114  National Patient Safety Foundation NPSF: independent, non-profit organization “a central voice for patient safety” Supported by well known patient safety leaders Enhances patient safety awareness through Educational programs for professionals Research project grants Awareness campaigns Supports and encourages patient and family involvement 115  The Leapfrog Group A coalition of Fortune 500 companies concerned about the impact of medical errors on the employees for whom they purchase health care benefits Computerized physician order entry (CPOE) Evidence-based hospital referral ICU physician staffing Leapfrog Quality Index –based on NQF’s Safe Practices Leapfrog Surveys 116  National Quality Forum Private nonprofit organization seeking to improve US healthcare Develop consensus standards Published set of 34 hospital safe practices aimed at reducing harm to patients Published set of 28 Serious Reportable Events –never events Of concern to public, healthcare professionals, and providers Identifiable and measurable Risk of occurrence is significantly influenced by the policy and procedures of the organization Patient Safety Taxonomy 117  AHRQ –Culture Survey and Patient Safety Indicators Patient Safety Culture Survey PSIs focus on potentially preventable complications and iatrogenic events for patients treated in hospitals and are measures that screen for adverse events PSQIA To improve patient safety and reduce the incidence of events that adversely affect patient safety Creates “Patient Safety Organizations” (PSOs) Establishes “Network of Patient Safety Databases” (NPSD) Provides federal confidentiality protections for analyses and reports completely voluntary Makes patient safety a strategic priority Medical errors are caused by: (1) Communication problems (2) Inadequate information flow (3) Human factor-related problems (4) Patient-related problems 118  CMS –Hospital Acquired Conditions (HACs) CMS to select conditions that are: High cost, high volume or both; Assigned to higher paying DRG when present as a secondary diagnosis; and Could reasonably have been prevented through the application of evidence-based guidelines 119  The Joint Commission: Identifies the National Patient Safety Goals (NPSGs) and makes recommendations to The Joint Commission May recommend retirement of selected NPSGs to maintain the focus of accredited organizations on the most critical patient safety issues Reviews draft patient safety suggested actions for potential publication in The Joint Commission's Sentinel Event Alert patient safety advisory 120  Retired Goals Free-flow IV’s Universal Protocols Alarms Abbreviations U = units MSO4 Leading and trailing 0’s All applicable NPSGs or acceptable alternative approaches must be implemented. Surveyors evaluate the actual performance, not just the intent of meeting the NPSGs. NPSGs are scored as either Compliant or Not Compliant. Failure to comply with a NPSG will result in a “Requirement for Improvement” (RFI). 121 122 123 124  Sentinel Event event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm or severe temporary harm comply with Joint Commission requirements voluntary reporting of sentinel events Must conduct a root-cause analysis (RCA) on all sentinel events 125 125  Sentinel Event The event is one of the following Suicide of any patient receiving care, treatment, and services in a staffed around- the-clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED) Unanticipated death of a full-term infant Discharge of an infant to the wrong family Abduction of any patient receiving care, treatment or services Any elopement leading to death, permanent harm, or severe temporary harm to the patient Hemolytic transfusion reaction involving major blood group incompatibility Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the 126 hospital 126 127 128  Root Cause Analysis –RCA: A process to identify the most basic causal factor or factors that underlie a variation in performance, including the occurrence of sentinel event It identifies changes that could be made in the system and processes When? Sentinel events Adverse events Near misses 129  Root Cause Analysis –RCA: A process to identify the most basic causal factor or factors that underlie a variation in performance, including the occurrence of sentinel event It identifies changes that could be made in the system and processes When? Sentinel events Adverse events Near misses 130 130 131  Root Cause Analysis –RCA: Preparing for a Successful RCA Interdisciplinary review that includes those closest to the process Focus on systems and processes rather than individual performance Analysis digs deep until all factors(Contributory, Direct:, Root:) are identified Analysis identifies changes that can be made in systems and processes Who’s Running the Show? 132  Root Cause Analysis –RCA: Define the problem What?? Gather evidence/data Identify issues that contributed to the problem How?? Find root causes Develop solution recommendations Implement the recommendations What now?? Observe the recommended solutions to ensure effectiveness 133  Root Cause Analysis –RCA: Investigations Should Represent Just or Fair Culture Understanding of System Failures In-depth review of problem and opportunity to make system changes that Human Physical Latent Tools: 134  Root Cause Analysis –RCA: Advantages of Reporting Sentinel Events Enables lessons learned to be added to The Joint Commission’s sentinel event database and contributes to general knowledge of the causes of such events Provides for an opportunity to consult with The Joint Commission staff on development of RCA and action plan Sends a positive, proactive message to the public Promotes transparency assist in prioritization of events, hazards and vulnerabilities in the system 135 - RCA ACTION PLANS: TJC Requirements - GOAL: - Action Planning Tools - Benefits of a early draft action plan - Components of Action Plan - Recommendations will fail if: 136  Submitting RCA to TJC a) Submit RCA and action plan to The Joint Commission Organization should consider their comfort level with preserving the confidentiality of the reports May take reports directly to TJC offices in Illinois May pay for TJC staff to come to the hospital to review reports May submit a summary of RCA, action plan, relevant policies, etc 137 138 139 140  Failure Mode, Effect, and Criticality Analysis (FMECA) Method used to identify those risks inherent in care delivery FMECA is a proactive model designed to identify weak points, incidents or events before they occur The Joint Commission requires hospitals to select one high-risk process at least every 18 months upon which to conduct a proactive risk assessment (FMECA is one method) 141 TJC Patient Safety Standards require organizations to develop policies and procedures for which of the following? 1. Proper response to an adverse event 2. Prevention of accidental harm 3. Disclosure of adverse events to patients and families 4. Fiscal accountability A. 3 only B. 1 and 3 only C. 1, 2 and 3 only D. All of the above 142 143 Critical Incident Debriefing: Can occur for any reason Do it when memories are fresh Include the members of the “team” Don’t “point fingers” Provide a safe environment of inclusion An opportunity for individual, team and organizational learning The greater the specificity, the better What would we do differently next time? What did we do well? What did we learn? 144 Patients as Partners in Patient Safety Partnering With Patients to Reduce Medical Errors Education Health care literacy Speak-up campaign Decision-making Disclosure and transparency Fair and “just” culture Teamwork Let’s Talk! Speak up The Joint Commission (The JC) Patient participation Root Cause Analysis (RCA) Failure Mode, Effect and Criticality Analysis (FMECA) Patient Safety information Rapid Response Team (RRT) Driven by medical profession Driven by patients (Condition H) 145 Patients as Partners in Patient Safety Patient rights for empowered consumers and risk managers Organization has multiple goals Education of professional staff, leadership, frontline staff and others To ensure quality consumer care and patient safety To prevent claims that can impact the organization’s business portfolio Informed consent Bill of rights Consumer Rights and Responsibilities: 1997 Advisory Committee on Consumer Protection and Quality Information disclosure Choice of providers and plans Access to emergency services Participation in treatment decisions Respect and discrimination provisions Confidentiality of health information Complaints and appeals Consumer responsibilities 146 Patients as Partners in Patient Safety The “new patient” 1. Patients have become more educated consumers 2. New patient focus that addresses Access Choice Affordability Availability Timeliness Satisfaction Quality Rights 147 Patients as Partners in Patient Safety Increasing patient/consumer responsibilities Individuals have legal obligation to exercise caution and refrain from negligent acts that result in injury to others Individuals have duty to refrain from negligently exposing themselves to harm Patients are required to assume increased control of their personal health care and to communicate their health care needs to their providers 148 Patients as Partners in Patient Safety New risk challenges/new competencies Caring competence Cultural competence Culture is composed of the beliefs, values, morals, customs, traditions, knowledge and habits acquired through living in the community and within society Addressed in TJC standards Guidance provided by the US Department of Health and Human Services Potential for “cultural negligence” claims Educational competence Internet Direct-to-consumer advertising Community 149 Patients as Partners in Patient Safety Risk Interventions Safety policies articulating support of the organizational mission and values Posting patient rights Credential staff on matters involving newly identified competencies Promoting cultural knowledge and competent care Training staff to improve communication and patient education skills Grievance policies and appropriate execution of policies Evaluating patient education and training Addressing diversity through interdisciplinary quality improvement activities Literacy testing on all patient education materials and tools Assessing community needs 150 151 152 153 154 155 156  Patient Safety Challenges: 1 2 3 4 5 6 7 Electronic Electronic COPE. Bar coding. Robotics. eICUs. SmartPumps. Health Record. Medical Record. 157  delivery of news to the patient or family that they may not otherwise learn Purpose: to give patients/families information they need to make further decisions Medical decisions Decisions to pursue legitimate compensation It is not strictly related to medical error, nor necessarily to bad news 158  Key Concepts First obligation always to the immediate needs of the patient(stabilization, comfort, care, etc.) Obligation to discern facts from “hearsay” Obligation to come from a place of integrity Obligation to take care of the needs of providers and others involved in the incident Recognize that disclosure is a process that will require multiple discussions, not an “event.” Recognize that the purpose of disclosure is not to avert litigation, but to respect the integrity of the patient/caregiver relationship. Whatever promises are made during this process must be kept; trust is at stake. Maintain close contact with the patient/family during the process. Do not put the onus of responsibility on them to maintain the relationship. 159  Reasons to Disclose: Right thing to do Patients expect it Professional responsibility Earn trust/possibly forgiveness of patient Supports patient safety initiatives Required by The Joint Commission for unanticipated outcomes 160 Framing the Conversation: Acknowledgement that adverse event occurred An explanation as to why it happened Statement that organization taking event seriously and investigating it Statement that organization taking steps to prevent similar event from happening An apology (as appropriate) 161 The Four “R”s of Apology: 1.Recognition Knowing when an apology is in order 2.Regret Responding empathetically 3.Responsibility Owning up to what has happened 4.Remedy Making it right 162 Barriers to Disclosure Fear of legal liability Fear of loss of credibility and reputation Fear of loss of licensure Fear of punishment by organization or loss of job Feelings of vulnerability Difficulty in accepting role in error System Barriers We’ve always done it this way Hierarchical structure of medicine Profession demands perfection Struggle with accepting even most well trained and competent can make mistakes Conflict of Interest 163 A successful disclosure allows the patient and family: To understand what happened To understand the ramifications of the event To have sufficient information to make future decisions (including seeking compensation) To receive an apology from the organization To begin to heal 164  Communication : 1- feedback 2- culture ,physical challenge 3- intial visit 4- handling crying , anger, denial 5- end conversation 6- demeaning ,rude beahvior 7- un cooperative patient 8- communication () teamwork ,barriers 9- personal style of provider 10- patient complain 11- apologies 165 Measuring a Culture of Safety Survey Rounding Reporting Trust 166  AHRQ: Hospital Survey on Patient Safety Culture Communication openness Feedback & communication  Staffing about error  Supervisor/manager Frequency of events expectations & actions reported promoting safety Handoffs & transitions  Teamwork across units Management support for  Teamwork within units patient safety  Two additional questions Non-punitive response to ▪ Overall grade on patient error safety Organizational learning ▪ Number of events reported Overall perceptions of in last 12 months patient safety 167  Measuring Patient Safety: “The delivery of survey results is not the end point in the survey process; it is just the beginning. Often, the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey follow up.” 168  Measuring Patient Safety: “Pre and Post Safety Interventions Utilize results for PI Action Plan Understand your results Communicate and discuss the results Develop focused action plans Communicate action plans and deliverables Implement action plans Track progress and evaluate impact Share what works 169  Patient Safety Metrics Involves both reactive and proactive measures Good catches resulting in a practice change Number of FMECAs Number of RCAs resulting in a P&P change Sentinel events with and without disclosure Number of disclosures involving risk management Number of lessons learned from RCA that impacted more than 2 units Participation in a periodic PS culture survey Number of committees/family councils in which patients/families participate 170