Appendix G
Governance Board
LD.04.04.05  The Organization has an organization-wide,
Integrated patient safety program
Sentinel Events

SETMA has a six-clinic structure spread over thirty miles with ten different pods (team units organized within a clinic).  In 2014, a seventh clinic will be added which is at an eighty mile distance.  In addition, the clinic has three, geographically diverse hospital affiliations and twenty-two nursing home relationships. 

The patient safety program is supported by digital telephone and extension services throughout all clinical settings.  In addition, SETMA maintains secure web portal communication with all patients from all site and a health information exchange between all of our locations and multiple other sites in the medical neighborhood. 

All patient encounters are completed in the same EHR whether at all clinics, hospital, emergency departments, nursing homes, etc.  All patient documents are instantly available in all locations.  The following documents are made completed at one location and with two-factor authentication and other surety measures are instantly available at all sites:

• Hospital Admission Plan of Care and Treatment Plan
• Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan
• Disease Process Plan of Care and Treatment Plan
• Preventive and Screening Clinical Decision Support
• Health Maintenance Auditing
• Medical Home Summary
• Referrals in process and status
• Provider Workflow
• Patient Request for Information
• Transitions of Care Information
• Follow-up Telephone Call
• Consultation Results
• Cardiovascular Risk

In addition, the following care audits are done centrally which simultaneously audit all patient care at all sites:

• Quality Metric Improvement
• Unanswered Telephone calls
• Unanswered request for information
• Unanswered request for medication refills
• Population Management Audits for deficiencies of care
• Patient missing important visits
• Care Coordination needs for overcoming barriers of Care
• Use of Potentially High Risk Medications
• Complaints and complaint resolution
• Access of same-day appointments
• Responding to a telephone request within two hours

In analyzing, SETMA’s approach to patient safety and quality improvement, the Governance Board has reviewed the Joint Commission’s discussion of a “sentinel effect,” and includes in this appendix the following statement from the Commission’s website:

“In support of its mission to continuously improve the safety and quality of health care provided to the public, The Joint Commission reviews organizations’ activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys and, as appropriate, for-cause surveys.

• “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
• “Such events are called ‘sentinel’ because they signal the need for immediate investigation and response.
• “The terms ‘sentinel event’ and ‘medical error’ are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.”

In the ambulatory setting, most sentinel events relate to medication errors.  SETMA’s systems enable us to avoid patient specific medication allergies, medication/medication errors and condition specific medication errors.   SETMA reviews any medication errors which occur; however, they are rare.

Physical injury due to falling is minimized with OSHA compliant plant review and with assistance for patients who are vulnerable to falls.   Patient and employee slips and falls are tracked by clinic location. These are discussed bi-annually during the Risk Management Committee meetings.