The Compliance Guide to The Joint Commission’s Patient Safety Systems Chapter

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The Compliance Guide to The Joint Commission’s Patient Safety Systems Chapter

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The Compliance Guide to The Joint Commission’s Patient Safety Systems Chapter

Sena Blickenstaff, BSN, MBA

Prepare for the new Patient Safety Systems chapter with The Compliance Guide to The Joint Commission’s Patient Safety Systems Chapter.

The Joint Commission added a new Patient Safety Systems (PS) chapter that became effective on January 1, 2015, and highlights the accreditor’s patient safety requirements.

The new chapter explains how to become a learning organization, the role of hospital leaders in patient safety, use of data and reporting systems, conducting proactive risk assessments, and patient involvement.

This book provides insight into the existing standards that comprise this new chapter and will help you put together an integrated patient safety system in your facility.


  • Prepare for The Joint Commission’s new Patient Safety Systems chapter
  • Analyze data to improve quality of care and reduce patient harm
  • Develop sustainable patient safety systems to enhance quality and safety
  • Effectively analyze and use data to identify and mitigate risk and enhance the knowledge, skills, and competence of staff
  • Understand the expectations under The Joint Commission’s new Patient Safety Systems chapter
  • Align existing Joint Commission standards with clinical care processes and work activities
  • Align Clinical Transformation™ with process improvement methodologies to promote and foster sustainable patient-centric safety systems

Table of Contents

  • Chapter 1: Understanding The Joint Commission’s New Patient Safety Systems Chapter
  • Chapter 2: The Role of Leadership in Patient Safety Systems
  • Chapter 3: Leadership and a Culture of Safety – Systems of Care
  • Chapter 4: Safety Program
  • Chapter 5: Surgical Services, Anesthesia Services, and Infection Prevention Systems of Care
    • Collecting and Analyzing Data
  • Chapter 6: Infection Prevention and Control
    • Proactive Risk Assessment and Risk Mitigation
    • Cleaning, Disinfecting, and Sterilizing
  • Chapter 7: Dialysis – Contracted Services Oversight as a Leadership Safety System
  • Chapter 8: Patient Involvement and Patient Rights
  • Chapter 9: Quality Assurance/Performance Improvement
    • Validating High-Quality, Safe Patient Care
  • Chapter 10: Dialysis Patient Care
    • Key Performance Indicators and Survey Strategies
    • Data Collection and Analysis
  • Chapter 11: ED – Behavioral Health Patient
    • Environmental Proactive Risk Assessment
    • Using Data to Drive Improvement
  • Chapter 12: ED – Behavioral Health Patient
    • Clinical Proactive Risk Assessment
    • Kaizen!
  • Chapter 13: Aligning Clinical Transformation™

About the Author

Sena Blickenstaff, BSN, MBA, is a dynamic healthcare leader and former Joint Commission and CMS deemed status surveyor with more than 25 years of progressive experience in hospital and ambulatory services leadership and accreditation/regulatory preparedness. Her responsibilities have encompassed strategic planning, business development, regulatory compliance/survey preparedness, clinical integration, and service line optimization in organizations ranging from critical access hospitals to large, multi-site healthcare systems.

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Published: April 2015

Page count: 268
Dimensions: 8.5x11
ISBN: 978-1-55645-295-6