February 18, 2009 | | Comments 0
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Safety education for LIPs doesn’t have to center on test scores

A safety officer at a healthcare system with 800 licensed independent practitioners (LIPs) asked me whether it was acceptable to The Joint Commission that instead of an annual safety test, physicians read material relative to risks in the environment and attest to their knowledge and by signing a form.

She specifically pointed to EC.03.01.01, which requires staff members and LIPs to be familiar with their roles in the EC.

First off, the language involved in establishing the expectations comes down to an individual’s ability to “describe or demonstrate” methods, actions, reporting, etc. The acceptability of one strategy versus another is a function of the organization’s determination based on ongoing monitoring of data (more on that in a moment) rather than a function of Joint Commission process.

To be honest, I’m not necessarily a big fan of using test scores as a gauge of the success of education programs. I think scores are usually more indicative of how well a person can take a test, but that’s me.

Where the rubber meets the road is out in the physical environment: Are folks (including the physicians) managing those daily risks appropriately, do they know what they are doing, etc.?

That’s where hazard surveillance/safety rounds become the most useful data source for validating the effectiveness of education (you can also review occurrence reports, results of root cause analyses, etc.).

The level of knowledge is going to be different for each constituent group. I really don’t think that organizations can get the physicians to clean up spills, but they should be able to let someone know that there is a spill). It becomes the responsibility of the EC committee to identify what the core knowledge needs are for each group and to enact an education process that provides that information to folks.

If you can look a surveyor in the eye and say that you know your process is effective because of XYZ, and show them the data to support that assessment, then you are in absolute compliance with the standard. It’s not the how that matters – it’s the end result.

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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