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The Answer Guide and Frequently Asked Questions (FAQs) for the NQF Safe Practices section of The
Leapfrog Group’s Hospital Quality and Safety Survey
Important Notice:
Please review the FAQs below before answering the question for each Safe Practice. The NQF Safe
Practices section of The Leapfrog Group Hospital Quality and Safety Survey are applicable for all
hospitals (including rural and pediatric) unless noted in the FAQs below.
General FAQs for the Safe Practices:
1) Can the line item budget requirement be met if the budget includes categories which address
the Safe Practice, but do not specifically name the Safe Practice?
Yes, if it can be verified that any of the additional specifications or example implementations can be
identified in a line item manner within a department budget that rolls up into the hospital budget; or if
during the course of a current budget year, a department or hospital has a clear paper trail of any
outlay of expenses specific to the safe practices the intent of this question will be met.
2) In the Awareness section of many of the questions the term “direct accountability” is used.
What does this mean in the context of answering the questions?
Direct accountability refers to a senior or department level manager who has oversight responsibility
for those areas of the hospital that implementation of any particular Safe Practice may impact. This
person would be directly accountable through performance reviews or compensation incentives.
3) How does the assignment of individual accountability, ongoing monitoring, and management
of the Safe Practice better meet these requirements?
The intent of this requirement is that an individual has accountability to assure the safe practice is
fully implemented and maintained on an ongoing basis. Broad safety statements or monitoring “by
committee” does not adequately meet this requirement.
4) The phrases “personal performance reviews” and “personal compensation incentives” are
used throughout the survey within many Accountable responses. Do such reviews and
incentives need to have specific language about a safe practice, or can a set of patient safety
goals be attached?
A performance review or incentive plan should include specific language about a safe practice. A list
of safe practices and related goals may be incorporated into the performance review and/or incentive
plan.
5) If education policies and procedures for a Safe Practice are already in place and compliance is
monitored, are annual staff education and skill development programs still required?
Even if policies and procedures for a safe practice are already in place and compliance can be
monitored, annual education sessions or skills fairs are required to address frequent high staff
turnover, use of agency/traveler staff, and updated changes in policies and practices.
6) Education is a frequent requirement for credit throughout the survey. How should employee
education be measured?
To qualify for credit, educational meetings should clearly address the subject matter pertinent to
adverse events and performance improvement targeted by the Safe Practice being surveyed.
Hospitals should track meeting or presentation dates, frequency of employee training sessions
provided, attendance records and the percent of the total employee population who received the
information.
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7) If a staff educator’s role and function include education specific to the Safe Practices, does
this meet the line item budget requirement, or does the budget need to allocate a specific
amount of time to the Safe Practices?
If the staff educator’s job description identifies the specific safe practices they address in their
educational role, the intent of this item is met. Any documentation of training or education time spent
on a safe practice or expenditures on educational supplies or meeting preparation materials that
address any of the safe practices will meet the intent of the line item budget requirements. Specific
time allocations per safe practice are not required as long as there is documentation of staff
participation through meeting minutes and attendance records.
8) Why is it necessary to continue to review a safe practice once it has been implemented?
All too often in the hectic pace of providing patient care in a hospital; with frequent staff turnover and
lots of part-time employees; it is difficult to get a change in practice well established. Annual review
with monitoring and tracking of the safe practices will assure they are embedded in the operations of
the hospital and not lost in the shuffle of new staff coming in or part-time employees coming and
going.
9) Why do some commitment responses have a higher level of expectation than the action
response for the same question within a Safe Practice?
Commitment responses are designed to “set the bar higher,” and generally require expansion of
patient safety practices and activities across the hospital. Hospitals which have not yet met the action
response requirements may need to accelerate efforts to achieve a higher level of performance.
10) Why do some questions include a commitment response option, and some questions do not?
Commitment responses are designed to require a higher level of performance (e.g., expansion of
specified activities across the hospital). For some safe practices, a hospital-wide focus would not be
required, and therefore some answers do not include a commitment response option.
11) The term “senior executives” is used through out the survey. What employee categories
would qualify as senior executives?
For the purposes of the survey, “senior executives” refers to managers who are responsible for
hospital-wide departments or services.
12) How is the term “regular” used in the survey?
For the purposes of the survey, “regular” shall mean at least monthly, if typical meeting or reporting
activities are undertaken. If aggregated data is being gathered and analyzed, then such reporting
may be quarterly for the data component.
13) The term “enterprise-wide” is used throughout the survey. Does this mean throughout the
hospital, or throughout a health system?
Since individual hospitals are required to complete the survey, “enterprise-wide” refers to
departments within a hospital. For hospitals which are part of a larger health system, a desired
patient safety goal would be to roll out best practices in a coordinated program across the entire
system.
14) The phrase “frequency and severity of …” is used throughout the survey within many Aware
responses. What is the intent and how can a hospital satisfy this requirement?
In order for a hospital to be fully aware of the extent that any patient safety issue exists within the
organization, a hospital needs to review all adverse events to determine how often they occur and
establish an impact severity scale to the patient (e.g., the NCC MERP Index).
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15) What constitutes direct and regular reporting to trustees or boards of directors by a Patient
Safety Officer?
A senior executive (who may or may not have the title “Patient Safety Officer”) satisfies this reporting
requirement if he or she has responsibility for multiple and integrated areas of patient safety. Multiple
executives, who may be responsible for one area of safety each, however do not assess the overall
integrated safety issues, would not qualify.
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Individual department safety reports may be submitted to a Patient Safety Officer or senior
executive responsible for safety, who provides a comprehensive report to the Board.
Direct means personal reporting to a safety or quality sub-committee of a board of
trustees/directors or direct reporting to the board.
Regular means monthly regarding status reporting. If aggregated data is being gathered
and analyzed, then such reporting may be quarterly for the data component.
16) Can a designated full-time employee spending the majority of their time coordinating and
integrating the activities for patient safety qualify as a Patient Safety Officer?
Yes, as noted above, the title of Patient Safety Officer is not a requirement.
17) Numerous survey questions provide opportunities to generate credit for having undertaken
Performance Improvement Programs or for committing to undertake them. What are the
minimum requirements to qualify as such a program?
Performance improvement programs should include all of the following five elements: Education
regarding the pertinent adverse event frequency, severity, and/or impact of best practices, skill
building in use of performance improvement tools, measurement of process measures or outcomes
measures, process improvement, interventions, and reporting of performance outcomes.
18) How would a hospital earn maximum points for all of the Action sections dealing with
Performance Improvement projects/programs?
A hospital that has undertaken performance improvement projects on individual units and throughout
the entire hospital facility would receive full credit for both. Performance Improvement Programs must
have the five elements addressed in FAQ #17 above.
Safe Practice # 1
Create a Healthcare Culture of Safety
General Hospital
19) Ref Survey Questions 1.1, 1.13, 1.14, 1.21, 1.22: What subject matter qualifies for credit for
educational programs in the Awareness section of the culture questions?
To qualify for credit, educational meetings should clearly address the “Additional Specifications”
and “Example Implementation Approaches” sections of the NQF Safe Practices report that
relates to creating a culture of safety. Educational topics that qualify also include reliability science,
systems theory and thinking, simulation, Complex Adaptive System theory, human factors science,
and use of Failure Mode and Effects Analysis.
20) Ref Survey Question 1.1: If a hospital is involved in the IHI 100,000 Lives Campaign regarding
Deployment of Rapid Response Teams, does this help address the Awareness expectations of
this survey question?
Yes, If a hospital is collecting data on the frequency and severity of incidents of “Failure to Rescue”
and is submitting this data as part of the intervention of Rapid Response Teams, this will provide
credit towards the Awareness answers for this survey question.
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21) Ref Survey Questions 1.1, 1.13, 1.14, 1.21, 1.22: How should employee education be
measured? Hospitals should track meeting or presentation dates, frequency of employee training
sessions provided, attendance records, and the percent of the total employee population attending
the educational programs.
22) Ref Survey Question 1.2: What qualifies as a cultural survey? Does an employee satisfaction
survey qualify?
A number of surveys are readily available that specifically address culture, safety climate, and
teamwork. A general employee satisfaction survey that only measures employee satisfaction does
not qualify.
23) Ref Survey Question 1.2: How can a valid and measurable self-assessment process be
established?
The intent of this Safe Practice addresses a similar issue being addressed in the JCAHO standard PI
1.1.0 (which addresses staff and customer satisfaction). A Culture survey must be undertaken at
minimum once yearly across all the organization. Progress must be tracked and specific strategies
for remediation and performance improvement implemented.
24) Ref Survey Questions 1.2, 1.23, 1.25: Can data collection from use of Trigger Tools be used
for this Safe Practice?
Yes. Supporting source data to answer this question may include the number of charts reviewed
using a Trigger Tool or incident reporting (see example implementation approaches); performed
manually or on an automated basis.
25) Ref Survey Question 1.23: If a hospital joins the IHI 100,000 Lives Campaign and has
implemented a Performance Improvement project to deploy Rapid Response Teams, does this
help address the Action expectations of this survey question?
Yes. If a hospital has developed a Performance Improvement project to implement Rapid Response
Teams this will provide credit towards the Action answers for this survey.
26) Ref Survey Question 1.3, 1.4, 1.9: What employee categories are meant by the term senior
executives?
For the purposes of the survey, “senior executives” refers to managers who are responsible for
hospital-wide departments or services.
27) Ref Survey Questions 1.3, 1.4, 1.11: What does the term “regular” mean in terms of senior
executives in reporting or measurement of performance?
For the purposes of the survey, “regular” shall mean at least monthly, if typical meeting or reporting
activities are undertaken. If aggregated data is being gathered and analyzed, then such reporting
may be quarterly for the data component.
28) Ref Survey Question 1.3: What is meant by Executive Walk Arounds and how often should it
take place?
The Executive Walk Arounds provide visibility and access to senior management by frontline clinical
staff. Management has the opportunity to address issues and concerns in various departments while
they are on site. Monthly meetings with staff in a centralized location do not meet the intent of this
Safe Practice.
29) Ref Survey Question 1.3: What is the value of Executive Walk Rounds?
Executive Walk Arounds provide visibility and direct access to senior management by frontline clinical
staff, and as such create an opportunity to address safety issues and concerns in various
departments while on site. The process also provides an opportunity for feedback on implementation
of improvement strategies and tactics.
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30) Ref Survey Question 1.3: How can progress on the implementation of Executive Walk Rounds
be measured?
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The number of walk arounds performed per unit or clinical area may be measured for
designated time periods. Some progressive hospitals have tied incentives to regular
executive walk arounds and to reliable exchange of information on clinical unit
performance.
Some hospitals have established a feedback loop between senior executives and frontline
staff to measure the implementation of performance improvement ideas that were
generated by Executive Walk Rounds.
31) Ref Survey Questions 1.6, 1.20: What types of events should be included in “incidents,”
“errors,” and “reported events?” Does this include only major incidents and near misses, or
all events reported?
A hospital needs to review all reported adverse events and near misses.
32) Ref Survey Question 1.7: Safety Culture has a very heavily weighted score contribution. How
will hospitals that have made real progress in culture be recognized over hospitals that have
not made as much progress, however make major commitments to increase their scores in
the survey?
Hospitals are ranked in quartiles based on their raw score out of a possible 1,000 points. Of this,
Safety Culture is 263 points. To rank in the top quartile hospitals have to meet the two following
requirements:
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A hospital must first rank in the top quartile by total raw scores
A hospital must have individual scores of real progress points (not commitment points) for
each of the four most heavily weighted practices, that rank in the top quartiles for those
practices against all submitting hospitals. These four Safe Practices are: #1 – Culture of
Safety, #3 – Workforce, #9 – Communication of Information, and #18 – Anticoagulation
Services. Hospitals who have made real progress will be recognized in their ability to
qualify in the top quartile.
The second requirement, therefore, recognizes those hospitals that have made real progress in this
high point area and hospitals that have made commitments, but have much farther to go in
implementing a Safety Culture.
33) Ref Survey Questions 1.8, 1.9: What “Additional Specifications” or “Example Implementation
Approaches” cited in the NQF report may be tied to performance or personal compensation
incentives qualify for credit?
Formalized programs based on or encompassing those activities that are listed in the “Additional
Specifications” or “Example Implementation Approaches”, or Performance Improvement programs
whereby a measure of success of those activities or programs is tied to the personal performance
reviews or personal compensation incentive plans of executives.
34) Ref Survey Questions 1.9, 1.10, 1.11: What constitutes “direct accountability”?
Direct accountability refers to a senior or department level manager who has oversight responsibility
for the area of the hospital that implementation of any particular safe practice may impact.
This correlates with JCAHO Standard LD4.40, which states that Leaders ensure an integrated patient
safety program is implemented throughout the hospital.
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35) Ref Survey Question 1.11: What constitutes direct and regular reporting to trustees or board
of directors by a Patient Safety Officer or senior executive responsible for safety?
A senior executive (who may or may not have the title “Patient Safety Officer”) satisfies the reporting
requirement if he or she has responsibility for multiple and integrated areas of patient safety. Multiple
executives who may be responsible for one area of safety each, however do not assess the
integrated safety issues, would not qualify.
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Individual department safety reports may be submitted to a Patient Safety Officer or senior
executive responsible for safety, who provides a comprehensive report to the Board.
Direct means personal reporting to a safety or quality sub-committee of a board of
trustees/directors or direct reporting to the board.
Regular means monthly regarding status reporting. If aggregated data is being gathered
and analyzed, then such reporting may be quarterly for the data component.
36) Ref Survey Question 1.12: What would qualify to fulfill the additional specification by NQF to
“publicly disclose implementation of compliance with NQF Safe Practices” applicable to the
organization or facility?
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Each organization must determine how to publicize their compliance with the NQF Safe
Practices in their individual market area.
The Leapfrog Group will be publishing the results of this survey on their Web site which will
be open to the public. However, each organization must determine how to publicize their
compliance with the safe practices in their market area.
Public disclosure may include putting the results of this survey on a hospital Web site if
available, placing notices or posters throughout the organization, including information in
newsletters and annual reports that are sent to the public with other marketing materials.
If a hospital has a mechanism in place to annually report quality and safety performance
outcomes to the public, that includes a subset of the NQF Safe Practices, the expectations
of this question have been met.
37) Ref Survey Question 1.12: How does our hospital communicate our performance on the NQF
Safe Practices to the public?
The requirements of this question have been met if a hospital has a mechanism in place to report
publicly, at least yearly, quality and safety performance outcomes that includes a subset of the NQF
Safe Practices.
38) Ref Survey Question 1.11: What components qualify for reporting quality and safety
performance activities to the Board?
To meet the requirements of this Safe Practice, a Board Quality Committee should include Board
Members and senior executives, and patient safety should be a standing agenda item for the meeting
that includes reports on metrics, actions, and areas of focus which are being accomplished.
39) Ref Survey Question 1.15: How many of the Additional Specifications or Example Approaches
cited in the NQF report should have explicit line item budget allocations?
If it can be verified that any of the additional specifications or example implementations can be
identified in a line item manner in the budget, within a department budget that rolls up into the hospital
budget or if during the course of a current budget year, a department or hospital has a clear paper
trail of any outlay of expenses specific to the safe practices the intent of this question will be met.
40) Ref Survey Question 1.16: Does the hospital have to have a full-time Patient Safety Officer to
receive full credit for question 1.20?
A senior executive who may or may not have the title “Patient Safety Officer” satisfies the reporting
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requirement if he or she has responsibility for multiple and integrated areas of patient safety. Multiple
executives who may be responsible for one area of safety each, and do not assess the overall
integrated safety issues would not qualify.
41) Ref Survey Question 1.17; What actions are needed to receive credit for having an explicit line
item budget related to Creating a Healthcare Culture of Safety?
Hospitals who have not allocated funding in the current budget year may receive credit for this
question if they can demonstrate expenditures in the operational or other budgets that can be tied
back to actions to develop a culture of safety in their organization as defined in the example
implementation approaches outlined in the NQF Safe Practices report. In addition, plans to allocate
specific budget dollars to this safe practice should be incorporated into the next upcoming budget
year.
42) Ref Survey Questions 1.21 through 1.25: What Action areas may be performance
improvement program focus areas?
The NQF states that organizations that are creating a culture of safety should at a minimum be
undertaking the activities addressed in the “Additional Specifications” section on page 18 of the NQF
report. Performance improvement programs may qualify if they address the “Additional
Specifications” and “Example Implementation Approaches” and the subject matter addressed in FAQ
#11 above. Such Performance Improvement Programs must have the five elements of education,
skill building (regarding use of Performance Improvement tools), measurement, process
improvement, and reporting.
Another example of a performance improvement opportunity would be a hospital’s decision to seek
credit for the American Association of Critical Care Nurses (AACN) Beacon Award for Critical Care
Excellence, which requires the following elements:
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Recognized excellence in the intensive care environments in which nurses work and
critically ill patients live
Recognized excellence of the highest quality measures, processes, structures, and
outcomes based upon evidence
Recognized excellence in collaboration, communication, and partnerships that support the
value of healing and humane environments
Developed a program that contributes to actualization of AACN’s mission, vision, and
values
43) Ref Survey Question 1.20: What is the difference between a multi-disciplinary external
committee, which reviews all incidents, and an interdisciplinary patient safety committee?
The NQF offers an example for incident oversight that includes community members and other
disciplines outside the walls of the hospital to review incidents on a routine basis.
The interdisciplinary patient safety committee is an internal hospital committee that oversees root
cause analysis of incidents and develops action plans to create solutions and changes in
performance. These are example approaches offered by the NQF, not specific requirements.
44) Ref Survey Questions 1.23, 1.24, 1.25: How would a hospital earn maximum points for all of
the Action sections dealing with Performance Improvement projects/programs?
A hospital that has undertaken performance improvement projects on individual units and throughout
the entire hospital facility would receive full credit for those questions if the question addresses
projects at either the unit level or full facility level.
45) Ref Survey Question 1.25: How is a formal performance improvement program defined?
Performance improvement programs should include five elements: Education regarding the pertinent
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adverse event frequency, severity, and/or impact of best practices, skill building in use of
performance improvement tools, measurement of process measures or outcomes measures,
process improvement, and reporting of performance.
Rural Hospital
46) Ref Survey Question 1.1: Are there any exemptions for the rural hospitals?
No.
47) Ref Survey Question 1.16: How will rural hospitals meet the expectation for a Patient Safety
Officer?
Rural hospitals will need to meet the same expectations as outlined in the FAQs for General
Hospitals listed above.
Pediatric Hospital
48) Ref Survey Question 1.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 3
Specify an explicit protocol to be used to ensure an adequate level of nursing care based on the
institution's usual patient mix and the experience and training of its nursing staff.
General Hospital
49) Ref Survey Question 3.9: What is required to meet the line item budget allocation for this safe
practice?
Hospitals who can demonstrate expenditures in the current budget year that tie directly to developing
and monitoring targeted staffing levels as outlined in the additional specifications of the NQF Safe
Practices report will meet the expectations of this item. In addition, plans to allocate specific budget
dollars to this safe practice should be incorporated into the next upcoming budget year.
50) Ref Survey Question 3.10: How does a hospital receive credit for staffing performance
improvement activities not planned in the budget?
If a hospital has not allocated budget dollars for a performance improvement project tied to this safe
practice but can demonstrate expenses tied to a project to improve nurse staffing targets in their
organization they can receive credit for this question. In addition, plans to allocate specific budget
dollars to this safe practice should be incorporated into the next upcoming budget year as an ongoing
process to maintain appropriate staffing patterns.
51) Ref Survey Question 3.11: What constitutes “explicit organizational policies and procedures”
related to nurse staffing?
Explicit organizational policies and procedures refers to nursing policies and procedures or a specific
process used by the organization to pre-determine appropriate staffing patterns based on usual
patient mix and nursing qualifications.
52) Ref Survey Questions 3.11, 3.12, 3.13, 3.14: What staffing processes address the expectations
of the Action answer of this Safe Practice?
Recognizing there is no galvanized number that represents “the correct” nurse staffing pattern,
organizations must integrate a number of data sets into a staffing system that pre-defines and
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quantifies appropriate staffing targets. These data sets include:
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Historical Data (e.g., patient volumes, acuity levels, and staff volumes of direct caregivers)
Comparative Data (e.g., comparisons between similar units internally and comparative
external data from hospitals of like size and geographic location)
Clinical Outcomes
Skill Mix of Staff (e.g., licensing levels and educational training, years of experience, and
volume of new graduates on a unit)
Physical environment (distance staff have to travel to access support equipment, visibility of
patients, locations of nursing stations to patient rooms, etc.)
Type of patient care needs
Support services available
Daily monitoring should take place to determine variances between pre-determined staffing patterns
and actual staffing patterns. If necessary, corrective action should be taken. Regular monitoring
should take place to determine accuracy of targets established and determine adjustments as
needed.
This correlates with JCAHO Standard HR 1.30, which addresses the use of clinical/service screening
indicators and human resource screening indicators to assess staffing effectiveness.
53) Ref Survey Questions 3.11, 3.14: Are the specifications required by magnet hospital sufficient
to address this Safe Practice?
Magnet hospitals measurement criteria fully meet the requirements of this question.
54) Ref Survey Questions 3.11, 3.14: Can the Action expectations for these questions be met
without using ratios or automated patient acuity systems?
Yes, if your organization has a defined process to determine appropriate staffing patterns, automated
acuity systems are not required.
55) Ref Survey Questions 3.11, 3.14: JCAHO requires staffing effectiveness measures. If safety
issues are used (e.g., medication errors), does this help meet the intent of the Safe Practice?
The JCAHO staffing effectiveness measures focus on selected indicators, which are meant to
measure effective care for all inpatients. These measures can be incorporated into a process to
design appropriate staffing patterns but by themselves do not meet the action answer of this Safe
Practice alone.
56) Ref Survey Question 3.11, 3.14: Are there other examples of Performance Improvement
activities that would help provide credit towards this safe practice?
Yes, another example of a performance improvement project that would help provide Action credit for
this safe practice would be for a hospital to commit to achieve the American Association of Critical
Care Nurses (AACN) Beacon award for Critical Care Excellence. The criteria to be met include:
 Recognized excellence in the intensive care environments in which nurses work and
critically ill patients live
 Recognized excellence of the highest quality measures, processes, structures and
outcomes based upon evidence
 Recognized excellence in collaboration, communication, and partnerships that support the
value of healing and humane environments
 Developed a program that contributes to actualization of AACN’s mission, vision and values.
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Rural Hospital
57) Ref Survey Question 3.1: Does this Safe Practice apply to rural facilities?
No. The NQF report indicates this practice excludes “licensed healthcare facilities in rural areas as
defined by the U.S. Census Bureau (e.g., territory, population, and housing units not classified as
urban).” (pg.23)
Scoring and Ranking will be prorated by hospital type. Top quartile requirements will not include this
practice for Rural Hospitals.
Pediatric Hospital
58) Ref Survey Question 3.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 5
Pharmacists should actively participate in the medication-use process, including, at a minimum,
being available for consultation with prescribers on medication ordering, interpretation and
review of medication orders, preparation of medications, dispensing of medications, and
administration and monitoring of medications.
General Hospital
59) Ref Survey Question 5.1: Can the data collected in a pharmacy computer system be used to
evaluate the frequency and severity of potential adverse events avoided by a pharmacist’s
intervention, to document the impact of the pharmacist’s involvement in the medication use
process?
Yes. The frequency of pharmacist interventions should be part of the data tracked for this Safe
Practice. It could also include the percent of orders reviewed by the pharmacist prior to
administration.
60) Ref Survey Question 5.4: What qualifies as acceptable activities of the pharmacist to address
the expectations of the Action answer of this Safe Practice?
A designated pharmacist must be available 24/7 to consult with prescribers on medication orders and
should review patient medications before they are dispensed, except in those instances when review
would cause a medically unacceptable delay, as indicated by the additional specifications in the NQF
report (pg. 26).
This safe practice correlates with JCAHO Standard MM 4.10.1, which address the role of the
Licensed Pharmacist to review all prescription medication orders.
If a pharmacist is not available on site, one should be accessible by phone as permitted by each
State Board of Pharmacy.
Rural Hospital
61) Ref Survey Question 5.1: Does this Safe Practice apply to rural facilities?
Yes. Rural hospitals should make arrangements to have a pharmacist available by telephone
consultation for those hours when the pharmacist is not on site. Some rural hospitals have
established contractual arrangements with 24-hour pharmacy services in order to meet the
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requirements of this practice.
Hospitals should establish strategic plans to acquire computerized medication dispensing units.
62) Ref Survey Question 5.4: Can a mix of pharmacists and support staff meet the expectations of
this safety area in the rural facility?
Yes, however, rural facilities should be able to demonstrate a process that meets the same
expectations of urban facilities where medication orders are interpreted and reviewed prior to
dispensing and administration of the first dose of all medication orders, except in those instances
when review would cause a medically unacceptable delay. The hospital should monitor the
effectiveness of the process, once established.
Pediatric Hospital
63) Ref Survey Question 5.4: Is there a difference in the role of a pharmacist dealing with
Pediatric patients and/or in Pediatric Specialty Hospitals?
Yes, in addition to the general hospital requirements for pediatric patients, the pharmacist must
review medication orders and take into consideration the weight (based in kilograms) and size of the
patient to determine the appropriate drug dosage and to make sure the dose is properly prepared.
Safe Practice # 6
Verbal or telephone orders or critical test results should be recorded whenever possible and
immediately read back to the prescriber, e.g., a healthcare provider receiving a verbal or
telephone order should read or repeat back the information the prescriber conveys in order to
verify the accuracy of what was heard.
General Hospital
64) Ref Survey Question 6.1: How does a hospital address the definition of critical test results?
Hospitals need to establish how a critical test result is defined for their organization.
65) Ref Survey Question 6.2: How might a hospital earn credit for question 6.2 pertaining to
Accountability?
As part of the overall management responsibilities, the pertinent department/clinical service line
manager is accountable for the reduction of adverse events, specifically including those relating to
miscommunication of orders.
66) Ref Survey Question 6.4: What are the qualifications for verbal orders?
Hospitals should have policies and procedures in place that require hospital staff to record a verbal
order in writing immediately (whenever possible) and to read and repeat the information back to the
prescriber for clarification and confirmation. Verbal orders may never be given or received for
chemotherapy agents.
This safe practice correlates with JCAHO Standards IM 3.10.10 and IM 6.50.4 which address the
hospitals responsibility to develop processes to ensure accurate, timely and complete verbal and
written communication.
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67) Ref Survey Question 6.4: Does this policy apply to chemotherapy agents that are being used
for indications other then cancer treatment?
Yes.
68) Ref Survey Question 6.4: Is it acceptable to read back the order for clarification after it has
been written down?
Yes.
69) Ref Survey Question 6.4: How does this Safe Practice apply during an emergency code, the
operating room, or other settings where verbal orders are not easily reduced to written
format?
In certain situations, “hear back” is an appropriate process to implement. “Hear back” is where the
verbal order is repeated back to the presciber for clarification or confirmation as to what was heard.
70) Ref Survey Question 6.4: Are the expectations different for organizations with electronic
medical records (EMR) systems?
The expectations are not different, other than whenever possible the information should be entered
directly in the EMR and read back to the prescriber.
Rural Hospital
71) Ref Survey Question 6.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
72) Ref Survey Question 6.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 7
Use only standardized abbreviations and dose designations.
General Hospital
73) Ref Survey Questions 7.2, 7.4: How can a hospital measure compliance with policies and
procedures on this Safe Practice?
As a means of measuring progress of improved performance in this safety area, hospitals may
undertake random chart audits to determine how often inappropriate abbreviations and dose
designations are being used, and take corrective action as needed.
74) Ref Survey Question 7.4: What are the changes needed to meet this question?
Hospitals should include the following elements to address this Safe Practice:

Establish policies and procedures requiring the use of standardized abbreviations and dose
designations.
 Create and maintain an up-to-date list of acceptable abbreviations and dose designations
and a “Do NOT Use List” of abbreviations that are known to have multiple meanings, as
prescribed by the JCAHO Standards MM 4.30 and IM 3.10.2.
 The metric system of measurement should be used for all prescription orders, except in
cases where therapies use standard units of measurement, such as insulin. This correlates
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with JCAHO Standard MM 2.20.8 and .9 that address limitation and standardization of drug
concentrations.
75) Ref Survey Question 7.4: Does having a computer physician order entry (CPOE) system meet
the expectations of this question?
Yes, if the abbreviation policy is an integrated component of the CPOE system and the system is
configured not to accept or display unacceptable abbreviations and dose designations.
Rural Hospital
76) Ref Survey Question 7.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
77) Ref Survey Question 7.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 8
Patient care summaries or other similar records should not be prepared from memory.
General Hospital
78) Ref Survey Questions 8.1, 8.4: How can progress be measured?
Progress in this area can be measured through an audit process to verify that all the necessary
documents are available for the dictating clinician.
79) Ref Survey Question 8.3: How does a hospital gain credit for this question related to line item
budget allocations?
Hospitals that can demonstrate expenses in the current budget year that are tied to development of a
process or system to have all original source documents available for transcribers as they develop
patient care summaries for the medical record as defined in the additional specifications of the NQF
Safe Practices report will receive credit for this question. In addition, plans to allocate specific budget
dollars to this safe practice should be incorporated into the next upcoming budget year.
80) Ref Survey Question 8.4: What is the hospital’s responsibility on this Safe Practice?
Hospitals need to have a process in place that allows clinicians full access to all original source
documents, including but not limited to: laboratory, radiology, medication administration records,
operative notes, and interim summaries; and, any other documentation included in the medical record
that will increase the accuracy of the patient care summaries written or dictated for discharge,
consultations, or other similar records.
81) Ref Survey Question 8.4: Will an Electronic Medical Record (EMR) system meet the
expectations of this question?
EMR can meet the action answer of this practice if the EMR system is fully integrated with Lab,
Radiology, Medication Systems, operative notes, and is readily accessible at all locations where
patient care summaries are prepared.
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82) Ref Survey Question 8.4: Clarify use of the term “transcriber” as used in the context of
addressing the creation of patient care summaries and/or other records.
“Transcriber” for Safe Practice # 8 refers to any clinician documenting patient information in a medical
record.
Rural Hospital
83) Ref Survey Question 8.1: Should rural hospitals be held to the same requirements as general
hospitals for this Safe Practice?
Yes, however, rural hospitals will need to examine their transcription process to make sure the
turnaround time for production of records does not impede provider access to the documents needed
to complete a patient care summary.
Pediatric Hospital
84) Ref Survey Question 8.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 9
Ensure that care information, especially changes in orders and new diagnostic information, is
transmitted in a timely and clearly understandable form to all of the patient’s healthcare
providers/professionals who need that information to provide care.
General Hospital
85) Ref Survey Questions 9.1, 9.2, 9.13, 9.14, 9.15: If a hospital is involved in the IHI 100,000 Lives
Campaign to Prevent Adverse Drug Events (ADEs) does this address the Awareness
expectations of this survey question?
Yes. If a hospital is collecting data on ADEs as part of the ADE intervention of the 100,000 lives
campaign and communicating the results of that data as part of a performance improvement project
this will provide credit towards the Awareness answers for this survey question.
86) Ref Survey Questions 9.1, 9.2, 9.13, 9.14, 9.15: What kind of Performance Improvement
programs would optimize communication?
Performance Improvement programs should include five elements: Education regarding the
pertinent adverse event frequency, severity, and/or impact of best practices, skill building in use of
performance improvement tools, measurement of process measures or outcomes measures,
process improvement, and reporting of performance
87) Ref Survey Questions 9.1, 9.8, 9.9: What educational content could be presented to staff?
Education sessions for current staff and new staff orientations should focus on the issue of adverse
events resulting from inaccurate, delayed or omitted information given to clinicians regarding current
patient medications on admission, changes in medications during the hospital stay, and critical test
results.
88) Ref Survey Question 9.11: How does a hospital receive credit related to a line item budget for
this safe practice?
Facilities that can demonstrate current year hospital or departmental expenses tied to the
development of a process to address this safe practice as outlined in the NQF Safe Practices Report
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additional specifications can receive credit for this question. In addition, plans to allocate specific
budget dollars for this safe practice to assure ongoing process development should be incorporated
into the next upcoming budget year.
89) Ref Survey Questions 9.12, 9.13, 9.14, 9.15: What can be done to address the performance
improvement processes in the action related questions, to facilitate accurate communication
of new orders and new diagnostic information of patients?
Accurate communication of new orders and new diagnostic information can be facilitated by:



Including the use of Medication Reconciliation Process steps that review and update all
medications at every hospital/clinic/outpatient visit and provides evidence that the
reconciliation process is being done.
-orHospitals having a community outreach program that educates patients about the need for
comprehensive care information prior to admission, as listed in the NQF “Additional
Specifications” bullet 1, pg. 30,
-orHospitals using Change of Shift reports to identify patient safety issues (e.g., two patients
with the same last name) in all departments.
90) Ref Survey Questions 9.1, 9.2, 9.13, 9.14, 9.15: If a hospital has initiated a Performance
Improvement project regarding the ADE intervention of the 100,000 Lives Campaign, does this
provide credit towards the Action Answer?
Yes. If a hospital has initiated a Performance Improvement project to implement the ADE intervention
of the IHI 100,000 Lives Campaign, which includes development of a medication reconciliation
process, this will provide credit towards the Action Answer for this safe practice.
91) Ref Survey Question 9.15: How can progress in this area be measured?
One measure might include the percent of patients presenting at each transition in the care setting
(e.g., Transfer from ICU to another unit) with necessary information as outlined in the NQF report (pg.
30).
92) Ref Survey Question 9.15: Can the active and updated ‘problem list’ for the patient suffice as
evidence for this?
No. This Safe Practice is focused on communication of patient care information through the
continuum of care within and from the inpatient setting to the outpatient setting and includes care
information provided by all the caregivers including nurses, primary care physicians, and consultants.
93) Ref Survey Question 9.15: How does an organization address this communication area and
remain within the requirements of the Health Insurance Portability and Accountability Act
(HIPAA) regulations?
HIPAA regulations provide for the communication of pertinent patient care information between
various patient care providers in the form of consultation reports, discharge summaries, discharge
transfer forms between nursing professionals, etc. Hospitals are responsible to establish a process
that assures that communication of pertinent patient care information consistently takes place
internally between care providers and into the continuum of care as appropriate.
94) Ref Survey Question 9.15: If our organization is already undertaking improvement activities
involving accurate communication, how should we make a commitment to improve it?
The intent of question has been met if your organization can demonstrate how it measures the
reliability of its communication system and what has been done to improve accurate communication.
As for commitment, the organization should commit to measure the accuracy of communication in the
organization and to determine how information transfer will improve care.
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Rural Hospital
95) Ref Survey Question 9.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
96) Ref Survey Question 9.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 10
Ask each patient or legal surrogate to recount what he or she has been told during the informed
consent discussion.
General Hospital
97) Ref Survey Question 10.3: What processes need to be addressed by hospitals in the informed
consent process?
To facilitate a shared decision making process between patients and providers, hospitals must have
in place a process that documents that an informed consent has occurred between the patient and
the provider written in simple, understandable sentences in the primary language of the patient, or
provide an alternate form of interpretation to non-English speaking patients. Those who are visually
or hearing impaired, or have a low literacy level, as well as provide opportunities for patients to have
their questions fully addressed by the physician provider.
This safe practice correlates with JCAHO Standards RI 2.40, RI 2.90, and RI 2.10, which indicate
patients and families, where appropriate received an informed consent. The rationale for this standard
speaks to the goal to establish a mutual understanding between the patient and physician.
98) Ref Survey Question 10.3: How can urban hospitals address the primary language element of
this Safe Practice with numerous patients for whom English is not their primary language?
For patients for whom English is not their primary language, the language requirement may be
addressed by using the AT&T Language Line or by utilizing individual state required interpreter
services.
99) Ref Survey Question 10.4: How do we establish a Performance Improvement project on the
issue of informed consent if there is no (or very limited) data in our adverse events database
that indicates this is an area that needs improved performance?
Hospitals should be aware that informed consent is a legal and ethical issue in healthcare as a whole.
High performance organizations have demonstrated a pro-active response to this issue by reviewing
their policies, procedures, and processes for informed consent to make sure they address the needs
of all patient populations being served. These organizations also have reviewed all their consent
forms to improve their format and readability for patients.
100) Ref Survey Question 10.4: How can hospitals measure progress on this Safe Practice?
Hospitals can measure progress in this area by using patient satisfaction surveys or focus groups
with patients to determine if they received satisfactory information from their physician provider in
order to make an informed consent.
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Rural Hospital
101) Ref Survey Question 10.3: Are there any different expectations for rural hospitals?
No. Rural hospitals will be held to the same expectations. The AT&T language line is an example of
a resource that can be used for non-English speaking patients.
Pediatric Hospital
102) Ref Survey Question 10.3: How does the issue of informed consent apply to pediatric
patients?
The intent of this practice is to assure that the person responsible to provide consent for treatment,
whether that is the patient, their parent, guardian, or judge, fully understands what will be done and
to what they are consenting.
Safe Practice # 11
Ensure that written documentation of the patient's preference for life-sustaining treatments is
prominently displayed in his or her chart.
General Hospital
103) Ref Survey Question 11.4: What processes address the expectations of the Action answer of
this Safe Practice?
Hospitals can establish a measurable process that accurately captures the patient’s preferences for
life sustaining treatment and consistently makes that information clearly visible on the patient’s
medical record in order to reduce the opportunity for adverse events related to unwanted treatment.
This same information should also be available when patients are transitioned from the acute care
setting to long-term care.
This correlates with JCAHO Standard RI 2:80, which addresses the wishes of the patient-related to
end-of-life decisions.
104) Ref Survey Question 11.4: How can a hospital measure progress to receive credit for taking
Action on this Safe Practice?
Hospitals can measure progress in this area by establishing a periodic audit process to determine
compliance, perhaps utilizing chart reviews through the Medical Record Coding department or other
means.
Rural Hospital
105) Ref Survey Question 11.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
106) Ref Survey Question 11.1: Does this Safe Practice apply to pediatrics?
No. An Advance Directive is a pre-determined decision regarding the use of life sustaining treatment
measures made by individuals over the age of 18.
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Safe Practice # 13
Implement a standardized protocol to prevent the mislabeling of radiographs.
General Hospital
107) Ref Survey Question 13.1: Does the intent of this Safe Practice apply to imaging departments
only?
No. This applies to any setting in the hospital where images of patients are being created.
108) Ref Survey Question 13.1: Does this Safe Practice apply to digital radiography?
Yes. A process to prevent the mislabeling of radiographs applies to all forms of imaging.
109) Ref Survey Question 13.4: What processes address the expectations of the Action answer of
this Safe Practice?
Hospitals should establish policies and procedures for consistent accuracy in labeling all forms of
imaging records. The policies should delineate flash/mark of X-rays with correct patient information
while in the darkroom or through the imaging device. Clear documentation should indicate which
side of the image is “left” or “right”. Accurate labeling of digital images must be included.
Hospitals should be aware of another potential process error related to labeling and re-labeling of
images to correct a prior error.
All policies and procedures developed or improved should include the dates and sequencing of
individual studies for the same patient.
Rural Hospital
110) Ref Survey Question 13.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
111) Ref Survey Question 13.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 14
Implement standardized protocols to prevent the occurrence of wrong-site procedures or wrongpatient procedures.
General Hospital
112) Ref Survey Question 14.3: Does monitoring by observation meet the educational intent of
this question?
Yes. If an organization has provided in-service education to staff regarding their policies and
procedures, observation of staff compliance including documentation of staff members who are
fulfilling the procedure meets the intent of this question to document staff’s ability to apply the
practice.
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113) Ref Survey Question 14.4: Does implementation of the JCAHO Universal Protocol address
the expectations of the Action answer of this Safe Practice?
Yes. If you have implemented the JCAHO Universal Protocol within 12 months prior to completing
the survey, you have fulfilled the Action answer of this survey question.
114) Ref Survey Question 14.4: Does a patient or knowledgeable family member have to mark the
operative site to meet the expectations of this Safe Practice?
The intent of the Safe Practice is to make sure the patient and the provider and operative team are
all in agreement as to what the correct site of the procedure will be. If a hospital can demonstrate
that they have put a process in place that brings everyone involved to that point of agreement, the
intent of the Safe Practice will have been met.
Rural Hospital
115) Ref Survey Question 14.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
116) Ref Survey Question 14.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 15
Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event
during surgery, and provide prophylactic treatment of high-risk patients with beta blockers.
General Hospital
117) Ref Survey Question 15.1: How is awareness of this Safe Practice implemented in a
performance improvement project?
As part of a performance improvement project an organization can develop specific guidelines and
protocols for the evaluation and prophylactic treatment of high-risk patients. They should also
measure the percent of patients on beta-blockers postoperatively.
If a hospital is involved with the IHI 100,000 Lives Campaign, another performance improvement
project would be to implement the Improved Care for Acute Myocardial Infarction (AMI) intervention
including use of Beta Blockers.
118) Ref Survey Question 15.2: How can hospitals be held accountable to meet the elements of a
Safe Practice that is driven by physician decision making?
It is clear that the hospital cannot force physician practice patterns. However, in an effort to improve
patient safety, managers can establish a process using a cardiac risk assessment form, which
includes a mechanism that requires physicians to document a choice, “yes or no”, to order a beta
blocker for their patient. The risk assessment form should be developed by a collaborative team of
hospital clinical staff, cardiologists, anesthesiologists, and surgeons to improve overall adoption of
the assessment and beta blocker ordering processes.
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119) Ref Survey Question 15.4: How can progress with this Safe Practice be measured?
Some forms of measurement may include:




Data collection on post-op MI rates
Pre-op Screening Rates
Percent of appropriate patients placed on a beta blockade
Data collection as part of the IHI 100,000 Lives Campaign AMI intervention including early
administration of Beta Blockers and use at discharge
Rural Hospital
120) Ref Survey Question 15.1: How will this be measured in rural hospitals that may need to
transfer patients?
Rural facilities with patients requiring transfer to a larger facility for cardiac surgery will need to
develop a process for performing risk assessments of those patients and then make decisions as to
whether or not to start them on a beta blocker before the transfer.
Pediatric Hospital
121) Ref Survey Question 15.1: Are there any exemptions for the pediatric hospitals?
Yes. This safe practice does not apply to pediatric hospitals.
Safe Practice # 16
Evaluate patients for pressure ulcers at regular intervals after admission and provide the
appropriate preventive measures.
General Hospital
122) Ref Survey Question 16.4: Is a separate risk assessment form needed to address the
expectations of the Action answer of this Safe Practice?
The intent of this Safe Practice is to have all patients screened for the risk of developing a pressure
ulcer. This can be accomplished through a component of the nursing admission assessment and a
component of individual shift assessments of patients that includes a scoring system like the Braden
Scale, with an in depth assessment being performed if a screening assessment reveals a concern.
123) Ref Survey Question 16.4: How can hospitals measure progress on this Safe Practice?
Hospitals need to have policies and procedures in place for a risk assessment process. This
screening process should address all patients upon admission in order to identify and document
those patients who may develop a pressure ulcer, documentation of ongoing risk assessments
throughout the hospitalization and, as needed, implementation and documentation of a prevention
plan in the patient’s medical record.
All at risk patients should be regularly evaluated according to a systematic scoring system such as
Braden or Norton Scale.
A quality performance improvement process in this area could demonstrate a 50% improvement in
the rate of hospital acquired pressure ulcers over a 12 month period.
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Rural Hospital
124) Ref Survey Question 16.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
125) Ref Survey Question 16.1: Are there any exemptions for the pediatric hospitals?
Yes. This safe practice does not apply to pediatric hospitals.
Safe Practice # 17
Evaluate each patient upon admission, and periodically thereafter, for the risk of developing
DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE.
General Hospital
126) Ref Survey Questions 17.1, 17.4: How can progress with this Safe Practice be quantifiably
measured?
Progress with this safe practice can be measured by data collection of the percentage of patients
deemed at high-risk that are placed on an appropriate DVT prophylaxis plan of care.
127) Ref Survey Question 17.4: If a hospital performs a general peripheral vascular assessment
as part of a routine nursing assessment, does this address the expectations of the Action
answer of this Safe Practice?
Yes. A peripheral vascular risk assessment (developed by an interdisciplinary team including
medical staff), which is performed as part of a routine nursing admission assessment that includes
ongoing assessment throughout the hospitalization, and implements a prevention plan as needed,
meets the expectations of the action answer of this question.
Rural Hospital
128) Ref Survey Question 17.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
129) Ref Survey Question 17.1: Are there any exemptions for the pediatric hospitals?
Yes. This safe practice does not apply to pediatric hospitals.
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Safe Practice # 18
Utilize dedicated anti-thrombotic (anticoagulation) services that facilitate coordinated care
management.
General Hospital
130) Ref Survey Question 18.1: Why has such heavy emphasis been placed on anticoagulation
management?
The incidence of anticoagulation management-related Adverse Drug Events is very high. There is a
great opportunity for prevention of these events through systematic anticoagulation management
after discharge. This is well documented in the medical literature and provides a real opportunity for
improved performance in this area across the healthcare industry.
131) Ref Survey Questions 18.8, 18.9: What specific content is recommended to be addressed in
educational programs for hospital staff?
During educational sessions for hospital staff it is recommended the following topics be addressed:





Understanding the need for anticoagulation therapy: the frequency of preventable adverse
events and the impact of systematic anticoagulation management on reducing such events.
The indications, risks, and benefits regarding typical patients receiving such therapy.
Critical information the patient needs to know at time of discharge
Risk for stroke and bleeding disorders in patients on anticoagulants
The need for active consistent tracking and monitoring as part of systematic management
132) Ref Survey Question 18.11: How does a hospital receive credit related to a line item budget
for this safe practice?
Hospitals that can demonstrate departmental expenses tied to the development of a process to
address this safe practice as outlined in the NQF Safe Practices Report example implementation
approaches can receive credit for this question. In addition, plans to allocate specific budget dollars
for this safe practice to assure ongoing process development should be incorporated into the next
upcoming budget year.
133) Ref Survey Question 18.12: What are the elements of a dedicated anticoagulation service or
protocol to meet the intent of this Safe Practice?
A dedicated service should include the following:




Regular and systematic PT/INR testing by reference lab or point of care testing
Dose adjustment based on lab results with timely communication to the patient for
medication dose changes
Education of the patient and family by their provider
Active consistent monitoring for patient compliance with taking medications and attending
follow up appointments
134) Ref Survey Question 18.12: Does an Anticoagulation Service mean an outpatient clinic is
required?
No. An anticoagulation service or system of care can be tailored to each organizational structure.
There must be a dedicated physician or advanced practice nurse to monitor the patient's
anticoagulation process, who will also implement standardized procedures and patient education
measures in order to provide consistent care for all anticoagulation patients.
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This may include designating someone during the inpatient hospitalization to oversee and monitor
use of standardized anti-coagulation procedures for all patients, and compliance by providers.
A collaborative relationship should be established between the hospitals and well-organized local
providers to manage anticoagulation processes that follow an active systematic anticoagulation
management program that includes the elements as listed in an earlier FAQ for 18.12. Such a
collaborative relationship may be centralized or distributed. It may be at one physical location or
virtual (electronic), as long as the elements of systematic anticoagulation management are
implemented.
135) Ref Survey Question 18.14: What is the greatest opportunity for performance improvement in
anticoagulation management?
Patients receiving oral anticoagulation medication while hospitalized are often not well-managed
after discharge. The greatest opportunity for acute care hospitals to improve anticoagulation
management is to assure that discharged patients are enrolled in a systematic anticoagulation
management program through an outpatient Anticoagulation Clinic or that systematic anticoagulation
management will be undertaken by an appropriate care giver following a standardized protocol.
136) Ref Survey Question 18.15: If anticoagulation policies and procedures are in place, why
should hospitals get more credit if they have a performance improvement project or program
in place?
It is clear that Adverse Drug Event rates for hospitals in this area are high regardless of whether
policies and procedures are established. Unless performance improvement projects include
systematic measurement on a routine basis that provides feedback to caregivers, they may not know
if the protocols and processes put in place are successful.
137) Ref Survey Question 18.15: How can progress with this Safe Practice be quantifiably
measured?
Performance Improvement programs could be designed to measure:



The percent of patients overdue for follow-up testing each month, and/or
Data collection of the percent of INR results within therapeutic range, or
Percent of patients on anticoagulant therapy that have laboratory values which are out of
range
Rural Hospital
138) Ref Survey Question 18.1: How should this Safe Practice be addressed by rural hospitals?
Should rural hospitals be expected to provide this service?
In rural environments a collaborative relationship should be established between the hospital and
well-organized local providers to manage anticoagulation processes that follow an active systematic
anticoagulation management program including the elements listed in the FAQs for General
hospitals 18.12. If a reference lab is not available, Point of Care testing devices may be used.
In light of often limited resources, rural facilities will need “low tech” methods to implement
anticoagulation management. Although very low cost, web-based tools are available, the critical
issue is to provide continuity of care when patients transition out of the hospital and that they will be
systematically managed by a qualified caregiver who is tracking laboratory values, adjusting
medication dosages, and providing patient education as necessary either by phone or in person.
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Pediatric Hospital
139) Ref Survey Question 18.1: Are there any exemptions for the pediatric hospitals?
Yes. This safe practice does not apply to pediatric hospitals.
Safe Practice # 19
Upon admission, and periodically thereafter, evaluate each patient for the risk of aspiration.
General Hospital
140) Ref Survey Question 19.1: Why does this Safe Practice address aspiration when the
“example implementation approaches” focus on ventilator acquired pneumonia?
The evidence-based medicine literature indicates 15% of nosocomial infections are respiratory
related, occurring as the result of poor general hygiene of caregivers and potential swallowing
limitations.
The problem statement of this Safe Practice includes issues related to nosocomial infections and the
increased risk of aspiration associated the recumbent position especially for ventilated patients.
Current literature indicates use of a semi-recumbent position for ventilated patients will significantly
reduce their rate of developing a nosocomial respiratory infection.
141) Ref Survey Question 19.1: If a hospital is involved in the IHI 100,000 Lives Campaign to
implement the Prevention of Ventilator Associated Pneumonia (VAP), does this count
towards the Awareness answer for this survey question?
Yes. If a hospital is collecting data on the frequency and severity of incidents of Ventilator
Associated Pneumonia as part of the IHI 100,000 Lives Campaign, this would count towards credit
for the Awareness expectations of this survey question.
142) Ref Survey Question 19.4: What activities address the expectations of the Action answer of
this Safe Practice?
The action expectations of this survey question may be satisfied by:
 Nursing admission and routine screening assessment of all at risk patients. The
assessment should be developed by an interdisciplinary team including medical staff.
 Consistent use of universal precautions
 For all ventilated patients, high return practices containing the following elements should
become part of explicit protocols. These practices should be implemented simultaneously
(unless clinically contraindicated):
a. Head of bed elevation to 30 degrees
b. Appropriate sedation
c. Appropriate DVT Prophylaxis
d. Appropriate PUD Prophylaxis
e. Readiness to extubate
 A bundle or a set of strong clinical interventions such as those described above provide an
ideal focus area for performance improvement programs which can then generate credit for
this survey question.
 Participation in the IHI 100,000 Lives Campaign to implement the above interventions to
Prevent Ventilator Associated Pneumonia
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143) Ref Survey Question 19.4: Does “each patient” refer to all admissions or only those patients
on ventilators?
The intent of this Safe Practice is to prevent the problem of airborne and aspiration associated
nosocomial infections. Since airborne infections can be contracted by ventilator and non-ventilator
patients alike, all patients should be evaluated, not just those on ventilators.
Rural Hospital
144) Ref Survey Question 19.1: How will this apply to rural hospitals?
Rural hospitals are expected to fulfill the same requirements for risk assessment. Arrangements may
be needed to have on-call access to a speech therapist to perform an in-depth evaluation and to
develop a prevention plan for patients with swallowing disorders or poor gag reflex if one is
available.
Pediatric Hospital
145) Ref Survey Question 19.1: Are there any exemptions for the pediatric hospitals?
Yes. This safe practice does not apply to pediatric hospitals.
Safe Practice # 20
Adhere to effective methods of preventing central venous catheter-related blood stream
infections.
General Hospital
146) Ref Survey Question 20.1: If a hospital is involved in the IHI 100,000 Lives Campaign to
implement the Prevention of Central Line Associated Blood Stream Infections, does this
count towards the Awareness answer for this survey question?
Yes. If a hospital is collecting data on the frequency and severity of Central Line Blood Stream
Infections as part of the IHI 100,000 Lives Campaign, this would count towards credit for the
Awareness expectations of this survey question.
147) Ref Survey Question 20.3: How does a hospital receive credit related to a line item budget for
this safe practice?
Hospitals that can demonstrate departmental expenses tied to the development of a process to
address prevention of central venous line infections as outlined in the NQF Safe Practices Report
example implementation approaches can receive credit for this question. In addition, plans to
allocate specific budget dollars for this safe practice to assure ongoing process development should
be incorporated into the next upcoming budget year.
148) Ref Survey Question 20.4: What activities address the expectations of the Action answer of
this Safe Practice?
Organizations should develop policies and procedures for central venous catheters that include, at
minimum, the following elements:

Use of aseptic technique during central venous catheter insertion, including cap, mask,
sterile gown, sterile gloves and sterile drapes
 Disinfection of skin with an appropriate antiseptic before catheter insertion and at the time
of dressing changes (preferably with a 2 percent chlorhexidine-based preparation;
alternatively use of tincture of iodine, an iodophor, or 70 percent alcohol)
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Promptly removal of the catheter as soon as it is no longer essential
Implementation of a central catheter insertion and care protocol that addresses evidencebased strategies for infection reduction, and monitoring of compliance and infection rates
149) Ref Survey Question 20.4: If a hospital is involved in the IHI 100,000 Lives Campaign
regarding the Prevention of Central Line Associated Blood Stream Infection does this count
towards credit for the Action answer of this survey question?
Yes. If a hospital develops a Performance Improvement project to implement this IHI intervention, it
will provide credit towards the Action answer of this survey question.
150) Ref Survey Question 20.4: How can progress with this Safe Practice be measured?
A run chart illustrating reductions in catheter related blood stream infections tied to process
improvement interventions is one example of a performance improvement measure.
Rural Hospital
151) Ref Survey Question 20.1: Are the expectations for performance of rural hospitals any
different than for urban hospitals?
No. But due to the potential low volume of use of central venous catheters, maintaining staff
education levels will be imperative and at a minimum annual education documentation is needed.
Pediatric Hospital
152) Ref Survey Question 20.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 21
Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of
surgical site infection (SSI), and implement appropriate antibiotic prophylaxis and other
preventative measures based on that evaluation.
General Hospital
153) Ref Survey Question 21.1: If a hospital is involved in the IHI 100,000 Lives Campaign to
implement the Prevention of Surgical Site Infections, does this count towards the Awareness
answer for this survey question?
Yes. If a hospital is collecting data on the frequency and severity of Surgical Site Infections as part of
the IHI 100,000 Lives Campaign, this would count towards credit for the Awareness expectations of
this survey question.
154) Ref Survey Question 21.4: What activities address the expectations of the Action answer of
this Safe Practice?
There is a great opportunity to reduce surgical site infections (SSI) by applying simple strategies.
The hospital should develop policies and procedures that include most of the following elements:

Identify and treat all infections remote to the surgical site before an elective operation, and
postpone elective operations until the infection has resolved
 Utilize mechanical and intraluminal antibiotic bowel preparation for patients undergoing
elective colorectal surgery.
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Remove hair from the incision site only if the hair interferes with the operation by clipping
(not shaving) immediately before the operation
Administer prophylactic antimicrobial agent to patients based on published guidelines and
recommendations targeting the most common pathogens for the planned procedure
Maintain glucose control
Optimize oxygen levels
Prevent and manage bleeding and unanticipated major hemorrhage
Regularly calculate operation-specific SSI rates and report these rates to surgical team
members
Utilize other surgical infection prevention methods in accordance with the patient's specific
clinical situation
If the majority of the elements above are not incorporated into explicit protocols that have
been implemented, a performance improvement program that includes education, skill
development (to implement the actions), measurement, process improvement, and
reporting indicators that address the majority of the elements above will be done to meet
the expectations of the survey question for commitment credit.
155) Ref Survey Question 21.4: If a hospital is involved in the IHI 100,000 Lives Campaign
regarding the Prevention of Surgical Site Infections, does this count towards credit for the
Action answer of this survey question?
Yes. If a hospital develops a Performance Improvement project to implement this IHI intervention, it
will provide credit towards the Action answer of this survey question.
156) Ref Survey Question 21.4: How can progress in this patient safety area be measured?
Both process measures and outcome measures may be tracked and quantified. Many hospitals
measure the percentage, timing, and effectiveness of pre-operative antibiotic prophylaxis on surgical
site infections and post-operative infections rates.
This correlates with JCAHO Standard HR 1.30, which includes a screening for post-operative
infections.
Rural Hospital
157) Ref Survey Question 21.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
158) Ref Survey Question 21.1: Are there any exemptions for the pediatric hospitals?
No.
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Safe Practice # 22
Utilize validated protocols to evaluate patients who are at-risk for contrast media-induced renal
failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the
patient's kidney function evaluation.
General Hospital
159) Ref Survey Question 22.4: What activities address the expectations of the Action answer of
this Safe Practice?
Hospital should incorporate the following elements into policies and procedures:



Establish screening protocols to identify patients that are at risk
Perform baseline kidney function assessments
Use low osmolar contrast media for all patients
160) Ref Survey Question 22.4: Should all patients be assessed for the risk of contrast-induced
renal failure?
Yes. The intent of this Safe Practice is to develop a protocol that identifies those patients who may
be at risk for renal failure associated with the use of contrast media and to utilize appropriate clinical
interventions to reduce the risk to those patients.
161) Ref Survey Question 22.4: How can hospitals measure progress on this Safe Practice?
Hospital may track process measures that are elements of established policies or procedures. The
incidence of such adverse events may be low; however, the adverse impact of these events is high.
Such cases should be counted and evaluated as data input into process improvement plans.
Performance improvement programs should include education regarding the frequency and severity
of adverse events, the impact of best practices, skill building regarding recognition of the adverse
events, measurement of process outcomes, compliance with the processes (adherence to the
procedures), and reporting of performance outcomes.
Rural Hospital
162) Ref Survey Question 22.4: How will rural hospitals be expected to address the expectations
of the Action answer of this Safe Practice?
Rural facilities will be expected to perform risk assessments of those patients that may experience
renal failure; however, they will need to explore feasibility and costs associated with the use of lowosmolar contrast media to provide an alternative care for patients at-risk.
Pediatric Hospital
163) Ref Survey Question 22.1: Are there any exemptions for the pediatric hospitals?
No.
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Safe Practice # 23
Evaluate each patient upon admission, and periodically thereafter, for risk of malnutrition. Employ
clinically appropriate strategies to prevent malnutrition.
General Hospital
164) Ref Survey Question 23.4: What activities address the expectations of the Action answer of
this Safe Practice?
Hospital should consider including the following elements:




Initial baseline screening by nursing
In depth nutritional assessment by a dietician for patients deemed at risk through initial
screening
Development and implementation of malnutrition prevention plan documented in the
medical records
Follow through with a patient teaching plan developed by the dietician and implemented by
nursing for discharge
165) Ref Survey Question 23.4: What is a risk assessment instrument?
A risk assessment instrument is a formally designed assessment tool (a form) that contains pertinent
assessment criteria to determine if a patient is malnourished and requires some form of nutritional
intervention.
166) Ref Survey Question 23.4: How can a hospital measure progress in reducing the risk for
malnutrition of patients?
An institution can develop a performance improvement program that tracks process measures
included in the implementation of malnutrition prevention plans.
Rural Hospital
167) Ref Survey Question 23.3: If a facility has a dedicated clinical dietician, is it still necessary
for that individual to train staff formally on issues of malnutrition?
Yes. The dietician should provide in-service education to nursing staff regarding initial and ongoing
screening assessment for malnutrition during the nursing admission assessment of all patients. Then
a referral can be made to the dietician to follow-up with an in-depth nutritional assessment and plan
of care for those patients which appear to be at-risk based on the nursing assessment.
Pediatric Hospital
168) Ref Survey Question 23.1: Are there any exemptions for the pediatric hospitals?
No.
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Safe Practice # 24
Whenever a pneumatic tourniquet is used, evaluate the patient for risk of ischemia and/or
thrombotic complication and utilize appropriate prophylactic measures.
General Hospital
169) Ref Survey Question 24.4: What activities address the expectations of the Action answer of
this Safe Practice?
Hospitals should consider including the following elements:

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

Track and trend complications related to the use of pneumatic tourniquets on a quarterly
basis
Use of protocols regarding minimum inflation time and pressure, and continuous monitoring
during inflation period
Customized staff education based on frequency of use of the equipment and patient
outcomes provide and document the volume of in-services annually to keep knowledge
base of infrequent users accurate
Establish a process to review clinical performance of units, those units that have poor
patient outcomes associated with the use of pneumatic tourniquets will require additional
education, and monitoring as needed
Rural Hospital
170) Ref Survey Question 24.1: Will this Safe Practice be applied to rural hospitals with limited
technology?
Yes. Although all rural facilities may not have pneumatic tourniquets, the intent of the Safe Practice
is to evaluate the risk for ischemia and potential development of embolic debris as a result of
pneumatic compression that can be achieved with a low tech device such as a blood pressure cuff.
Pediatric Hospital
171) Ref Survey Question 24.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 25
Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior
to and after direct contact with the patient or objects immediately around the patient.
General Hospital
172) Ref Survey Question 25.3: How does a hospital receive credit tied to line item budget
allocation for this safe practice?
If a hospital has any documentation of training or education time spent on this safe practice or
expenditures on educational supplies or meeting preparation materials that address this safe
practice in the current budget year requirements for this question will be met. In addition, plans to
allocate specific budget dollars for this safe practice to assure ongoing process development should
be incorporated into the next upcoming budget year.
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173) Ref Survey Question 25.4: How will institutions measure or monitor progress with this Safe
Practice?
The following elements may be monitored as part of a performance improvement project:

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
Implementation of the nationally-approved hand washing guidelines as established by the
Centers for Disease Control (CDC)
Nosocomial infection rates as a pre and post test after the implementation of interventions
such as bedside dispensers or other equipment for hand decontamination made available
to staff
This correlates with JCAHO Standards IC 1.10, IC 4.10.1 and IC5.10, which address a
hospital’s coordinated effort to reduce the risk of nosocomial infections, implementation of
strategies to reduce the risk and prevent the transmission of infections, and action is taken
to control outbreaks of nosocomial infections
174) Ref Survey Question 25.4: Will use of the CDC guidelines for hand washing meet this Safe
Practice?
Yes.
175) Ref Survey Question 25.4: What is a quantifiable measure for this Safe Practice?
One quantifiable indicator might include the volume of alcohol-based hand wash used per patient
day measured against volumes used prior to implementing process changes.
Rural Hospital
176) Ref Survey Question 25.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
177) Ref Survey Question 25.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 26
Vaccinate healthcare workers against influenza to protect both them and patients from influenza.
General Hospital
178) Ref Survey Question 26.2: How can a senior executive and department/service line manager
be held accountable for employees who refuse to be vaccinated?
A senior executive and manager should be held accountable for having a process in place that
provides the opportunity for all employees to be vaccinated and documents which employees and
how many received or refused to be vaccinated.
179) Ref Survey Question 26.4: What elements of a performance improvement process address
the expectations of the Action answer of this Safe Practice?
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Each hospital should be able to provide documentation that indicates the number of
employees who have received the vaccine, and what measures have been taken to
encourage vaccination for all employees.
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A process should also be in place to document which employees have refused the vaccine.

This correlates with JCAHO Standard IC 6.30 in which hospitals implement a means to
intervene in the potential transmission of infection between patients and staff.
Rural Hospital
180) Ref Survey Question 26.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
181) Ref Survey Question 26.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 27
Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter,
distraction, and noise.
General Hospital
182) Ref Survey Question 27.1: How would a hospital develop a performance improvement plan?
The performance improvement plan should include process measures that address the balance
between workload and work environment in order to reduce the potential for adverse events due to
errors by the caregivers and operators in the environment being addressed. Clearly, a well
organized work area with efficient work process flow will be a safer environment especially for high
volume tasks.
183) Ref Survey Question 27.4: How can hospitals address the expectations of the Action answer
of this Safe Practice?
Clearly, this is difficult to measure and assess without established clear criteria. Hospitals need to
establish a process to monitor compliance with clean, orderly, and well lit work areas in the
pharmacy where medications are prepared and in the clinical units where medications are
dispensed. Throughput volume and optimal work flow can be linked to adverse events. If a hospital
has established a plan that monitors work flow and addresses those areas defined in the NQF
report, the expectations of this Safe Practice will be met.
This correlates with JCAHO Standard MM 4.20.4, which addresses the need to maintain clean,
uncluttered and functionally separate areas for product preparation.
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Rural Hospital
184) Ref Survey Question 27.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
185) Ref Survey Question 27.1: Are there any exemptions for the pediatric hospitals?
No.
Safe Practice # 28
Standardize the methods of labeling, packaging, and storing medications.
General Hospital
186) Ref Survey Question 28.1: Does reporting adverse drug reactions to the Pharmacy and
Therapeutics Committee address the Awareness part of this question?
Yes, provided someone from the hospital administration consistently participates in that committee
and that the organization can provide evidence that these reports have identified specific problem
areas and/or opportunities for improvement.
187) Ref Survey Question 28.4: What activities address the expectations of the Action answer of
this Safe Practice?
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



Hospitals need to establish appropriate procedures that require standardization of labeling
of all medications
The hospital should define physically separate storage arrangements for medications with
similar or “look alike” names, strengths and labels
Documentation of the lot number of medications and the expiration dates
Personnel responsible to prepare and check medications prior to dispensing should be
identified
This correlates with JCAHO Standard MM 2.20.6, MM 4.30, and MM 7.10.2, which address
separation of “look alike-sound alike drugs; standardization of labeling and development of
appropriate processes for procuring, storing, preparation and dispensing
Rural Hospital
188) Ref Survey Question 28.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
189) Ref Survey Question 28.1: Are there any exemptions for the pediatric hospitals?
No.
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Safe Practice # 29
Improve the safety of using high-alert medications (e.g., intravenous adrenergic agonists and
antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral
electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics,
narcotics and opiates).
General Hospital
190) Ref Survey Question 29.4: What activities address the expectations of the Action answer of
this Safe Practice?
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

Hospitals should develop, update, and maintain a list of “high alert” medications as outlined
in the NQF Safe Practices report
Protocols (e.g., nomograms) or guidelines for dosing should be established and made
available throughout the hospital
A process should be established to audit use and compliance with policies and procedures
by providers
191) Ref Survey Question 29.4: How can a hospital measure progress in this Safe Practice?
A hospital that is in compliance with the JCAHO standard MM.7.10 - hospitals develop processes for
managing high-risk or high-alert medications - will meet the intent of the Action answer of this Safe
Practice.
192) Ref Survey Question 29.4: Which dangerous high alert medications should be addressed
first?
Hospitals may consider prioritizing actions for the following medications: concentrated electrolyte
solutions (e.g., concentrated potassium chloride solution), insulin, chemotherapeutic agents,
intravenous opiate solutions, and anticoagulants such as heparin and warfarin.
An example list for high alert medications to address is posted on the Institute for Safe Medication
Practices (ISMP) Web site: www.ismp.org.
Rural Hospital
193) Ref Survey Question 29.1: Are there any exemptions for the rural hospitals?
No.
Pediatric Hospital
194) Ref Survey Question 29.1: Are there any exemptions for the pediatric hospitals?
No.
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Safe Practice # 30
Dispense medications in unit-dose or when appropriate unit-of-use form, whenever possible.
General Hospital
195) Ref Survey Question 30.4: What activities address the expectations of the Action answer of
this Safe Practice?
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



Medications dispensed from the pharmacy should be contained in single use (unit dose)
packaging, in a ready-to-use form
A 24-hour supply of medications should be dispensed to clinical units
A process should be in place to monitor compliance and opportunities for improvement in
unit dose medication dispensing
If a unit dose preparation is commercially unavailable, a unit dose may be created under
the direction and review of the pharmacist
This correlates with JCAHO Standards MM 2.20.10, which addresses medications being
maintained in the most ready-to-administer form available from manufacturers
196) Ref Survey Question 30.4: How can hospitals measure progress with this Safe Practice?
A quantifiable measure could be the percentage of medications dispensed in unit dose format.
197) Ref Survey Question 30.4: One of the “additional specifications” is for unit dose medications
to have a machine readable code that identifies the product name, strength, manufacturer,
and expiration date and lot number. Is this a requirement to meet the expectations of this
Safe Practice?
Not at this time, since it is still under regulatory review.
Rural Hospital
198) Ref Survey Question 30.1: Will rural hospitals be held to this Safe Practice?
Yes. Due to limited size and financial resources, rural facilities will need to develop a process that
addresses the need for unit dose dispensing of medications. Rural facilities should be aware that
purchasing bulk supplies and re-packaging them holds significant potential for adverse drug events.
Pediatric Hospital
199) Ref Survey Question 30.1: How is unit dose defined for pediatrics?
A unit dose for a pediatric patient can be defined as an individual dose created for the patient by the
pharmacist that is based on weight and size of the patient and is packaged in individual doses that
can then be administered.
Other alternatives for medications required when a pharmacist may not be on site are the use of
standardized protocols with dose ranges based on size and weight of for a limited number of
medications, which can then be packaged in pre-filled and labeled syringes for oral solutions or
scored tablets or single use vials for oral and injectable medications.
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