118.3. Are the results of the assessment used to improve X office services? Event Report 118.4. Is there documentation and tracking of X complaints to identify trends and make improvements? 119. Is there a policy in place that includes criteria for X termination of care/discharge from the practice? 119.1. Is the patient notified in writing by registered or X certified mail?* 119.2. Does the termination letter inform the patient X about how to obtain the services of another physician and clearly state the effective termination date? 119.3. Are records made available to the new physician X upon receipt of the patient's authorization? Event Report 120. Does the practice have a formal, nonpunitive X system for reporting events, near misses, hazards, and patient safety issues? 120.1. Is there an approved event reporting form (paper X or electronic) available to providers and staff of the practice to report events, near misses, hazards, and patient safety issues? 120.2 Are reported events, patient safety issues, and near X misses investigated through interviews, medical record reviews, inspections, and observations? 120.3. Are reports and investigations analyzed to X identify areas for quality and safety improvement? Staff Process 120.4. Is there a committee or other forum regularly X Improvement held to communicate quality and safety issues and Committee to discuss improvement action plans and results of actions taken? 120.5. Is feedback provided to the practice managers, providers, and staff? 120.6. Does the committee review reports of X events (e.g., events per 1,000 office visits) compared to previous reporting periods? 121. Does the practice endorse open communication X with patients, and has it adopted a practice of disclosing to patients when an unanticipated adverse event or error has occurred?
118.3. Are the results of the assessment used to improve office services? X 118.4. Is there documentation and tracking of complaints to identify trends and make improvements? X Event Report 119. Is there a policy in place that includes criteria for termination of care/discharge from the practice? X 119.1. Is the patient notified in writing by registered or certified mail?* X 119.2. Does the termination letter inform the patient about how to obtain the services of another physician and clearly state the effective termination date? X 119.3. Are records made available to the new physician upon receipt of the patient's authorization? X 120. Does the practice have a formal, nonpunitive system for reporting events, near misses, hazards, and patient safety issues? X Event Report 120.1. Is there an approved event reporting form (paper or electronic) available to providers and staff of the practice to report events, near misses, hazards, and patient safety issues? X 120.2 Are reported events, patient safety issues, and near misses investigated through interviews, medical record reviews, inspections, and observations? X 120.3. Are reports and investigations analyzed to identify areas for quality and safety improvement? X 120.4. Is there a committee or other forum regularly held to communicate quality and safety issues and to discuss improvement action plans and results of actions taken? X Staff Process Improvement Committee 120.5. Is feedback provided to the practice managers, providers, and staff? 120.6. Does the committee review reports of events (e.g., events per 1,000 office visits) compared to previous reporting periods? X 121. Does the practice endorse open communication with patients, and has it adopted a practice of disclosing to patients when an unanticipated adverse event or error has occurred? X
2a._ECRI-Risk_Management_September_2013.docx