N.J. Admin. Code § 8:43E-10.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:43E-10.4 - Patient or resident safety committee

(a) Each facility shall establish a patient or resident safety committee, as applicable to the type of facility.

1. General hospitals shall establish a patient safety committee no later than June 1, 2008.

2. All other facilities shall establish a patient or resident safety committee no later than the effective date of this subchapter, applicable to the particular type of facility as set forth at N.J.A.C. 8:43E-10.2(a).

(b) The purposes of the patient or resident safety committee are as follows:

1. To develop a patient or resident safety plan for the facility;

2. To conduct ongoing analysis and application of evidence-based patient or resident safety practices in order to reduce the probability of adverse events; and

3. To conduct analyses of near-misses and adverse events that occur within the facility, paying particular attention to serious preventable adverse events.

(c) A facility shall comply with the following standards in establishing a patient or resident safety committee:

1. The patient or resident safety committee shall be comprised of at least the following individuals:

i. A chairperson appointed by the chief executive officer (CEO) or administrator of the facility;

ii. If the applicable licensing standards require the facility to have a medical director, then the medical director of the facility or equivalent position or the medical director's designee, who must also be a physician;

iii. If the applicable licensing standards require the facility to have a chief nursing executive, a vice-president for nursing, or a director of nursing, then the chief nursing executive, vice-president for nursing, director of nursing of the facility or equivalent position or the designee of the chief nursing executive, vice-president for nursing or director of nursing, who must also be a nurse; and

iv. The risk manager or other employee of the facility exercising primary responsibility for monitoring adverse events within the facility or the risk manager's designee.

(1) For smaller facilities where there is no individual performing a separate risk management function, it is not necessary to have a separate risk manager represented on the committee;

2. When the nature of the facility and its staffing permits, the chairperson of the patient or resident safety committee shall also select ad hoc members for the patient or resident safety committee, based on the relevance of their job responsibilities and professional experience to the conduct of a root cause analysis of a specific adverse event or near-miss under investigation;

3. In the case of a facility that is part of a health care system that owns or operates multiple New Jersey facilities, the patient or resident safety committee may be operated at the system level, provided the following conditions are met:

i. There is a representative from each New Jersey-licensed facility on the committee; and

ii. The system patient or resident safety committee ensures that each individual member facility's data related to patient safety remains distinctly identifiable;

4. The patient or resident safety committee shall not constitute a subcommittee of any other committee within a facility or health care system;

5. For all matters related to the patient or resident safety committee the chairperson of the patient or resident safety committee shall report directly to the CEO or other administrative head of the facility or system, unless the CEO is the chairperson;

6. The patient or resident safety committee shall meet at least quarterly, but may meet on a more frequent basis as needed and determined by the committee; and

7. The patient or resident safety committee shall document the proceedings of each meeting in minutes, which shall contain, at minimum, the following:

i. The attendees at the meeting;

ii. The date and time of the meeting;

iii. A brief description of the issues discussed; and

iv. The recommendations made by the committee.

(d) To accomplish the purposes set forth in (b) above, the patient or resident safety committee shall perform the following activities:

1. Develop a written patient or resident safety plan for the facility, according to the requirements of N.J.A.C. 8:43E-10.5 no later than 180 days after the effective date of this subchapter, applicable to the particular type of facility as set forth at N.J.A.C. 8:43E-10.2(a).

i. There must be a facility-specific plan for facilities that are part of a health care system that employs a system patient or resident safety committee;

2. Review and revise, if appropriate, the patient or resident safety plan as often as the committee deems necessary, but at least once every three years;

3. Foster attitudes, beliefs, and behaviors supporting open communication within the facility about adverse events and near-misses by:

i. Developing and implementing a training program for all professional and direct patient or resident care employees and medical staff enabling them to recognize and report to the patient or resident safety committee all serious preventable adverse events, as well as other adverse events and near-misses;

ii. Disseminating information to all employees and medical staff on the process for filing anonymous reports with the Department of near-misses and preventable events that are not serious preventable adverse events; and

iii. Maintaining an internal tracking system for all reports of adverse events and near-misses that permits aggregation of the data and trend analysis;

4. Develop and recommend implementation of measures to minimize the risk of preventable adverse events;

5. Assure timely reporting to the Department or, in the case of a State psychiatric hospital, the Department of Human Services, of all serious preventable adverse events, in accordance with the requirements of N.J.A.C. 8:43E-10.6;

6. Review developments in evidence-based patient or resident safety practices appropriate to the services offered within the facility and recommend appropriate modification of facility policies and procedures to enhance patient or resident safety;

7. Except in the case of a Medicare and/or Medicaid nursing home, assemble an appropriate team to conduct a root cause analysis of every serious preventable adverse event, as well as at least one root cause analysis per year of a preventable adverse event that is not subject to mandatory reporting or of a near-miss reported to the patient or resident safety committee.

i. Facilities, other than hospitals that do not belong to a health care system, may assemble a team of one and/or retain a consultant to perform the root cause analysis.

ii. The patient or resident safety committee shall review the results of each root cause analysis and, as appropriate, recommend modification of facility systems, technology, policies or procedures to enhance patient or resident safety;

8. Analyze, on a quarterly basis, the aggregated data in the internal facility-specific tracking system to determine patterns of similar problems or events, which may otherwise not be detected by the patient or resident safety committee, in order to identify problems or events appropriate for further analysis;

9. Document whether the facility accepted, rejected, or modified the recommendations of the patient or resident safety committee for modifications in facility policies or procedures.

i. In the case of rejection or modification of a recommendation, the patient or resident safety committee shall ensure that the documentation includes the rationale for the action taken; and

10. Monitor modified policies and procedures after implementation to determine the impact of the revised policies and procedures on preventable adverse events.

N.J. Admin. Code § 8:43E-10.4