1. Conquer Compliance with Performance Support
Allegheny Health Network
Conquer Compliance with Performance Support
Learning Orlando , FL November 4 – 7, 2018
Molly Petroff, MEd, RN, FCN

2. Foundational Principles of PS
5 Moments of Need:
PS Pyramid:
Apply
Solve
Change
More
New
Picture slide: Diagrams od 5MoN and PS Pyramid
Conrad Gottfredson & Bob Mosher Used with permission

3. Snapshot: 300 bed tertiary-care hospital in NW PA Satellite sites:
2 rural hospitals
25+ medical offices
Diagnostic and treatment centers
3000 associates system-wide
Slide 1

4. Under the Regulation of Multiple Agencies
TJC:
The Joint Commission for Accreditation of Healthcare Organizations
DOH:
PA Dept of Health
OSHA
Picture slide: Regulatory diagram
CMS:
Fed Agency: Medicare, etc.
Etc.

5. How We Developed Our Solution
Reviewed regulatory standards to assure all requirements were included
Focus Groups
One group for each different aspect of safety
2 - 5 people per group
Focus on defining what staff needs to DO to be safe and what they need to KNOW in order to do that
Slide 2

6. Matrix of Mandatory Review Topics
CMS REGULATORY TRAINING REQUIREMENTS
Picture slide: example of Mandatory Matrix
Organizational definition of “on-going”

7. Demo of Safety GPS

8. Safety GPS in the SV Culture
Introduction to leadership & incumbents
Introduction in New Hire Orientation
New approach to Annual Safety
New approach to Survey Prep
Slide 3

9. Picture slide: Example of scavenger hunt screen

10. Results
JCAHO surveys 2013 and 2016 and intermittent DOH inspections yielded NO deficiencies in environmental safety
JCAHO survey 2016 named SV Safety GPS an Exemplary Practice for safety education in healthcare organizations.
EPSS for a Continuously Safe Environment based on the Safety GPS accepted into JCAHO Leading Practice Library in 2017.
Slide 4

11. Questions? Comments? Performance Support Community
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Slide 5