Florida continues its efforts to improve patient safety in hospitals and Ambulatory Surgical Centers (ASCs). The Florida Legislature previously approved requiring hospitals and Ambulatory Surgical Centers (ASCs) to conduct patient safety investigations and directed the Agency for Healthcare Administration (AHCA) to implement implement a rule specifying the process for submitting such surveys. The AHCA’s proposed rule (proposed rule) was announced on November 4, 2021.
Patient Safety Surveys
Every two years, Florida licensed hospitals and CHWs are required to conduct a patient safety culture survey using the applicable Patient Safety Culture Survey developed by the Federal Research Agency and Health Care Quality (AHRQ) (the Safety Act). Surveys should be conducted anonymously to encourage completion of surveys by all employed and contracted personnel. Facilities are permitted to contract with vendors to administer the survey.
Survey data will need to be submitted to the AHCA in the format specified by the proposed rule once it has been finalized and implemented. Submissions must include survey participation rate, although no minimum participation amount is specified. The AHCA’s proposed rule outlines the requirements outlined below.
Within twenty-four months of the proposed rule taking effect, and for each subsequent license renewal, each hospital and each ASC will be required to submit patient safety culture survey data to the AHCA. patients.
Data File Specifications
Facilities must submit data to the AHCA in the format specified by the AHRQ. AHRQ has different data file specifications for hospitals and CHWs.
The AHCA will provide the survey questions to ask, which are different for CHWs and hospitals. While the general concepts are similar, the question categories are different. The majority of questions in both surveys require the participant to respond to statements by answering: Never; Rarely; Occasionally; Most of the time; Always; Not applicable or don’t know.
The Hospital Survey groups questions into specific sections: (1) area of work of the respondent, (2) hospital management, (3) communication, (4) reporting safety events of patients, (5) evaluation of patient safety, (6) the hospital in general, and (7) the care provided.
The ASC survey groups questions into the following sections: (1) work environment, (2) teamwork and training, (3) organizational learning, (4) documentation of near misses, (5) leadership for patient safety, (6) overall facility assessment, and (7) communication in the surgery/procedure room.
Additional Patient Safety Requirements
Hospitals and CHWs do not yet need to submit patient safety surveys, as the proposed rule requires surveys to be conducted within twenty-four months of the effective date of the proposed rule. However, it is important to remember that requiring investigations to be conducted is only part of Florida’s strategy to ensure patient safety.
The Safety Act requires that hospitals and CHWs already have the following in place:
- The adoption of a patient safety plan. The plan will be considered compliant with this requirement if it adheres to the Centers for Medicare & Medicaid Services Participation Requirements for Quality Assessments and Performance Improvement Plans.
- Appointment of a patient safety officer and a committee responsible for promoting patient health and safety, reviewing the quality of patient safety measures and assisting in the implementation of the safety plan patients at the facility. The committee must include at least one person who is not employed or practicing in the establishment.
In addition to the above requirements, hospitals are required to provide the AHCA Hospital Quality Measurement/Patient Safety Information Form (1) to any patient or patient representative when planning non-emergency patient care, Where (2) to any other stabilized patient or their representative within 24 hours of the patient’s stabilization or upon discharge, whichever comes first. In addition, the form must always be provided to anyone requesting this information. The form should include the hospital and state average for the most recent year related to the following quality measures:
- The rate of nosocomial infections;
- The overall score of the Hospital Consumer Assessment of Healthcare Providers and Systems survey; and
- The 15-day readmission rate.
Prepare a patient safety plan
Florida is making progress in its goal to advance patient safety. Hospitals and CHWs are non-compliant if they fail to adhere to previously implemented patient safety requirements, such as adopting a patient safety plan. Once the proposed rule for patient surveys is finalized, hospitals and CHWs will need to turn their attention to implementing a timely biennial survey submission process.