The document outlines Required Organizational Practices (ROPs) designed to enhance patient safety and minimize risk within healthcare organizations. It categorizes ROPs into six key areas: safety culture, communication, medication use, worklife/workforce, infection control, and risk assessment, each with specific goals and compliance expectations. Developed by the Patient Safety Advisory Committee, ROPs are regularly updated based on national and international feedback to address evolving safety issues.

2. By
Abdalla Ibrahim
Healthcare Surveyor
Accreditation Specialist
May, 2013
5/27/2013 :
abdallaibrahim@hotmail.com 2

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4. Required Organizational Practices
(ROPs)
Essential practice that organization must
have in place to:
 enhance patient/client safety
 minimize risk.
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6. The Required Organizational Practices
The ROP
 Statement defines the practice that is expected.
Guidelines
 Context and motivation on why ROP is important to patient
safety and risk management.
Tests for Compliance (major and minor)
 Expectations of surveyors during on-site assessment to
determine compliances with ROP.
 Categorized as major or minor.
Reference Material
 Sources of evidence, tools and resources to assist
organizations in meeting tests for compliance.
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7. Pathway of Development
 Developed in 2004 by Patient Safety Advisory Committee
 Developing:
 National and international literature reviews
 Analysis of survey results and compliance rates
 Research with regard to other accrediting bodies
 ROPs Extensive testing and national consultation
 Feedback from expert advisory committees, client organizations,
surveyors and stakeholders
 ROPs reviewed and updated
 New ROPs are developed as recommended by advisory
committees and field-specific consultation.
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8. ROPs categories
ROPs are categorized into six patient safety
areas:
1. Safety culture
2. Communication
3. Medication use
4. Worklife/workforce
5. Infection control
6. Risk assessment
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10. SAFETY AREAS, GOAL AND ROPs
SAFETY CULTURE:
Create a culture of
safety within the
organization
• Adverse events
disclosure
• Adverse events reporting
• Client safety quarterly
reports
• Client safety-related
prospective analysis
e.g.
Failure Modes and Effects
Analysis (FMEA)
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11. SAFETY AREAS, GOAL AND ROPs
Organizational culture
 The collective behavior of humans who are part
of an organization.
 The organization values, visions, norms, working
language, systems, symbols, beliefs and habits.
 The pattern that are taught to new organizational
members as a way of perceiving, and even
thinking and feeling.
 Organizational culture affects the way people and
groups interact with each other, with clients, and
with stakeholders.
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12. SAFETY AREAS, GOAL AND ROPs
COMMUNICATION
Improve effective and
coordinated
communication among
service providers and
recipients of care
• Two client identifiers
• Safe surgery Practices (Sign in,
Time out, Sign out)
• Dangerous abbreviations (Do not Do
List)
• Medication reconciliation:
• at admission
• at transfer or discharge
• Transfer of Client information at a
transition point:
(SBAR: Situation, Background,
assessment and recommendation)
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16. SAFETY AREAS, GOAL AND ROPs
MEDICATION USE:
Ensure the safe use of
high-risk medications
• Concentrated electrolytes
(Ca >10%, Mg> 20%, K >2 mEq/ml,
Na > 0.9%)
• High alert medication: eg.
 adrenergic agent,
narcotics, insulin,
chemotherapy, sedatives,
neuromascular blockaing,
heparine,
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18. SAFETY AREAS, GOAL AND ROPs
WORKLIFE/
WORKFORCE:
Create a worklife and
physical environment
that supports safe
delivery of care and
service
• Workplace violence
prevention
• Client safety plan
• Client safety: Education
and training
• Preventive maintenance
program
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20. SAFETY AREAS, GOAL AND ROPs
INFECTION
CONTROL:
Reduce risk of health
care-associated
infections and their
impact across the
continuum of
care/service
• Hand-hygiene education
and training
• Hand-hygiene audit
• Infection rates
• Pneumococcal vaccine
• Sterilization processes
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22. SAFETY AREAS, GOAL AND ROPs
RISK
ASSESSMENT:
Identify safety risks
inherent in the client
population
• Falls prevention
strategy
• Home safety risk
assessment
• Pressure ulcer
prevention
• Suicide prevention
• Venous
thromboembolism
(VTE) prophylaxis
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