b'Preventive actions include, but are not limited to,Clause 6: Planningchanges in policies and procedures, repairing or replacing equipment, staff education and training, etc. Ways toRRequires using risk-based thinking. Risk based enhance patient education on safety measures involvethinking: an organization shall plan and implement actions information technology platforms (e.g., Get Well network),to address risks and opportunities. Addressing both risks outpatient and inpatient rounding, assessment programsand opportunities establishes a basis for increasing (e.g., the Humpty Dumpty Falls Assessment Program), IVthe effectiveness of the quality management system, infiltrate prevention, medication safety rights, food andachieving improved results, and preventing negative drug interactions, community projects. effects.The patient safety program provides an interactive andThis risk-based thinking can determine the internal continuous educational campaign for patients/parents/ and external factors that could cause its processes and families, employees, medical staff, medical fellows, andManagement System to deviate from the planned results residents. The team promotes a Just Culture to ensureand regulatory requirements.shared accountability whereby NCHS is accountable forQuality Objectivesthe system and for responding to employees in a fair and just manner, and employees are accountable for theThe organization shall establish quality objectives at quality of their choices and for reporting adverse eventsrelevant functions, levels, and the processes needed for and system vulnerabilities. the quality management system. The quality objectives Service Excellence Data shall be documented and:Service Excellence data includes: Consistent with the quality policy MeasurablePatient Satisfaction SurveyConsider applicable requirementsInter-department SurveyRelevant to conformity of products and services and to Complaints & Grievance enhancement of customer satisfactionSocial Media SentimentMonitoredData is tracked and trended to identify key drivers and Communicatedareas of focus. Updated as appropriateThe framework for the quality objectives is established within our quality policy with objectives. Objectives may apply broadly across the organization or more narrowly to a specific site, department, or process. A methodology for communicating these objectives should be implemented to ensure that personnel responsible for their attainment are aware of them. Objectives shall be monitored and updated as appropriate.Personnel, including newly hired, part-time, and even contracted or temporary employees, should understand the applicable objectives at their level. They should be able to translate these objectives into their everyday work duties.Clause 7: SupportNCHS cannot provide patient services without sufficient allocated resources including people, equipment, buildings and all the services required to admit, treat, and discharge our patients.Properly trained staff is a critical component of this clause. Employees must be qualified and trained to do 12 Nicklaus Childrens Health System'