PSQ NABH 6th Edition Implementation Guide

Chapter Purpose

PSQ connects quality governance, patient-safety incidents, indicators, audits, RCA, CAPA and management review into one improvement system.

Departments Involved

• Quality team
• Clinical leaders
• Nursing
• Patient safety committee
• Medical records
• Risk owners
• Hospital management

Implementation Responsibilities

• Maintain patient-safety goals, incident reporting and quality indicators.
• Run RCA and CAPA for selected events and trends.
• Use audits and data to improve process reliability.
• Report meaningful quality information to leadership.

Evidence Categories

• Incident reports
• RCA and CAPA records
• Quality indicators
• Clinical audits
• Management review minutes

Policy/SOP Categories

• Quality improvement
• Incident reporting
• Sentinel and adverse event handling
• Clinical audit
• RCA and CAPA

Quality Indicators

• Incident reporting rate
• CAPA closure compliance
• Clinical audit completion
• Indicator review compliance

Internal-audit Questions

• Are incidents reported without hiding near misses?
• Are CAPA actions linked to root causes?
• Do indicators have owners, targets and trend review?
• Are clinical audits followed by re-audit?

Common Gaps

• Indicator dashboards exist but do not drive action.
• CAPA is recorded without effectiveness checks.
• Near misses are not reported.
• Clinical audits remain file exercises.

Training Topics

• Patient safety goals
• Incident reporting
• RCA and CAPA
• Indicator interpretation
• Clinical audit methodology

Practical Implementation Notes

• PSQ should be the bridge between departmental evidence and leadership decisions.
• Avoid measuring too many indicators without ownership and action discipline.