Section 629-3-4 - Safety Star Validation Process1.Purpose. The purpose of the validation process is to confirm that Safety Star applicants are meeting appropriate MQF thresholds. MQF uses a peer validation process to confirm each applicant's adherence with Safety Star standards. The Validation Team (VT) responsible for the validation process is comprised of volunteer Quality Improvement professionals from within Maine's hospital system. Each Safety Star application will be verified with a site visit.2.Timeline. The validation process timeline is as follows: MQF receives completed Safety Star Application Form. MQF acknowledges receipt of the application within 30 calendar days of receipt and queues it for VT. MQF and VT meet to review the application and establish Site Visit Team (SVT) for site visit. Validation process is completed within 90 calendar days of MQF's acknowledgement of a satisfactorily completed application. o SVT conducts site visit, completing a Validation Form for each Safety Star practice.
o SVT submits Site Visit Report to MQF.
MQF reviews Site Visit Report and notifies applicant of award decision within 10 business days of receiving the report. MQF publicly announces Safety Star Award recipients at time and place intended to generate the most favorable publicity. Each applicant is informed of its Safety Star award decision within approximately 140 calendar days of MQF's receipt of a satisfactorily completed application. 3.Validating Safety Star Practices. To verify most Safety Star practices, VT members will conduct policy and record reviews during site visits, based on the version of the Safety Star validation criteria in place at the time of the application. These reviews will ensure that an appropriate protocol for a specific practice is in place, hospital employees understand the protocol, and hospital employees follow the established protocol. A. The number of interviews conducted in conjunction with a policy review, along with the selection of patient charts for record reviews will be guided by the Validation Manual.4.Site VisitsAfter MQF acknowledges receipt of an application, it will meet with the Validation Team (VT) to determine which members will be a part of the team that will conduct the site visit for the application.
A.Site Visit Team Membership1. At least two VT members and one representative from MQF will comprise each Site Visit Team (SVT).2. Where possible, the SVT will include at least one member from a hospital of size and complexity comparable to that of the applicant and at least one member from a dissimilar hospital.B.Information Sources. The information that the SVT gathers during the site visit will be guided by two sources: the Safety Star application itself and Validation Forms. Safety Star applications will contain information regarding any supporting documents the applicant has for each practice threshold, where site teams can find those documents, and identify the appropriate contact person for obtaining the documents.C.Validation Forms. The Validation Forms pinpoint the specific information the SVT must find to validate each Safety Star practice. During the site visit, the SVT will complete a Validation Form for each safe practice to represent the SVT's pooled observations.E.Applicant Responsibilities. On the day of the site visit, the applicant must make sure all supporting documentation noted in the application is available for SVT review. The applicant must ensure that the SVT can review records in a way that assures patient privacy. Additionally, hospital unit managers should be made aware of the site visit.F. The timeline for the day of the site visit is as follows: o SVT meets and greets hospital representatives.
o SVT conducts site visit.
o SVT meets briefly and reviews site visit.
o SVT meets with hospital representatives to share general impressions of visit, for informational purposes only.
G.Post Site Visit. After the site visit, the SVT will complete the most recent version of the Site Visit Report, which has two parts: a summary of the site visit and the Validation Forms (one for each Safety Star practice).95- 629 C.M.R. ch. 3, § 4