JOINT COMMISSION REQUIREMENTS UPDATE
June 2010
Some EP’s Removed, Some EP’s Revised
The June edition of Perspectives has an article describing an analysis undertaken by
the Joint Commission with feedback from hospitals to identify and remove certain
elements of performance that did not actually support or enhance patient safety or
quality of care. This process lead to the identification of 52 potentially removable
elements of performance, and later to the actual approval for removal of 16
elements of performance. This outcome is somewhat disappointing because earlier
on in the process it was thought that they might eliminate more of the consistently
non scored elements of performance, or elements of performance that are not
consistent with CMS expectations. There are many requirements in the manual that
sound reasonable, but they are not really measureable and never scored on survey,
however organizations struggle in terms of preparing for these requirements.
Nevertheless, removal of 16 is somewhat helpful.
It appears that some elements of performance that were removed were limited in
application to long stay patients only. Specifically 4 elements of performance from
the EC chapter for long stay patients and 5 from the RI chapter specifically covering
psychiatric hospitals have been deleted. Additionally 6 relatively new, but tedious
expectations from the 2009 leadership chapter have been deleted. There were also
two EP’s from MM that were deleted, but it is a good news, bad news situation. The
requirement that was deleted was MM.07.01.01, EP’s 1 and 2 regarding response to
medication and the patient’s perception of efficacy side effects. This is an
infrequently scored issue today and one that most organizations conducted in a
passive, routine care format without specific documentation requirements.
Unfortunately the requirement did not disappear, but rather moved into
PC.01.02.01, EP 1 as a note which states: “Assessment and reassessment
information includes the patient’s perception of the effectiveness of, and any side
effects related to his or her medication(s).” There is no mandatory D for
documentation here from the Joint Commission, however we encourage our readers
to examine their assessment and reassessment policies to see what mandatory
documentation requirements you have established in your policiesYou may need to
refine your policies to include a reference to effectiveness and side effects of
medications. Additionally we encourage you to state that documentation is only
required if effectiveness is not seen, or side effects are seen. You do not want to
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mandate documentation of expected actions every shift as this will be more
vulnerable to omissions and gaps in documentation which can result in
requirements for improvement.
One More Thing
for your
Medical Staff Documents
UPDATE
ON STERILIZATION
In our April Newsletter we talked about changes which may be needed in your
medical staff bylaws, rules and regulations and policies as a result of MS.01.01.01. In
the June Perspectives we learned of one additional item that should be added and
that is a non discrimination clause for issuance of privileges and a similar clause for
membership on the medical staff organization. These requirements had been
eliminated several years ago as it was thought that the issue was covered by
workplace non discrimination regulations. The American Medical Association has
notified the Joint Commission that these non discrimination regulations only
covered employees of the hospital, not practitioners with privileges. We suggest that
as you do your gap analysis for MS.01.01.01, incorporate two placeholders to weave
in these non discrimination requirements.
Teleradiology Services
If you were concerned about the pending July deadline to credential and privilege
the physicians that may be interpreting radiologic images through a teleradiology
contract, the deadline has been moved from July 2010 to at least March 2011. As you
may recall the issue surrounds to concept of privileging by proxy, which CMS had
told the Joint Commission was prohibited and they would have to change their
standards to also prohibit it. CMS has now published a notice in the Federal Register
that they are reconsidering this position and may allow the practice among
Medicare certified hospitals. This potential change still has to go through the
regulatory review and notification process, but the fact that it is being considered
enabled Joint Commission to delay their implementation date. In the end, most of
our readers that use any external resources for after hour’s radiology services use
the services of a teleradiology provider instead of another Medicare certified
hospitals radiology service. Nothing in the proposed rule would permit a hospital to
accept privileging decisions from a non Medicare certified teleradiology group.
However as Joint Commission has documented in their FAQ on the subject a hospital
can use the credentials verification information from the teleradiology provider if
that provider follows the principles of a CVO as defined in the CAMH glossary. The
hospital will still need to make its own privileging decision, however some of the
background documentation can be simplified if the teleradiology provider meets
those CVO principles.
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If there was any doubt about Multidose Vials….
The Joint Commission has now made it clear that there is only one acceptable
technique to document expiration of a multidose vial. That one technique is to place
a beyond use, or expiration date on the vial that is 28 days in the future. Previously
there was some ambiguity if it was 28 or 30 days and if it was date of opening or
date of expiration. In the June Perspectives TJC has stipulated that they want an
expiration date and it can only be 28 days unless the manufacturer says otherwise.
This announcement also mentioned that the change in requirement was effective
immediately, not at a later date or the 6 months called for in your accreditation
contract with TJC. For those hospitals that have implemented the process we have
suggested whereby your pharmacists conduct their monthly inspections every 28
days and discard all open multidose vials, it appears this will no longer be
acceptable.
One issue that hospitals often struggle with is knowing what specific date is 28 days
from today. We have seen two best practices that may help with this process. One
practice is to place a one page, yearly calendar in each medication room for staff to
count forward 4 weeks. A second practice, though more time consuming was where
the pharmacy posted a daily notice each day such as “28 days from today is July XX”.
Any supportive practice that helps staff to accommodate this change is helpful. Since
a change in an existing practice often comes slowly we encourage our readers to
announce the change ASAP and to begin monitoring to determine if you can achieve
a 90% compliance rate.
Standing Orders, Protocols and Preprinted Order Sets
We have seen RFI’s in recent years that indicate that hospitals may be getting
confused about how to use standing orders, protocols and preprinted order sets. To
a large extent these 3 terms are blurring together, however there are important
differences in how these can be used, and what must be done before we do use
them. The most common of these is a preprinted order set and there are two
variations on these. A preprinted order set most often consists of an entire set of
orders for medications, tests and monitoring which have check boxes next to them
for the physician or other authorized practitioner to check the specific treatments
he/she wants administered to the specific patient. The practitioner checks the
desired treatments by hand or by computer and authenticates by written or
electronic signature, or authorizes those treatments by telephone and authenticates
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later. A second type of preprinted order set is one in which the physician always
wants the entire set implemented and the form has no check boxes. The physician
documents by signature or telephone order that he/she desires to have that
preprinted order set implemented. The most important thing to remember with
these preprinted order sets for accreditation purposes is that we cannot implement
or assume the physician will want to implement all or any portion of the form. We
must get authorization from the physician to implement these orders for a specific
patient. There are two standards in the CAMH that clearly stipulate this
requirement:
MM.05.01.07, EP 5 A: Medications are prepared and administered in
accordance with the orders of an LIP responsible for the patients care, and in
accordance with law and regulation.
PC.02.01.03, EP 1 A: Prior to providing care, treatment or services, the
hospital obtains or renews orders, verbal or written from and LIP in
accordance with the professional standards of practice, law and regulation.
Preprinted order sets should be reviewed and approved periodically by a committee
of the medical staff, pharmacy, nursing and medical records professionals to ensure
that they meet your hospitals requirements for abbreviations, minimum content,
formatting and clarity (see MM.04.01.01 EP7). The Institute for Safe Medication
Practices has prepared an excellent monograph, available on their website; ISMP.org
entitled “Guidelines for Standard Order Sets”. We encourage our readers to
download this document and to use the advice for designing preprinted order sets.
We wish they had not used the term “standard” order sets as it may tend to get
further confused with standing orders we will discuss later.
Protocols are a second type of structured orders used in hospitals, although they are
used less often than preprinted order sets. Protocols are synonymous with clinical
practice guidelines according to the glossary in the CAMH. We commonly will use a
protocol approved by the medical staff to dose a medication like warfarin, or an
aminoglycoside antibiotic. The protocol is something known to the medical staff and
approved by the medical staff, and in each case will be ordered by a physician if they
want the protocol used for a specific patient. The concept of ordering is consistent
with the MM and PC standards referenced above. From a survey perspective there
are two very important concepts we should adhere to:
1. We must have a documented protocol and demonstrate when and where
it was approved by the medical staff.
2. If we want to use a protocol it should be ordered by an LIP or other
approved practitioner.
Sometimes in survey reports we will see that the pharmacy staff are dosing
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anticoagulants or aminoglycoside antibiotics, but their decision making is not based
on rules previously approved in the protocol, but rather best judgment. This can
lead to major problems on survey because non independent practitioners are
supposed to follow approved protocols, not just use independent judgment. Scoring
for this issue will commonly occur in the human resources chapter with the
implication being practice of medicine without a license with a potential outcome of
preliminary denial of accreditation.
The Joint Commission, CMS and American Osteopathic Association’s HFAP
standards are quite consistent in this performance area, but HFAP has the clearest
explanation of the requirement where they state:
25.01.15: “When protocol orders are used, the practitioner individualizes the
orders for each patient. The order is dated, timed and signed by the ordering
practitioner. Annually protocol orders are reviewed, updated as indicated
and approved by the medical staff. The sponsoring practitioner authenticates
the master copy as evidenced by his/her signature”.
We would encourage our readers to use this strict annual process as defined by the
HFAP standards in their readiness for Joint Commission.
The third type of order set is perhaps the most confusing, and least commonly used
is a “standing order”. Part of the confusion is that standing orders were specifically
prohibited by CMS in 2008; only to later in 2008 have that prohibition overturned.
The classic example of a standing order is influenza vaccine or pneumonia vaccine
administered by a nurse after clinically screening the patient for contraindications,
using screening criteria approved by the medical staff. If the patient passes the
screening criteria, the medication can be administered without a physician having to
first write an order. Additional confusion was added by the Joint Commission when
performing the standards rewrite in 2009 when they changed their definition of a
standing order. In 2008 they had defined a standing order in MM.3.20 as: “written
instructions to administer a medication to a person in circumstances specified in
instructions without a prescription.” Perhaps TJC changed in 2009 due to the
transient prohibition by CMS, but in 2009 the CAMH in MM.04.01.01 now reads: “a
prewritten medication order and specific instructions from the licensed
independent practitioner to administer a medication to a person in clearly defined
circumstances”. In 2009 the definition added the concept that a standing order
comes from a practitioner and removed the concept that it can be done without a
prescription.
On October 24, 2008 CMS issued its Survey and Certification Letter SC-09-10 which
clarified that standing orders are permissible even though the COP language seems
restrictive. The COP states: 482.23(c)(2) “With the exception of influenza and
pneumococcal polysaccharide vaccines, which may be administered per physician
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approved hospital policy after an assessment of contraindications, orders for drugs
and biological must be documented and signed by a practitioner who is authorized
to write orders by hospital policy and in accordance with state law, and who is
responsible for the care of the patient as specified under 482.12(C)”. This language
appears to restrict standing orders to vaccines only, however in the survey and
certification letter CMS went on to say: “The use of standing orders must be
documented as an order in the patient’s medical record and authenticated by the
practitioner responsible for the care of the patient in accordance with the
regulations, but the timing of such documentation should not be a barrier to
effective emergency response, timely and necessary care, or other patient safety
advances. We would expect to see that the standing order had been entered into the
order entry section of the medical record as soon as possible after implementation
of the order, with authentication by the patient’s physician”. Bottom line here is that
the standing order can be implemented and the paperwork documentation can be
done after implementation. So where does this leave us in terms of remaining
compliant with regulations and standards, and meeting patient care needs quickly?
The best advice we can give here is to identify a very small subset of all orders that
are so critical, so essential and needed so quickly that a practitioner may not be able
to order it. These should be considered for approval by the medical staff as standing
orders. One type of treatment you may want to consider are medications
administered to a newborn such as eye ointments. We have seen this issue cause
problems on survey because the nurse administers the eye ointment to the newborn
before there is actually an order in the chart. If this is handled as a standing order,
approved by the medical staff and signed by the physician after administration it
would be compliant with the standards and COP’s. If done as a preprinted order set
it must be initiated prior to administration. It is also common in hospitals today to
conduct MRSA screening upon admission, or prior to a surgical procedure. This
practice if done prior to a physician ordering it as part of admission orders is
another example of a “standing order”.
Also remember that with standing orders you don’t want to go too far and place
many treatments on “auto pilot”, nor do you want to construct screening criteria
that become so complex they cannot be implemented consistently. We need to think
of the use of standing orders as in very limited situations, where there is broad
consensus that the treatment is appropriate, safe and needed urgently. Lastly you
are the most knowledgeable about state regulations and some states may still be
prohibiting standing orders. We noticed for example that the Ohio Boards of
Nursing and Pharmacy have posted a specific prohibition on the use of standing
orders and even adjustment of medications based on a protocol, so be careful with
state regulations. If you need copies of any of the references mentioned here from
CMS or ISMP please just email anyone of us and we will send it.
Enjoy your summer!
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6740 W. Deer Valley Rd.  Glendale, AZ 85310  Ph: 623.572.8487  Fax: 928.415.4677  www.PattonHC.com