JOINT COMMISSION, WHATS NEW,
FREQUENTLY SCORED STANDARDS
January 2014
Patton Healthcare Consulting
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CURRENT NEW DIRECTIONS AND THEMES
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EC/LS heavily focused and scored
High level disinfection
OR temperature and humidity
Air handling and pressure relationships
MS.01.01.01 gaps
Contract management
Closed record review to zero in on restraint
issues and ICU sedation issues
• Then there are the top 10
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New Focus
• High Reliability Organization
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GOOD IDEAS FOR TRACER INTERVIEW
• Be enthusiastic about how good you are
• Talk proudly about the excellent service and care you
provide
• Offer data or other follow up to support compliance if
available for areas cited by surveyor
• Have multiple staff (MD, pharmacist plus RN a BIG help)
participate in the unit interviews, one person can forget,
get intimidated
• Know what your EMR will display based on userid.
• Don’t think “what is the right answer” think about what
you do day after day.
• Know where policies are kept & how to access them
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When They Are on Your Unit
• Know where to find your policies & “fast
facts” or other tip tool
• Have two people in the patient record, a
second person as back up looking for stuff
• Offer policies, describe education
• Use your resources, you don’t need to
memorize
• Call on experts around you
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When They Leave…
• After the team leaves, find all “IOUs”
• Find the order
• Find the anesthesia record, the consent, etc
• Copy it, highlight the part the surveyor couldn’t
find
• Find the surveyor, show them AND/OR
• Bring a copy to the surveyor room during special
issue resolution, escort should record this
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Role of the Escort/Note Taker
• With an electronic system consider a buddy
system, have someone other than the nurse
search the record for requested information
• Gently coach
• Record offers to present support and record
surveyor’s response
• Record the “he said” “she said”
• Record MR numbers
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GOOD IDEAS FOR TRACER INTERVIEW
• In the PACU or PreOp holding know that your
surveyor is going to want to see:
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History and physical
Update to the H&P
Nursing assessment
Consults
Orders
Home medication list, reconciliation if inpatient
If surgical, pre anesthesia 1+2, time out,
Post procedure note with all elements
post anesthesia note.
• Train escorts and scribes where to find these.
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Tracer Tips For Staff
• Before answering a question:
– Take a deep breath
– Make sure you understand the question
– Or ask “Could you please rephrase that question…”
– Offer to provide the answer later in the day
– Stop talking once you have answered
– If your surveyor pauses after your answer, try to
seek acknowledgement that you have fully
answered the question don’t just restart talking.
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Tracer Tips For Staff, cont.
• Never, never “fix” a chart to avoid an RFI
• Never “make up” answers to please the surveyor
• Don’t be intimidated by surveyors, or by your own
management.
• Do not argue with the surveyor
• Take advantage of surveyor suggestions
• Know what improvements in patient care came from
PI (performance improvement) activities
• Don’t affirm the leading question…” this isn’t a very
good process, is it?”
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Focus on the Top 10 & NPSGs
• The 2014 standards have 1700 EPs that
can be scored
• The Joint Commission does >90% of its
scoring on about 25 standards/NPSGs
• Implement the top scored and all NPSGs
• Spend you dollar here!
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The Top 10 Most Frequently Cited TJC Standards
2013
1. Medical Record Entries
RC.01.01.01 EP 6, EP 11, EP 19
55%
– Information needed to justify the
patient’s care, treatment, and services
missing
– Entries are not dated, timed, signed
– Illegible hand writing
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The Top 10
2. Maintaining the Path of Egress
LS.02.01.20 EP 13, 16-22
54%
– Corridors are not free of clutter
– Exit door, exit sign
– Suites are not designated and maintained
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Top 10
3. High Level Disinfectant
IC.02.02.01
47%
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EP 1, EP 2, EP 4
High level disinfection and sterilization problems
Staff competency and staff supervision are focus areas
Poor low level disinfection – Ø contact time
Poor storage of equipment, devices, and supplies
Has resulted in Immediate Threat to Life and/or
Condition Level Finding
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Top 10
4. Manage risks with Ventilation systems
EC.02.05.01
46%
– Will lead to a Condition Level Finding
– New to the top 10 in 2012, scored in the ORs &
procedure areas
– Pos/Neg air pressure relationships
– Air exchanges, correct # per hour
– Filtration problems
• Surveyors can use Tissue Test
• Improper system design, or
• Lack of inspection, testing, maintenance or
performance problems
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Top 10
5. Maintain building features to prevent
effects of fire, smoke
LS.02.01.10
45%
– Penetrations in fire barriers and fire door
issues are still a problem.
– Usually fire doors not latching
– Doors undercut, gaps, rated
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Top 10
6. Maintenance of Fire Safety Equipment
EC.02.03.05 EPs 1- 25
44%
– Inspection, testing and maintenance of each piece
of fire safety device (smoke detector, fire pull
station, magnetic door release)
– Documentation in not readily available for testing fire
safety equipment
– Often a double hit against leadership
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Top 10
7. Maintain building features to protect against
fire and smoke
LS.02.01.30
43%
– Primary issue is doors to hazardous areas that are
propped open
– Smoke barrier penetrations, hazardous areas not
protected
– Gaps under doors
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Top 10
8. Maintain fire extinguishing features
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LS.02.01.35
35%
Sprinkler or fire extinguishment issues
Hanging things from sprinkler pipe,
18 inch rule, sprinkler head broken
Also, scored here: ventilation, temperature and
humidity problems.
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Top 10
9. Safe, functional environment
EC.02.06.01 EP 1, EP 13
36%
– Safe, functional area, a catch all standard for
ripped mattresses or stained ceiling tiles
– Maintain ventilation, temperature and humidity
• Door held open by air pressure, hot/cold calls,
humidity >60%RF
• Also scored here: storage of oxygen
cylinders
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Top 10
10.Safe medication storage
MM.03.01.01 EPs 2, 3, 6, 7, 8
33%
– Unsafe/secure storage of medication
– Refrigerator temperature not sustained/monitored
– Meds unsecured – not locked or under constant
surveillance
– Access by non-licensed is not approved by policy
– Terminated employee ADM access is not cut off
– Improperly labeled including Ø beyond-use date
– Expired or damaged are not removed
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And the Runner-Ups
11) EC.02.02.01 EP 3 & 5. Hazardous materials and
eye wash station testing
12) PC.01.03.01 - care plan can be interdisciplinary
and customized.
13) MM.04.01.01 - EP 13 Implementation of
medication orders.
14) EC.02.05.07 - Generator testing is not done on
time, or for long enough.
15) EC.02.05.09 - Problems with medical gas
systems.
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And the Runner-Ups
16) HR.01.02.05 - This standard made it back on the top
20 list! Primary source verification.
17) PC.01.02.03 - EP 5 The most frequent problem is the
update to the H&P.
18) EC.02.03.01 – This standard is a catch all for fire
safety issues.
19) MS.01.01.01 – The biggest issue is that the
requirement for completing the H&P is not specified
in the medical staff bylaw.s
20) PC.03.01.03 - The requirement for the preanesthesia and pre-sedation assessments
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Success Strategies:
Survey Checklist
Keep policies simple
Mock Tracers to check compliance
Fix it or find another way
Focus on the top 10 & NPSGs
Bullet proof weak areas
Avoid the Situational Rules
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STANDARDS THAT BECOME MORE
CHALLENGING
WITHassessment”
EMR
• “Find me
the pre-anesthesia
• “Show me the immediate reassessment just
prior to induction”
• “Show me the immediate post procedure
note”
• “Show me the documentation of time out”
• EMR will date and time these notes
automatically so audit and evaluate how your
records look.
• Make sure staff can even find these documents
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EMR AND TIMING
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6:30 am, patient arrives, IV started
H+P update 7 am
Pre-anesthesia assessment 7:15 am
Pre-procedure medication orders and IV by
anesthesia written at 7:30
Pre-procedural verification by staff 7:45
Time out 7:55
Anesthesia record case ends 10 am
Immediate post procedure note timed 7:30
Post procedure orders timed 7:30
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EMR AND TIMING
• If you want to start post procedure notes prior to
the case filling out demographic, diagnostic
information, make sure the note has a final time
documented electronically or by author.
• If you want to write post procedure medication
orders, there must be a process to pend, and unpend them which includes physician authorization
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WHAT REALLY ARE THE H+P
REQUIREMENTS?
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Done within 24 hours of inpatient admission
Done before surgery or invasive procedure
Follows your bylaws, R+R content expectations
If done in the community it can be updated if less
than or equal to 30 days old
• Update note must state: “I have examined the
patient, I have reviewed the H+P and there are/are
not changes except as noted”.
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WHAT ELSE SHOULD I WORRY ABOUT?
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Alarm Fatigue Focus Issue
• A sentinel event alert was released in April ’13
• Focus of a new National Patient Safety Goal for
2014
• Alarms have led to Immediate Threat
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Alarm being shut off or silenced
Not resetting alarm after silenced
Not trained on all equipment
Result in patient death
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Sentinel Event Alert
Recommendations
① Leaders ensure there is a process for safe
alarm management and response in highrisk areas.
② Prepare an inventory of alarm-equipped
medical devices and identify the default
alarm settings and appropriate alarm
limits.
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Sentinel Event Alert
Recommendations
③ Establish guidelines for alarm settings. Define
when alarms are not clinically necessary
④ Establish guidelines for tailoring alarm
settings and limits for individual patients
(who can modify and when)
⑤ Implement routine inspections and
maintenance of alarm-equipped devices.
⑥ Staff training on above
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Sentinel Event Alert
Recommendations
⑦ Adhere to manufacturer instruction for
use, eg: replace single use leads, replace
batteries
⑧ Assess acoustics of alarm sounds
⑨ Set as a leadership priority
⑩ Establish a team to address
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New NPSG on Alarm Safety
NPSG.06.01.01
1 Establish alarm safety as a priority (7/2014)
2 Identify the most important alarm signals to
manage (2014)
3 Establish policies and procedures for
managing clinical alarms. (1/2016)
4 educate staff and LIP’s about the purpose
and proper operation of alarm systems
(1/2016)
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HIGH LEVEL DISINFECTION
• Identify every location performing HLD and make sure you
have a standardized process.
• Visit every location performing HLD and make sure staff
can precisely verbalize the process including dilutions,
soak times, dating of chemicals, dating of test strips,
documentation of testing.
• Make sure there is adequate separation of clean and dirty
activities.
• Make sure scopes can hang freely, not touching the
bottom, not looping
• Close the scope storage cabinet
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HIGH LEVEL DISINFECTION
• Laryngoscopes, after HLD, must stay wrapped
• ET tubes, and stylets, purchased or cleaned must stay
wrapped
• If you open a package for a case, discard the device
or send for repeat cleaning and wrapping at the end
of the case.
• If you use a blade to test a laryngoscope, there must
be a process to keep it clean.
• Keep airway circuits wrapped, clean until ready for
use
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HIGH LEVEL DISINFECTION
• The endoscopy scope cleaning room should be
under negative pressure to remove contaminants
and Cidex or other vapors
• In endoscopy, the decontamination door is to stay
closed so that the negative pressure can work.
• The endoscopy procedural area should be under
positive pressure to avoid contaminants leaking in.
• If you have new space for bronchoscopy, it should
be under negative pressure.
• Obtain copies of your pressure reports to verify
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HIGH LEVEL DISINFECTION
• Surveyors will observe staff as they process dirty
equipment
• Surveyors will check manufacturer instructions
for use (IFU) for three things: the
device/instrument, the sterilizer itself, and the
packaging (i.e., blue wrap or flash pan.)
• Check your policy, check staff understand and
follow both. Create a recipe book
• Will observe proper use of PPE
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OR TEMP AND HUMIDITY
• There should be a process to measure and record daily.
• Can be building automation or staff performed.
• Humidity expectation is below 60% (mold and bacteria
concern) and has been greater than 35%, but CMS has
just authorized greater than or equal to 20% (fire hazard
concern)
• See S&C 13-25 4/19/13, must document use of their
blanket waiver on low humidity
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AIR HANDLING AND PRESSURE
RELATIONSHIPS
• OR’s, CSR, Endo, decontam, isolation rooms
• Surveyors will perform tissue tests, a crude approximation
of air pressure relationship.
• Based on observations they will ask for your validated
report.
• Many organizations have:
– Not performed the test
– Can’t find the test
– The test failed, and no correction
– The test is old and the relationship no longer works
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MS.01.01.01
• Required implementation April 2011
• Open book test, no performance requirement
• All you had to do is place required statements in
medical staff bylaws and rules and regs
• Many organizations ignored the differentiation
between bylaws and R+R.
• Bylaws are hard to change
• R+R and somewhat easier
• Tab a copy of your bylaws with EP’s 16-36 identified
– If gaps noticed, go back and add the content
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CONTRACT MANAGEMENT
• LD.04.03.09 clinical contracts must be identified and
a list provided to your surveyor
• Each contract must have:
– Performance expectations
– Performance evaluation
– Input from senior leadership/MS
• Surveyors will pick one or more of your contracts
from you list
• Challenge is being able to identify them all
– People who perform patient care, clinical services that
would otherwise be performed by an employed
healthcare professional
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CONTRACTS OFTEN MISSED
• Off site pharmacy compounding in a licensed
pharmacy (remember NECC)
• Nuclear isotope compounding in a licensed pharmacy
• Pacemaker interrogation by contractor
• Custom orthotic fittings requested and paid for by the
hospital
• Physician leaders, telemedicine contractor, anesthesia
group, ED group
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CLOSED RECORD REVIEW
• When surveyors perform tracers, they see patients
that your currently have
• They may miss the opportunity to see a restraint
patient, an ICU sedation patient, an insulin sliding
scale or drip patient, and anticoagulation adjustment
patient, a blood transfusion, a death, an ED transfer
out, a circumcision.
• Closed record review opens up all of these
• Must be able to find these types of records
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PLANS OF CARE
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Review the H+P
Review the initial nursing assessment
Identify care issues to manage
Does the read of the care plan sound like the
same patient you read about in H+P or initial
nursing assessment?
• Must update care plan immediately if placed in
restraint.
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MEDICAL GASES
• Staff can’t park anything in front of the gas shut off
valve
• Valve must be labeled correctly with room numbers
• Nursing staff must know what to do in the event of a
fire
• Engineering staff must have an inspection report on
proper functioning
– Defects noted in the report must be corrected and
the report annotated
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PAIN REASSESSMENT
• We perform pain reassessment at the required
intervals
• We perform pain reassessment within X
minutes of giving a pain med
– Try to keep it simple
• Document the reassessment, be careful in
EMR as it may document failure if the note is
late
– Consider late note process if using a flow sheet to
document. If end of shift note is permissible, not
necessary.
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Patient Flow
New Standards for 2013/2014
• Revisions to Standards
– LD.04.03.11 – hospital manages the flow
– PC.01.01.01 – Hospital meets the needs of the
patient
• Perspectives July, 2012
• A new R3 document was published
• Another addition planned for 2014 re boarded
patients
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Patient Flow
New Standards for 2013/2014
• LD.04.03.11 – hospital manages the flow
– Leaders use data
– Manage throughput – Not just ED, this include
PACU
– Behavioral Health communication (Jan 2014)
• PC.01.01.01 – focus on BHC boarded patients
– Staff training
– Environment safe and suited
– Patient assessment, policies, community
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BEHAVIORAL HEALTHCARE
• 37% CTS.03.01.03 Treatment planning reflect assessed
needs, strengths, preferences and goals
• 23% HR.02.01.03 LIP privileges or clinical
responsibilities
• 15% CTS.02.01.05** For non 24 hour settings: process
for a requiring a medical history and physical
• 15% HR.01.06.01 Competency assessment for staff
• 15% NPSG.15.01.01 Suicide screen
• 14% EC.02.06.01 Safe, functional environment
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BEHAVIORAL HEALTHCARE
• 13% HR.01.02.05 ** The organization verifies
staff qualifications
• 10% MM.03.01.01 Medication storage
• 13% CTS.04.03.33 Food sanitation/storage
• 13% CTS.02.01.11 Nutritional screen
• 11% CTS.02.01.09 Pain screen (‘12)
• 11% RC.01.01.01 Legibility (‘12)
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QUESTIONS?
• Kurt Patton
– Kurt@PattonHC.com
• Jennifer Cowel
– JenCowel@PattonHC.com
• John Rosing
– JohnRosing@PattonHC.com
• Mary Cesare Murphy
– MCM@PattonHC.com
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