Unannounced Visitors –
You and The Joint Commission (TJC)
David Gourley, RRT, MHA, FAARC
Executive Director of Regulatory Affairs
Chilton Hospital
Pompton Plains, New Jersey
Unannounced Visitors You and The Joint Commission (TJC)
 Shared Visions – New Pathways
 Periodic Performance Review
 Unannounced Surveys
 Priority Focus Process
 Tracer Methodology
 Patient Safety
 Emergency Preparedness
 Performance Measurement
 Hot Topics for RT’s
Focus Conference - Fall 2013
Accreditation
 Why are we accredited?
 Quality of patient
 Patient safety
 External validation
 CMS requirement
 Third party payors
 Accreditation options
 TJC
AOA
 DNV
 Home care (10 accrediting bodies)
Focus Conference - Fall 2013
CEO’s Perspective on Environment
 Affordable Care Act (ACA) requirements
 Clinically integrated services
 Team based models
 Accelerated changes to provide evidence-based care
 Pressures from physicians to affiliate with hospital
 Increased costs (drugs, supplies, technology, staff)
 Increased competition
 Consumer interest in public scorecards
 Decreased reimbursement
Focus Conference - Fall 2013
Intracycle Monitoring (ICM)
 Goals of ICM
 Improve/add value to PPR/FSA
 Significant improvements in process and assessment tool
 Valued, relevant, and efficient for customers and TJC
 Identify and proactively manage risk
 Focus on risk points throughout accreditation cycle
 Proximity to patient
 Probability of harm
 Severity of harm
 Number of patients at risk
 Provide tools/resources/solutions
Focus Conference - Fall 2013
Intracycle Monitoring (ICM) (cont.)
 Periodic Performance Review (PPR) changed to Focused
Standards Assessment (FSA)
 Completed annually
 Required to complete “Risk” standards
 Four options for completion of FSA
 Full FSA (self evaluation)
 Option I
 Option II
 Option III
Focus Conference - Fall 2013
Challenging Standards
 RC.01.01.01
 Hospital maintains complete and accurate medical record for
each individual patient
 All entries are timed
 All entries are dated (10/05/13)
 Information needed to justify the patient’s care, treatment, and services
 LS.02.01.20
 Hospital maintains the integrity of the means of egress
 Hallway clutter
Focus Conference - Fall 2013
Challenging Standards (cont.)
 Hallway clutter
 “If the hallway looks cluttered…. it
probably is!”
 Carts allowed:
 Code Carts
 Isolation Carts
 Chemo Carts
 Anything in egress corridor for more
than 30 minutes is storage
 Dead end corridors may be used for
storage
Focus Conference - Fall 2013
Challenging Standards (cont.)
 LS.02.01.10
 Building and fire protection features are
designed and maintained to minimize the effects
of fire, smoke, and heat.
 Fire barrier penetrations
 Fire door issues
 EC.02.03.05
 The hospital maintains fire safety equipment
and features.
Focus Conference - Fall 2013
Challenging Standards (cont.)
 IC.02.02.01
 Hospital reduces risk of infections associated with medical
equipment, devices, and supplies
 Intermediate and high-level disinfection and sterilization
 Storage of medical equipment, devices, and supplies
 Contact time for disinfectants
 MM.03.01.01
 Hospital safely stores medications
 Medications stored according to manufacturer’s specifications
 Medications are stored in secure area to prevent diversion
 Expired meds are removed from stock
Focus Conference - Fall 2013
Challenging Standards (cont.)
 LS.03.01.30
 Hospital provides and
maintains features to protect
from hazards of fire and
smoke
 Smoke barriers and doors
 Door “chocks”
 LS.02.01.35
 There is 18” or more
clearance maintained below
sprinkler head to the top of
storage
Focus Conference - Fall 2013
Challenging Standards (cont.)
 EC.02.06.01
 Interior spaces meet the needs of patient
population and are safe for care, treatment,
and services
 Unsecured oxygen cylinders
 Adequate ventilation, temperature, and humidity
 EC.02.02.01
 Personal protective equipment (PPE) and
process to manage hazardous materials and
waste
Focus Conference - Fall 2013
Challenging Standards (cont.)
 PC.01.02.03
 Hospital assesses and reassesses the patient according to defined
time frames.
 Initial assessment performed within defined time frame
 H&P no more than 30 days prior to surgery or procedure
 Updated H&P documenting any changes within 24 hours of admission
 RC.02.03.07
 Qualified staff receive and record verbal orders
 Verbal orders are authenticated within defined time frame
Focus Conference - Fall 2013
Challenging Standards (cont.)
 MM.04.01.01
 Medication orders are clear and accurate
 Hospital policy for medication orders are implemented
 Hospital reviews and updates preprinted order sheets within identified
time frame, based on current evidence and practice
 PC.01.03.01
 Hospital plans for patient’s care
 Based on assessment, reassessment, and results
 Written care plan based on patient goals and time frames
 Revises plan and goals, based on patient needs
Focus Conference - Fall 2013
Challenging Standards (cont.)
 EC.02.05.09
 Medical gas systems
 Inspection, testing, and maintenance
 Labeling of medical gas shut-off valves
 Contents of piping
 Areas served
 PC.03.01.03
 Hospital provides patient with care before initiating operative
or other high-risk procedures
 Pre-sedation/pre-anesthesia assessment
 Immediate reassessment
Focus Conference - Fall 2013
Challenging Standards (cont.)
 EC.02.03.01
 Fire safety
 More than 300 cubic feet of non-flammable medical gas open to egress
corridor
 Lack of fire safety training as per fire plan
 PC.01.02.07
 Hospital assesses and manages the patient’s pain
 Conduct comprehensive pain assessment
 Reassesses patient and responds to patient’s pain
 Consider overmedicating as much of a problem as undermedicating
Focus Conference - Fall 2013
New for 2014
 Clinical alarms
 Originally one of the National Patient Safety Goals (NPSG)
 Sentinel Event Alert # 50 (April 8, 2013)
 NPSG for 2014
 Incidents of alarms being silenced or shut off
 Default settings
 Incidents of inadequate staffing to support
 No mechanisms for monitoring/responding
 Incidents of “alarm fatigue”
 Overuse, excessive number of alarms
 Patient deaths have occurred
Focus Conference - Fall 2013
New for 2014 (cont.)
 Clinical alarms (cont.)
 Effective 7/1/14, leaders establish alarm system safety as a
hospital priority.
 During 2014, identify the most important alarm signals to
manage based on the following:
 Input from medical staff and clinical departments
 Risk to patients if alarm is not attended to or malfunctions
 Whether specific alarm signals are needed or unnecessarily contribute to
alarm noise and alarm fatigue
 Potential for patient harm based on internal incident history
 Published best practices and guidelines
Focus Conference - Fall 2013
New for 2014 (cont.)
 Clinical alarms (cont.)
 Effective 1/1/16, establish policies and procedures for
managing alarms, at a minimum, address the following:
 Clinically appropriate settings for alarm signals
 When alarm signals can be disabled
 When alarm parameters can be changed
 Who has authority to set alarm parameters
 Who has authority to change alarm parameters
 Who has authority to turn alarm off
 Monitoring and responding to alarms
 Checking alarm signals for accurate settings, operation, and detectability
Focus Conference - Fall 2013
New for 2014 (cont.)
 Clinical alarms (cont.)
 Effective 1/1/16, healthcare organizations must educate staff
about purpose and proper operation of alarm systems for which
they are responsible
Focus Conference - Fall 2013
Unannounced Surveys
 Survey may occur anytime from 18 to 36 months from last
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survey date
Promote a positive culture regarding accreditation
Create perpetual state of readiness
Eliminate need for ramp-up
Integrate prep activities with management activities
Develop internal accreditation experts
Focus Conference - Fall 2013
Unannounced Surveys (cont.)
 Arrival of surveyors on-site
 Prepare information desk
 Meet and greet surveyors
 Notification of all key personnel
 Notification of all staff
 Secure conference rooms
 Email notifications to appropriate staff
Focus Conference - Fall 2013
Unannounced Surveys (cont.)
 Preparing your department
 Educate back-up personnel
 Needed documents:
 Policy and procedure manual
 PI data
 Infection control data
 Competency assessment data
 Communicate with staff
Focus Conference - Fall 2013
Tracer Methodology
 “A Systems Approach to Evaluation”
 Traces a number of patients through Healthcare
organization’s entire process
 Surveyor may identify performance issues in one or more
steps of the process – or in interfaces between processes
 Initially uses priority focus areas and clinical service groups
Focus Conference - Fall 2013
Tracer Methodology (cont.)
 Follows course of care/service provided to patient
 Assesses relationship among disciplines and important
functions
 Evaluates performance relevant to the individual
 Comprises 50 – 60% of on-site survey
 Approximately 90 minutes in length
Focus Conference - Fall 2013
Tracer Methodology (cont.)
 Patient tracer selection criteria
 Clinical service groups
 Patients receiving complex services
 Patients crossing different programs/ services
 Patients related to systems tracers
 Infection Control
 Medication Management
Focus Conference - Fall 2013
Tracer Methodology (cont.)
 Starts in setting where patient is located
 May include sequential following of course of care
 Includes evaluation of top 4 – 5 priority focus areas
 Observation of care areas and environment of care issues
Focus Conference - Fall 2013
Tracer Methodology (cont.)
 Patient tracer visits may include:
 Observation of direct care
 Observation of medication mgmt. process
 Observation of care planning process
 Patient or family interview
 Review of medical record with staff
 Staff level interaction
 Review of policies and procedures
Focus Conference - Fall 2013
Tracer Methodology (cont.)
 Systems tracers
 Medication Management
 Data Use
 Infection Control
 Emergency Management
 Environment of Care
 Suicide Prevention
 Patient Flow
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Set of components working toward common goal
Evaluation of how well systems function
Addresses interrelationship of elements
Translates standards compliance into potential vulnerabilities
Focus Conference - Fall 2013
Patient safety
 Integrated patient safety program
 National patient safety goals (NPSG)
 Sentinel events
 Failure mode and effects analysis (FMEA)
Focus Conference - Fall 2013
Patient safety (cont.)
 Integrated patient safety program
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Managed by qualified individual or interdisciplinary team
Definition of scope of program oversight
Integrated throughout organization
Procedures for response
Systems for internal and external reporting
Defined responses to unanticipated events
Support systems for staff members
Annual reports on system/process failures and actions taken to
improve safety
Focus Conference - Fall 2013
Patient safety (cont.)
Focus Conference - Fall 2013
Patient safety (cont.)
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National patient safety goals for hospitals (2014)
1.
2.
3.
4.
5.
6.
7.
Improve accuracy of patient identification
Eliminate transfusion errors related to patient
misidentification
Report critical results of tests and diagnostic procedures on
a timely basis
Label all medications, med containers, and other solutions
Reduce patient harm from anticoagulant therapy
Accurately and completely reconcile medications across the
continuum of care
Comply with CDC or WHO hand hygiene guidelines
Focus Conference - Fall 2013
Patient safety (cont.)
 National patient safety goals for hospitals (2014) (cont.)
8. Implement evidence-based practices to prevent healthcareassociated infections from multidrug-resistant organisms
9. Implement evidence-based practices to prevent CLABSI
10. Implement evidence-based practices to prevent SSI
11. Implement evidence-based practices to prevent CAUTI
12. Identify patients at risk of suicide
13. Universal protocol
Focus Conference - Fall 2013
Patient safety (cont.)
Focus Conference - Fall 2013
Patient safety (cont.)
 Surveying and scoring NPSG
 All accreditation programs
 Must implement all relevant goals, or acceptable alternative
 Surveyors evaluate actual performance, not just intent
Focus Conference - Fall 2013
Patient safety (cont.)
 Sentinel events
 Defining sentinel events
 Reporting of sentinel events
 Conducting root cause analysis
 Creating risk reduction strategy
Focus Conference - Fall 2013
Patient safety (cont.)
 Failure mode and effects analysis (FMEA)
 Pro-active program for identifying and reducing
unanticipated adverse events
 Select high risk process to be analyzed
 One process to be analyzed annually
 Based in part on Sentinel Event Alerts
Focus Conference - Fall 2013
Patient safety (cont.)
 Failure mode and effects analysis (FMEA) (cont.)
 Identify high-risk process and assemble a team
 Diagram the process
 Brainstorm potential failure modes and their effects
 Prioritize failure modes
 Identify root causes of failure modes
 Redesign the process
 Analyze and test the new process
 Implement and monitor the redesigned process
Focus Conference - Fall 2013
Hot Topics for RT’s
 Orientation and Competency
 How were you oriented to vent care?
 How often is your competency evaluated?
 What is your newest ventilator?
 Did you get an in-service?
 Was there a competency?
 Do you intubate?
 How is your competency assessed?
 Are you ACLS or PALS certified?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Clinical Practice
 If two or three vent alarms are going off at once, how do you
differentiate?
 What is your role on the Code Team?
 What is the criteria for restraints and vent patients?
 How often are vents checked?
 How often do you check alarms?
 How often is tubing changed?
 How often is PM done on vents?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Clinical Practice
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Where do you document treatments?
Are you evaluating missed treatments?
Are missed treatments considered med errors?
What is the most common reason for missed treatments?
What can be done about it?
Are you drilling down “refusals”
Do you track by shift, time of day, RT?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Clinical Practice
 Do you draw blood gases?
 How do you label specimens?
 How do you identify the patient?
 What is your turnaround time?
 How do you communicate critical values?
 Have you had any needlesticks?
 Do you have safety devices on your needles?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Clinical Practice
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Do you have weaning protocols?
Who weans patients?
Do you attend critical care rounds?
What measures are being taken to prevent VAP?
How are vents cleaned between patients?
How would you evacuate vent patients?
Can RTs transcribe verbal orders?
What are the “don not use” abbreviations?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Assessment
 What is included in your assessment?
 What do you reassess after treatments?
 Do you assess smoking status?
 Staffing
 How many RTs are here during the day?
 How many RTs are here at night?
 What is the RT staffing plan?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Performance Improvement
 What PI projects are you working on?
 Do you track re-intubations?
 What is your vent LOS?
 How do you track VAP?
Focus Conference - Fall 2013
Hot Topics for RT’s (cont.)
 Medication Management
 How do you get meds for treatments?
 Are RT meds on med profile?
 Are RT meds reviewed by pharmacy?
 Who pulls RT meds from Pyxis?
 Are RT meds documented on MAR?
 Do you have a “window of time” before or after a treatment is
due to be considered late?
Focus Conference - Fall 2013
Questions?
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