Joint Commission Readiness
John R. Rosing, MHA, FACHE
Vice President and Principal
Patton Healthcare Consulting
Institute the Action Plan
Everyone in Position
2
WHATS NEW I SHOULD WORRY
ABOUT?
3
Focus on the Priority Issues
• The standards have ~1800 EPs that can be
scored
• The Joint Commission does >90% of its
scoring on about 25 standards/NPSGs
– Focus on the top scored
– Focus on all NPSGs
– Focus on any NEW standards/FAQ
– Focus on previously scored issues
4
AND THEN THERE ARE THE MOST
FREQUENTLY SCORED STANDARDS
• Low hanging fruit, almost fall on surveyor
• Learn from the mistakes of others
• If the surveyors see it everywhere and score it
everywhere, there is no chance they are going
to look the other way at your hospital.
• Focus on these issues and fix them long before
survey.
5
TOP SCORED, STANDARD LEVEL 2012
Source: Perspectives April 2012
1
2
3
4
5
Complete/accurate medical record (RC.01.01.01 –
66%)
Maintain egress (LS.02.01.20 – 56%)
Fire Protection features maintained (LS.02.01.10 –
52%)
Fire protection features maintained to protect
patients (LS.02.01.30 – 45%)
Maintain fire safety equipment (EC.02.03.05 – 40%)
6
Top Scored TJC 2012 cont.
Source: Perspectives April 2012
6
7
Medical Equip Infection Risk (IC.02.02.01 – 36%)
Assess and reasses per timeframes (PC.01.02.03 –
34%)
8 Medication Storage (MM.03.01.01 – 33%)
9 Verbal orders (RC.02.03.07 32%)
10 Maintain system for extinguishing fire (LS.03.01.35 –
31%)
7
Signing, Dating & Timing Medical Record Entries
(RC.01.01.01 – 66%)
Hospital maintains a complete and accurate medical record
• The author identified and authenticated. (EP 11)
• Timing - Biggest Problem (EP 19)
– Have you designed paper forms to enable success?
• Every form has a time box
• Multipurpose forms have time/date, signature for every section
• Information needed to justify patient care (EP 6)
**Legibility is scored here!
• Consider using data for OPPE or HR evaluation process
8
MEANS OF EGRESS, USUALLY EXITS
(LS.02.01.20) 56%
Hospital maintains means of egress
• Easy to find issues, educate on:
– Blocked or locked egress doors
– Corridor clutter, storage in hallways
• Linen carts and latex carts will be scored
• Cart on Wheels can be plugged in but not parked for
>30 minutes
• OK stuff:
– Crash carts are considered “in use”
– Isolation carts outside occupied room also considered “in
use”
– Dietary cart while delivering
– Med cart in use
9
Fire Protection Features
(LS.02.01.10 - 52%)
Building & fire protection features minimize the effects
of fire, smoke and heat.
32 elements of performance!
– Fire and smoke doors labeled, correct type, close,
label visible, under cut, door gaps, adhesive tape
over latch
– Penetrations are sealed with correct material
10
Fire Doors, cont
• Inspect and maintain fire doors
– Appropriate fire rating on doors
and frame
– Door positively latches
– Door had a closure
– No gaps > 1/8 inch, or undercut
>3/4 inch
– Resulted in ITL if multiple problems
11
LS -Maintain Building Features
(LS.02.01.30 – 45%)
25 elements of performance, 1 with its own
25 bulleted requirements.
Building features are provided and
maintained to protect individuals from
smoke
– Label all Hazardous Areas (such as boiler rooms, laboratories, O2
tank supply rooms, flammable liquid storage rooms)
– Limit access to hazardous areas
– Self closing doors work as expected and designed
12
EC.02.03.05 FIRE PROTECTION
EQUIPMENT 40%
• 21 elements of performance
• More focused on testing, inspection and
maintenance of fire protective features.
• Testing alarms and strobes
• Testing pumps and sprinklers
• Testing dampers
• And don’t forget the documentation
requirement for the new EP 25 to include NFPA
reference
13
Fire Protection Equipment
(EC.02.03.05 – 40%)
Hospital inspects, tests & maintains
fire safety equipment.
 Includes testing of: fire alarms boxes, smoke detectors,
sprinklers, portable extinguishers, magnetic release
devices, tamper switches & water flow devices.
 If outsourced to a vendor keep the report, read the
report and act on problems!
 Make sure reports are tied to an inventory of devices and
make sure the inventory doesn’t change every quarter
14
Fire Extinguisher Dating
(EC.02.03.05 EP 15)
 Month, day, year and initials of
inspector required per NFPA 10-1998
 They will review the tag
 If bar coded, they will review
documentation
 Required monthly
15
MEDICAL EQUIPMENT RISKS IC
(IC.02.02.01 – 36%)
Cleaning, sterilizing, storing and disposing
of medical equipment & supplies. C & 3
•
•
•
•
•
•
Problems or gaps with dating controls & biologicals
Store clean and dirty separately
Air handling
Flexible Scope Cleaning
Laryngoscope storage FAQ
Surveyors trained on AAMI standards for sterilization
and disinfection
16
Reduce Risk of Infection, cont
• 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 understanding, and
precision
• Will observe proper use of PPE
17
ASSESS AND REASSESS PER POLICY
(PC.01.02.03) 34%
• Initial nursing assessment done on time.
• If initial nursing assessment screened for dietary
consult or other, it is done on time.
• Reassessments are done per plan of care. If I+O is in
POC, it is done.
• H+P done or updated in 24 hours or updated prior
to surgery
– H+P isn’t more than 30 days old
– H+P update language includes: I have reviewed
the H+P, I have examined the patient and….
18
Safe Medication Storage
(MM.03.01.01 – 33%)
• Been a top 10 for years.
• Largest problem was medication storage
temps, this is now a C element!
• Tackle both refrigerators and warmers
– Warmers max and duration an issue
– 1 months log only if using paper
– Always Document actions taken
– Describe how you monitor on weekends in 5
day areas
19
Medication Storage, cont.
• Clarified - Expired medications including multidose
vials
– Use BUD label, not date open label
– Expire in 28 days or less, vaccines are exception
• Policy addressing med storage by a provider after
access and before administration (There are 19 MM
chapter D’s)
• Unauthorized access to medications – “do what you
say” If housekeepers are permitted or prohibited.
20
Verbal Orders
RC.02.03.07 32%
When required by law or regulation, verbal or telephone
orders are authenticated within the specified
timeframe. (48 hours)
– And the authentication is timed
• It’s a C element of performance, no MOS
• It’s a criticality 4 so you have 60 days to fix it if scored
• Consider data use for OPPE, consider hard-stops in
your EHR
– EHR is not foolproof on this issue
21
Provide/Maintain Fire Systems and Equip
(LS.02.01.35)
Sprinklers
• 18 inch rule
• Sprinkler pipes can not support other items like
cables or wires
• Sprinkler head clean and free of obstruction,
collar flush
• Ansul system shuts off gas, activates alarm,
controls exhaust system.
22
NOT TOP 10, BUT FREQUENT FLYERS
• Additional, problematic standards that are
frequently scored on surveys.
23
Primary Source Verification
(HR.01.02.05)
Photocopies of licenses have no validity in the Joint
Commission process.
Primary source verification of licensure on time, prior to
expiration
– If the individual really was unlicensed for a period of
time, risk of PDA/CON
• Problem areas: Decentralized responsibility with lack of
oversight
• Special competencies or certifications required by the
hospital are obtained according to hospital policy. ACLS,
BLS
24
Assess & Reassess Pain
(PC.01.02.07)
• Sev. 3- Conduct a comprehensive pain
assessment consistent with scope of care, Tx,
services and patients condition.
• Your policy spells out the depth of the
assessment, the form, the timing.
• Follow your policies or TJC RFI
• Keep your policies simple, 90% minimum
compliance?
25
Medical Gas
(EC.02.05.09)
• Hospital inspects, tests & maintains
medical gas and vacuum systems.
• No parking zone!
• Get vendor reports, fix problems noted
• Gas shut off valves must be labeled with
rooms they shut off. Staff must know who
can shut these off and when.
• Alarms must be working. Has led to ITL
26
Document Operative & High Risk Procedures
(RC.02.01.03)
•
•
•
H&P in MR before procedure (EP 3)
Post op, post procedure report is
dictated is before transfer to next level
(EP 5)
The post operative/procedure report
includes: name of LIPs, procedure name
and description, findings, EBL,
specimens, post op diagnosis (EP 6 Top Scorer)
27
NATIONAL PATIENT SAFETY GOALS
• Must be evaluated by your surveyors
• They are almost all criticality 3, so they
count
• Always a focus of surveyor training
• They are complex because you have to
know the requirements and the FAQ
explanation of details.
28
GOAL 1, USE OF 2 PATIENT
IDENTIFIERS
• Nothing new here, just get staff to
correctly verbalize what your two
identifiers are.
• Make sure staff really use those 2
identifiers on each patient interaction,
even when they know the patient.
– Be careful in amb care, hyperbaric, dialysis
still need to use 2 ID
29
GOAL 2, CRITICAL TEST RESULTS
• Do you have a goal or timeframe in which
your staff are expected to reach the LIP?
• Are you meeting that expectation?
• Remember, the lab reaching a nurse is only
step 1 in the process and timeline.
• Do you expect something to be in the
chart? Do you do a READ-BACK??
• How do you monitor performance?
30
GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
• Part 1 – label every medication or solution on a
sterile field. This includes water, saline,
chlorhexidine, propofol or one syringe.
• Do staff have the tools they need to perform this
function? Look at bedside procedures in ICU, OR
and minor procedures in AHC settings.
– “show me where you store your sterile labels”
– “what is your process to make sure that
proper labeling is performed?”
31
THE ONE ON THE LEFT IS FENTANYL, THE ONE
ON THE RIGHT IS….
ITS WHITE, THEREFORE IT DOESN’T…..
TWO ARE LABELED, THEREFORE THE
THIRD IS….
ITS ONLY WATER, ITS ONLY REFUSE, IT
DOESN’T NEED A LABEL
GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
Part 2: Reduce harm from anticoagulation
therapy.
Do you have and do you use protocols for
anticoagulants?
Surveyors will trace anticoagulation
patients so is it clear that protocols are
being used?
36
GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
• Part 3 Medication reconciliation
– Is a list created for each inpatient or outpatient?
– Does someone analyze the list to “identify and
resolve discrepancies?”
– Procedural settings can be simplified and made
easy
– Inpatient admission reconciliation is not easy.
Discrepancies include omissions and changes.
– Inpatient discharge reconciliation is not easy.
Requires one complete list
37
GOAL 7 INFECTION PREVENTION
• Part 1 – your hand hygiene program
– You have a program, you have goals, you are
improving.
– Be prepared to discuss at IC system tracer and
Data use tracer.
– Will surveyors see your program implemented
and working or significantly missed?
– Reduce your vulnerability in ICU, ED, PACU,
dialysis, infusion center by conducting tracer
interview where less observation is possible.
38
GOAL 7 INFECTION PREVENTION
• Part 2 – prevention of MDRO infections
– Show me your risk assessment, and most recent
update, EP 1
– Lets ask staff, patients and LIP’s about your education
or optionally lets look at some documentation. EP 2
and 3
– Show me your measurement data from surveillance
and how this was presented to leadership. EP 5,6
– Show me which CPG’s you used. EP 7
– Show me how you alert ICP to new cases. EP 8
– Show me how you alert your ICP and staff to a
readmission of an MDRO patient. EP 9
39
GOAL 7 INFECTION PREVENTION
• Part 3 – central line infection prevention
– Lets talk with patients, families, staff and LIP’s about
your education, or optionally show me documentation.
EP 1,2
– Show me your CPG’s. EP 3
– Show me your most recent risk assessment. EP 4
– Show me the report you sent to leadership with the
data analysis. EP 5
– Show me you catheter insertion checklist. EP 6
– Show me your standardized supply cart. EP 9
– During tracers what will the surveyor see during and
insertion relative to femoral vein, barrier precautions
used, hand hygiene and antiseptic used? EP 7,10,11
40
GOAL 7 INFECTION PREVENTION
• Part 4 – prevention of surgical site infection
– Lets talk with staff, LIP’s and patients about the
education you provided or optionally lets look
at documentation.
– Same CPG, risk assessment, measurement,
report to leaders.
– Hair removal technique and antibiotic
prophylaxis in accordance with CPG’s.
41
GOAL 7 INFECTION PREVENTION
• Part 5 – CAUTI
– Have you implemented CAUTI in 2013?
– What CPG are you planning to use?
– What data are you going to collect and who is
going to do it?
42
GOAL 15 IDENTIFY PATIENT SAFETY RISKS
INHERENT IN THE POPULATION
• Part 1: Conduct a risk assessment for the patient and the
environment for features that may increase or decrease
risk for suicide.
– Each patient is clinically screened and a decision
reached about their risk.
– Environmental risks are identified and evaluated to
determine if we can mitigate the risk or must
eliminate the risk.
• Part 2: do something about it
• Part 3: upon discharge give each patient a list of
resources such as crisis lines.
43
UNIVERSAL PROTOCOL
• Part 1: pre-procedure verification process
– We have the right patient, procedure, plan and
equipment present
•
•
•
•
•
Part 2: site marking by the surgeon
Part 3: Time out just prior to the procedure
Take a look at ambulatory and bedside procedures.
Make sure no one leaves the room after timeout.
Does your paperwork trail and timing make sense?
44
MISC UPDATES
•
•
•
•
•
The One and Only campaign
OR fire prevention
Scope cleaning and high level disinfection
Pressure relationships, OR’s, decontamination areas
Central supply adherence to manufacturers
sterilization guidance.
• Look at CMS tracer checklists for ideas.
• Know that multi-dose vials are vulnerable
• Closed Record Review is BACK! Stop, see Medical
Record Review Tool
45
Tracer Tips For Staff
•
•
•
•
Its not a police interrogation, its not root canal
Be enthusiastic about how good we are
Focus on the excellent service and care we provide
Find a quiet room, out of main traffic path to review the
medical record for the patient tracer
• Before answering a question:
– Take a deep breath
– Make sure you understand the question
– Or ask “Could you please rephrase that question…”
– Talk about what you do, don’t over-think it
– Offer to provide the answer later in the day
– Stop talking once you have answered
– Know where policies are kept & how to access them.
• Make sure you have the right policy, screen
46
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
Do not argue with the surveyor
Welcome surveyor suggestions
Know what improvements in patient care came
from PI (performance improvement) activities
• Help the surveyor navigate, tell the patient story
• Don’t affirm the leading question…” this isn’t a
very good process, is it?”
47
Role of the Escort/Note Taker
• Upon arrival handle introductions and get the
ball rolling ASAP
• Gently coach struggling staff
• Record offers to present support and record
surveyor’s response
• Record the “he said” “she said”
• Record MR numbers
• ID potential pitfalls, RFI’s, or potential disasters
48
TRACERS FOLLOW THE PATH OF THE PATIENT
• Patient evaluated in the ED, and a decision made to
admit the patient
• Patient transferred to the inpatient medical surgical
unit.
• Patient sent to radiology the next morning for CT with
contrast
• Patient scheduled for surgical procedure
• Patient sent post surgery to ICU
• Patient transferred to med surg unit
• Patient discharged to home.
TRACERS EVALUATE THE INTERFACES OF CARE
• Each transfer of responsibility involves
the transfer of critical information
necessary to provide safe and effective
services. (especially medications)
• Communication breakdowns during
these transfers are common root
causes as identified by hospitals.
TRACER – EVALUATE EXECUTION OF YOUR POLICIES
AND PROCEDURES
• At the start of our patients episode of care in the ED, what can
we evaluate?
– Timeliness of triage, evaluation, treatment, transfer after
decision to admit.
– Depth, completeness and appropriateness of assessments
– Staff knowledge of hospital assigned responsibilities
– TAT of critical tests, results or treatments
– Handoff to the unit
– Issues about flow
– Privacy and patient rights
– Medication security and storage
– Hand hygiene and IC in general
TRACER TECHNIQUE
• Staff should be programmed to pick a room, get the chart, get the
nurse, get other disciplines, get surveyor out of the hallway.
• At the start, try to put staff at ease, consider their case load and
timing of the visit, relieve staff of their assignment if possible.
• Chart review, followed by oral interview, or vice versa, or tour first.
Surveyors pick their most comfortable technique.
• Concurrent oral interview and staff guided tour with presentation of
key documents pertinent to the responses.
• Surveyors listen to the responses and allow those responses to shape
the next question.
• Remember Peter Falk, Inspector Columbo?
• They ask questions pertinent to the patient being traced.
• They keep their checklist or form in the background
TRACER TECHNIQUE
•
•
•
•
•
•
•
•
•
How do you do…..?
What did you do……?
What would you do if…?
Can you show me where/how that is documented?
Are the responses consistent from staff person to staff person?
Are the responses consistent with hospital policies?
Can staff find policies?
Surveyor may validate staff responses prn with patient directly.
Surveyor may listen to and observe pertinent practices that may be
taking place in the background.
• Surveyors rarely ask about specific standards or safety goals, they
ask only about what was done for the patient.
WHAT DO WE HOPE TO AVOID?
• Knowledge deficits
• Process variation unit to unit, person to person
and acceptance of the practice.
– Listen carefully to response: “I do” vs.
“Usually…”
• Short cuts, work arounds, and personal belief
systems
• Policy deficits or non compliance with policy
• Documentation defects
• Fumbles
Patient Tracers
– Focus is on actual care practices.
• The patient’s care drives assessment of compliance to
standards not vice versa
• Focus is on linkages, continuum of care, and
communication among the healthcare team
• Quality, timeliness, and completeness of the medical
record drives compliance
• Focused tracers will go into depth on the issue.
System Tracers
– Interview Sessions, do mocks for these sessions also, practice!
– Come ready to talk proudly and showcase
– Hospital system tracers:
• Medication Management
• Data Use
• Environment of Care – must have documents at your finger
tips.
• Emergency Management – make sure your plan addressed
every EP
• Competency Assessment - HR
• Infection Control – make sure your plan addressed every EP
Picking the Patient
• Where will the surveyor visit:
– All anesthesia and sedation areas
– At least 50%-100% inpatient locations
– Sample of outpatient sites
• Picking an internal tracer patient:
– Multiple units, enter through the ED, transfer from
another facility, had surgery
– Watch procedures everywhere all the time!
– Can’t decide? Pick the fattest chart or at least a 2 day
chart, procedure patients, restrained patients
Why Do they want to See a Med Pass?
• Standards you can observe during a pain med
pass
– If med is drawn up prior to administration was the
medication properly labeled
– Two patient identifiers
– EMAR, bar code compliance
– Hand hygiene x2
– Nursing 5 rights
– Pain assessment and reassessment
– Patient education on the medication
WHAT IS ASKED?
• Tell me about the initial nursing
assessment. What do you look for?
– Fall risk screening and actions taken
– Nutritional screening and timeliness
– Abuse screening
– Patient education
– Decubiti screening
– Pain assessment and reassessment process,
right technique and adherence to policy.
WHAT ELSE?
• Show me the H+P, is it done <24 hours, updated,
legible, complete?
– Does this H+P read like the same patient in the care plan?
• Show me the pre-anesthesia assessment and
immediate reassessment.
• Show me the time out documentation
– Unit staff, if not familiar with surgical area documentation SAY
SO, but see if someone can help find.
• Show me the consent; translator involvement?
• Keep track of names, who was interviewed, who was
the person that performed some task in the record.
WHAT ELSE ?
• Show me the immediate post procedure note, all
required elements? Time performed?
• Show me the post anesthesia assessment < 48 hours after
recovery
• Show me the nursing care plan, does it read like the
patient we just learned about?
• Show me the restraint documentation, order renewal
• Show me the lab work, any critical results? What is that
process?
• Lets look at medication orders, range, prn,
anticoagulation?
FOLLOW UP QUESTIONS
•
•
•
•
•
•
•
•
Do staff know how to navigate the chart?
Can staff find policies?
Were staff trained and competent?
Go to PACU, med orders, security
Go talk with anesthesia about med labeling and time out
Validate privileges or refer to colleague
Med Rec on admission and discharge?
Does the medical record tell the story?
Read the Book
4/7/2015
63
READ THIS NEWSLETTER
Get it Distributed
And Look on the Website, Print All FAQ’s
http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards
•
Standards
• Consist of Three Parts:
– Standard Statement
– Rationale and/or Notes (not in the
excel file)
– Elements of Performance (EP)
• These are the score-able elements
Scoring Sample
The CAMH
How EP’s are Scored
• Category A
– Relate to structural and process
requirements, such as policy
– Scored as either exist or not. Either
compliant or not. All or nothing.
How EP’s are Scored
• Category C
– Based on the number of times you do NOT meet a EP
– Scored by the surveyors as:
• 0 = Insufficient Compliance = 3 or > instances of noncompliance
• 1 = Partial Compliance = 2 instances of non-compliance
• 2 = Satisfactory Compliance = 0 – 1 instance of noncompliance
– For you…. Two observations is NON-COMPLIANT
Tracers reveal…..
Failures, defects, workarounds
or undesired variation……
Usually caused by one or more of
the following……
•
•
•
•
•
Poor process design in first place
Poor transfer of knowledge to users
Poor validation of competency of users
Poor measurement of conformance to design
Poor management intervention to fix
variation
5 Steps to doing the Right Thing Well : Sustained
Execution=Continuous Readiness
Measure conformance an ask...
Management Intervention
(appropriate action)
Poor design?
Inadequate education
Ineffective competency validation
Manager
Measure conformance
Variation due to
work-arounds
Manager
Variation due to unit, day of week, Validate competency
time of day, FT/PT/agency staff, etc.
John R. Rosing, MHA, FACHE
 Patton Healthcare Consulting
Educate
Focus/PDSA/Rapid
cycle design
Staff dev.
PI team
QUESTIONS?
johnrosing@pattonhc.com
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