Essentials of Joint Commission
Readiness
Dale Brown, RN, MSN
Stephen Dorman, MD
Day 2
Patient Centered
Communication
PC. 02.01.21
The hospital effectively communicates with
patients when providing care, treatment, and
services.
EP 1- (A)The hospital identifies the patients’ oral
and written communication needs, including the
patient’s preferred language for discussing health
care.
EP 2-(A) The hospital communicates with the
patient during the provision of care, treatment, and
services in a manner that meets the patient’s oral
and written communication needs.
3
RI. 01.01.01
The hospital respects, protects, and
promotes patient rights.
EP # 5-(C) the hospital respects the
patient’s right to and need for effective
communication
4
RI. 01.01.03
The hospital respects the patient’s right to
receive information in a manner he or she
understands.
EP# 2-The hospital provides language
interpreting and translation services.
(HR. 01.02.01, EP # 1)
EP # 3-The hospital provides information to
the patient who has vision, speech, hearing,
or cognitive impairments in a manner that
meets the patient’s needs.
5
Medication Management
MM.01.01.03
The organization safely manages highalert and hazardous medications.
7
MM.01.01.03
5-A: The hospital reports abuses and
losses of controlled substances to the
individual responsible for the pharmacy
department or service and to the chief
executive officer, in accordance with law
and regulation.
8
MM.03.01.01
The organization safely stores
medications.
Secure: no unsupervised,
unauthorized individuals may
access medications.
9
MM.03.01.01
3-A: The hospital stores controlled
(scheduled) medications in a locked,
secured area to prevent diversion, in
accordance with law and regulation.
Scheduled medications include those
listed in Schedules II–V of the
Comprehensive Drug Abuse Prevention
and Control Act of 1970.
10
MM.03.01.01
19-A: The hospital has a pharmacy
directed by a registered pharmacist or a
supervised drug storage area, in
accordance with law and regulation.
11
MM.05.01.07
The organization safely prepares
medication.
12
MM.05.01.07
5-DI,A: Medications are prepared and
administered in accordance with the
orders of a licensed independent
practitioner responsible for the patient's
care, and in accordance with law and
regulation.
13
MM.05.01.07
6-DI,A: In-house preparation of
radiopharmaceuticals is done by, or under
the direct supervision of, an appropriately
trained registered pharmacist or doctor of
medicine or osteopathy.
Note: Direct defined by CMS as “on the
same campus.”
14
MM.07.01.03
The organization responds to actual or
potential adverse drug events,
significant adverse drug reactions,
and medication errors.
15
MM.07.01.03
6-DI,A: Medication administration errors,
adverse drug reactions, and medication
incompatibilities are immediately reported
to the attending physician, and, as
determined by the hospital, to the
organization-wide performance
improvement program.
16
CMS Changes for 2013
CMS Changes
1. Removal of requirement for special
education for blood and medication
administration. (HR.01.02.01)
2. Mandate for CEO, nurse leaders and
medical staff leaders to address problems
identified by infection control
(LD.01.02.01).
3. A podiatrist may serve as a medical
staff leader including president
(LD.01.05.01).
CMS Changes
4. Permission to use standing orders
(without a requirement for an order) if:
– Based on best practice guidelines
– Approved by the medical staff, nursing and
pharmacy
– For a defined patient population
– No “choices” in the set.
– Maintain required to sign, date and time at
some point. (MM.04.01.01)
Restraint
5. Permission to use orders for care,
treatment of services for outpatients from
any licensed provider as allowed by laws
and regulation providing there is a
supporting hospital policy. (MM.05.01.07)
6. New reporting process for death in
restraints. Not required for death in wrist
restraints if the death is not related to the
restraint.
CMS Changes
7. All verbal orders must be authenticated
within law and regulation. All time
requirements have been removed but it is
clear that unauthenticated orders at 30
days would constitute a delinquent record.
8. Authentications may be performed on
behalf of partner physicians.
CMS Changes
9: Single governing body
10. ONE medical staff per CCN.
11. Nursing care plans may be included in
interdisciplinary care plans.
12. Removed requirement for one person
responsible for ambulatory and outpatient
care.
Field Review
Radiology Standards
Stephen M. Dorman, M.D.
23
EC.02.01.01
The hospital manages safety
and security risks.
24
EC.02.01.01
EP 14:
For hospitals that provide magnetic
resonance imaging (MRI) services: The
hospital manages safety risks in the MRI
environment associated with the following:
- Patients who may experience
claustrophobia, anxiety, or emotional
distress
25
EC.02.01.01
EP 14:
Patients who may require urgent or
emergent medical care
- Metallic implants and devices
- Ferrous objects entering the MRI
environment
26
EC.02.01.01
EP 16:
For hospitals that provide magnetic
resonance imaging (MRI) services: The
hospital manages safety risks by doing the
following:
- Restricting access of everyone not
trained screened by staff to an area that
immediately precedes the entrance to the
MRI scanner room
27
EC.02.01.01
EP 16:
- Making sure that this area is controlled
by and under the direct supervision MRI
trained staff
- Posting signage at the entrance to the
MRI scanner room that conveys that the
magnet is always on
28
EC.02.02.01
The hospital manages risks
related to hazardous materials
and waste.
29
EC.02.02.01
EP 17:
For hospitals that provide computed
tomography (CT), positron emission
tomography (PET), or nuclear medicine
(NM) services: The hospital monitors
radiation exposure levels for all staff and
licensed independent practitioners who
routinely work in CT, PET, and NM areas.
30
EC.02.02.01
EP 17:
Note: This is typically done through the
use of exposure meters, such as personal
dosimetry badges.
31
EC.02.04.01
The hospital manages
medical equipment risks.
32
EC.02.04.01
EP 7:
The hospital identifies activities and
frequencies to maintain the image quality of
the diagnostic images produced. The
content and frequency of these activities are
in accordance with state regulatory
requirements, manufacturers’ guidelines,
and the recommendations of a medical
physicist.
33
EC.02.04.03
The hospital inspects, tests,
and maintains medical
equipment.
34
EC.02.04.03
EP 15:
The hospital maintains the image
quality of the diagnostic images
produced.
(See also EC.02.04.01, EP 7)
35
EC.02.04.03
EP 17:
For hospitals that provide computed tomography
(CT) services: When utilizing standard adult brain,
adult abdomen, and pediatric brain protocols, a
qualified medical physicist measures the actual
radiation dose produced by each diagnostic CT
imaging system at least annually and verifies that
the radiation dose displayed on the system is
within 20 percent of the actual amount of radiation
dose delivered. The dates of these verifications
are documented.
36
EC.02.04.03
Note: This element of performance is
applicable only for systems capable of
calculating and displaying radiation doses.
37
EC.02.04.03
EP 19:
For hospitals that provide computed tomography (CT)
services: If the hospital does not utilize standard adult
brain, adult abdomen, or pediatric brain protocols, the
hospital uses a qualified medical physicist to measure the
actual radiation dose produced by each diagnostic CT
imaging system at least annually and verify that the
radiation dose displayed on the system is within 20 percent
of the actual amount of radiation dose delivered for the
three most common CT protocols used by the hospital. The
dates of these verifications are documented.
38
EC.02.04.03
Note: This element of performance is
applicable only for systems capable of
calculating and displaying radiation doses
39
EC.02.04.03
EP 20:
For hospitals that provide computed tomography
(CT) services: At least annually, a medical
physicist conducts a performance evaluation of all
CT imaging equipment. The evaluation results,
along with recommendations for correcting any
problems identified, are documented. The
evaluations include the use of phantoms to assess
the following imaging metrics:
40
EC.02.04.03
EP 20:
- Image uniformity
- Slice thickness accuracy
- Slice position accuracy
- High-contrast resolution
- Low-contrast resolution
- Geometric or distance accuracy
- CT number accuracy and uniformity
- Artifact evaluation
41
EC.02.04.03
EP 21:
For hospitals that provide magnetic resonance
imaging (MRI) services: At least annually, a
medical physicist or MRI scientist conducts a
performance evaluation of all MRI imaging
equipment. The evaluation results, along with
recommendations for correcting any problems
identified, are documented. The evaluations
include the use of phantoms to assess the
following imaging metrics:
42
EC.02.04.03
EP 21:
- Image uniformity
- Slice thickness accuracy
- Slice position accuracy
- High-contrast resolution
- Low-contrast resolution (or contrast-to-noise
ratio)
- Geometric or distance accuracy
- Magnetic field homogeneity (for MRI)
- Artifact evaluation
43
EC.02.04.03
EP 22:
For hospitals that provide positron emission
tomography (PET) or nuclear medicine (NM)
services: At least annually, a medical physicist
conducts a performance evaluation of all imaging
equipment. The evaluation results, along with
recommendations for correcting any problems
identified, are documented. The evaluations
include the use of phantoms to assess the
following imaging metrics:
44
EC.02.04.03
EP 22:
- Image uniformity
- Extrinsic or system uniformity
- Intrinsic or system spatial resolution
- Low-contrast resolution
- Sensitivity
- Energy resolution
- Count-rate performance
- Artifact evaluation
45
EC.02.06.05
The hospital manages its
environment during
demolition, renovation, or
new construction to reduce
risk to those in the
organization.
46
EC.02.06.05
EP 4:
For hospitals that provide computed tomography
(CT), positron emission tomography (PET), or
nuclear medicine (NM) services: The hospital
conducts a shielding integrity survey of rooms
where ionizing radiation will be emitted or
radioactive materials will be used or stored (for
example, scan rooms, injection rooms, hot lab).
47
EC.02.06.05
EP 4:
Note: For additional guidance on structural
shielding design, see National Council on
Radiation Protection and Measurements
Report No. 147 (NCRP-147).
48
HR.01.02.05
The hospital verifies staff
qualifications.
49
HR.01.02.05
EP 19:
For hospitals that provide computed
tomography (CT) services: The hospital
verifies and documents that a radiologic
technologist who performs CT exams has
the following qualifications:
50
HR.01.02.05
EP 19:
- Registered by the American Registry of
Radiologic Technologists (ARRT)
- Certified by the ARRT in radiography
and/or computed tomography
- Trained and experienced in operating CT
equipment
51
HR.01.02.05
EP 20:
For hospitals that provide computed tomography
(CT) services: Diagnostic medical physicists that
support CT services are board certified in
diagnostic radiological physics or radiological
physics by the American Board of Radiology, the
American Board of Medical Physics, or an
equivalent source. If the diagnostic medical
physicist is not board certified, then he or she has
completed the following:
52
HR.01.02.05
EP 20:
- A graduate degree in medical physics,
radiologic physics, physics, or another
relevant physical science or engineering
discipline
53
HR.01.02.05
EP 20:
- Formal coursework in the biological
sciences with at least one course in biology
or radiation biology, and one course in
anatomy, physiology, or a similar topic
related to the practice of medical physics
- Three years of documented experience in
a clinical CT environment
54
HR.01.05.03
Staff participate in ongoing
education and training.
55
HR.01.05.03
EP 14:
For hospitals that provide computed tomography
(CT) services: The hospital verifies and documents
that radiologic technologists who perform CT
examinations participate in ongoing education.
Ongoing education must include annual training on
radiation dose reduction awareness and
techniques following As Low As Reasonably
Achievable (ALARA), Image Gently, and Image
Wisely concepts.
56
HR.01.05.03
EP 25:
Staff providing magnetic resonance
imaging (MRI) services participate in
education and training on safe practices in
the MRI environment including the following:
57
HR.01.05.03
EP 25:
- Patient screening criteria for ferrous-based items
- Proper patient positioning activities to avoid burns
- Equipment and supplies that have been determined to
be safe for use in MRI areas
- MRI safety response procedures for patients who
require urgent or emergent medical care
- MRI equipment emergency shutdown procedures
58
LD.04.04.01 (new standard)
The hospital uses clinical practice
guidelines when providing the following
diagnostic imaging services: computed
tomography, magnetic resonance
imaging, positron emission
tomography, and nuclear medicine.
For Hospitals that use CT, MRI, PET and
NM:
59
LD.04.04.01
EP 1:
The hospital uses evidence-based
guidelines and considers the patient’s age
and previous imaging exams when deciding
on the most appropriate type of imaging
exam.
60
LD.04.04.01
EP 2:
The hospital establishes imaging protocols
based on current standards of practice,
which address key criteria including,
clinical indication, patient age, patient
positioning, scan times, radiation dose
limits, and contrast administration.
See (PI.01.01.01, EP 46)
61
LD.04.04.01
EP 3:
Imaging protocols are kept current and
adjusted with input from an interpreting
radiologist, medical physicist, and chief
imaging technologist. Imaging protocols
are adjusted based on individual patient
needs and on changes to standards of
practice.
62
MM.06.01.01
The hospital safely
administers medications.
63
MM.06.01.01
EP 13:
Before administering a radioactive isotope,
staff verify that the dose to be
administered is within 20% of the
prescribed dose, or, if the dose is
prescribed as a range, staff verify that the
dose to be administered is within the
prescribed range.
64
PC.01.02.15
The hospital provides for
diagnostic testing.
65
PC.01.02.15
EP 5:
The hospital documents in the patient’s
record the radiation dose on every study
produced during a CT examination.
Note 1: This element of performance is
applicable only for systems capable of
calculating and displaying radiation doses.
66
PC.01.02.15
EP 5:
Note 2: This element of performance does
not apply to systems used for therapeutic
radiation treatment planning or delivery, or
for calculating attenuation coefficients for
nuclear medicine studies.
67
PC.01.02.15
EP 6:
For hospitals that provide computed
tomography (CT) services: The interpretive
report of a diagnostic CT study includes the
radiation dose. The dose is either recorded
in the patient's interpretive report or included
on the protocol page, which is then attached
to the interpretive report. (used to apply
only to California).
68
PC.01.02.15
EP 7:
For hospitals that provide computed
tomography (CT) services: The hospital
electronically sends each CT study and
protocol page that lists the radiation dose
and related technical factors to the hospital’s
electronic picture archiving and
communications system (PACS).
69
PC.01.02.15
EP 7:
Note: This element of performance is only
applicable for systems capable of
calculating and displaying radiation doses.
70
PC.01.02.15
EP 10:
For hospitals that provide computed
tomography (CT), magnetic resonance
imaging (MRI), positron emission
tomography (PET), or nuclear medicine
(NM) services: Prior to conducting a
diagnostic imaging study, the hospital
verifies the following:
71
PC.01.02.15
EP 10:
Correct patient
- Correct imaging site
- Correct patient positioning
- For CT only: Correct imaging protocol
- For CT only: Correct scanner parameters
72
PC.01.02.15
EP 11:
For hospitals that provide computed tomography
(CT), magnetic resonance imaging (MRI), positron
emission tomography (PET), or nuclear medicine
(NM) services: The hospital makes certain that
imaging studies are based on an order from a
licensed independent practitioner or other qualified
practitioner in accordance with law and regulation.
73
PI.01.01.01
The hospital collects data to
monitor its performance.
74
PI.01.01.01
EP 46:
For hospitals that provide computed
tomography (CT) services: The hospital
collects data on incidents where radiation
dose limits identified in imaging protocols
have been exceeded.
75
PI.01.01.01
EP 47:
For hospitals that provide magnetic
resonance imaging (MRI) services: The
hospital collects data on patient burns that
occur during MRI exams.
76
PI.01.01.01
EP 48:
For hospitals that provide magnetic
resonance imaging (MRI) services: The
hospital collects data on the following:
- Incidents when ferrous-based items
entered the MRI scanner room
- Injuries resulting from the presence of
ferrous-based items in the MRI scanner
room
77
PI.02.01.01
The hospital compiles and
analyzes data.
78
PI.02.01.01
EP 6:
For hospitals that provide computed
tomography (CT) services: The hospital
analyzes data on CT radiation doses and
compares it with external benchmarks, when
available.
79
Medical Staff OPPE and FPPE
The Joint Commission’s New
Approach to Assessing
Physician Performance
The Standard: MS.05.01.01:
CLINICAL
The organized medical staff has a leadership
role in organization performance improvement
activities to improve quality of care, treatment,
and services and [patient] safety.
Relevant information developed from the
following processes is integrated into
performance improvement initiatives and
consistent with [organization] preservation of
confidentiality and privilege of information.
81
The Standard: MS.05.01.01
1: The organized medical staff provides
leadership for measuring, assessing, and
improving processes that primarily
depend on the activities of one or more
licensed independent practitioners, and
other practitioners credentialed and
privileged through the medical staff
process. (See also PI.03.01.01, EPs 1-4)
82
The Standard: MS.05.01.01
2: The medical staff is actively involved
in the measurement, assessment, and
improvement of the following: Medical
assessment and treatment of patients.
(See also PI.03.01.01, EPs 1-4)
83
The Standard: MS.05.01.01
3: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: Use of
information about adverse privileging
decisions for any practitioner privileged
through the medical staff process.
84
The Standard: MS.05.01.01
4: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: Use of
medications
85
The Standard: MS.05.01.01
5: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: Use of
blood and blood components
86
The Standard: MS.05.01.01
6: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: Operative
and other procedure(s)
– Judgment (decision making)
– Clinical and Technical Skills
87
The Standard: MS.05.01.01
7: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following:
Appropriateness of clinical practice
patterns.
– Utilization Review (LOS, Avoidable days,
denials)
88
The Standard: MS.05.01.01
8: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: Significant
departures from established patterns of
clinical practice.
– All other departments: Pathology,
radiology, anesthesiology, ER
89
The Standard: MS.05.01.01
9: The medical staff is actively involved in
the measurement, assessment, and
improvement of the following: The use of
developed criteria for autopsies. (CMS
REQUIREMENT)
90
The Standard: MS.05.01.01
10: Information used as part of the
performance improvement mechanisms,
measurement, or assessment includes the
following: Sentinel event data.
91
The Standard: MS.05.01.01
11: Information used as part of the
performance improvement mechanisms,
measurement, or assessment includes the
following: Patient safety data.
92
The Standard: MS.05.01.03:
CITIZENSHIP
1: The organized medical staff participates
in the following activities: Education of
patients and families.
93
The Standard: MS.05.01.03:
CITIZENSHIP
2: The organized medical staff participates
in the following activities: Coordination of
care, treatment, and services with other
practitioners and hospital personnel, as
relevant to the care, treatment, and
services of an individual patient.
94
The Standard: MS.05.01.03:
CITIZENSHIP
3: The organized medical staff participates
in the following activities: Accurate,
timely, and legible completion of
patient’s medical records.
95
The Standard: MS.05.01.03:
CITIZENSHIP
4: The organized medical staff participates
in the following activities: Review of
findings of the assessment process
that are relevant to an individual’s
performance. The organized medical
staff is responsible for determining the
use of this information in the ongoing
evaluations of a practitioner’s
competence.
96
The Standard: MS.05.01.03:
CITIZENSHIP
5: The organized medical staff participates
in the following activities: Communication
of findings, conclusions,
recommendations, and actions to improve
performance to appropriate staff members
and the governing body.
97
The Standard: MS.08.01.03
Ongoing professional practice evaluation
information is factored into the decision to
maintain existing privilege(s), to revise
existing privilege(s), or to revoke an
existing privilege prior to or at the time of
renewal.
98
The Standard: MS.08.01.03
1: The process for the ongoing
professional practice evaluation includes
the following: There is a clearly defined
process in place that facilitates the
evaluation of each practitioner’s
professional practice. (D means there
must be a policy)
99
The Standard: MS.08.01.03
2: The process for the ongoing
professional practice evaluation includes
the following: The type of data to be
collected is determined by individual
departments and approved by the
organized medical staff. (Performance
measures must be defined for CMS in a
Medical Staff Plan).
100
The Standard: MS.08.01.03
3: The process for the ongoing
professional practice evaluation includes
the following: Information resulting from
the ongoing professional practice
evaluation is used to determine whether
to continue, limit, or revoke any
existing privilege(s).
101
FOCUSED REVIEW
While it was a good thing to evaluate
providers after they had already been
working 6 months, it was apparent that
there was real risk in the “unknown”.
Peer Recommendations could not be
trusted.
Harm could come to patients soon after
practice began.
102
FOCUSED REVIEW
There were analogous standards in the
Human Resources chapter for an “initial
assessment of competency” before
hospital staff could carry out job
responsibilities independently.
103
FOCUSED REVIEW
It was clear that something was needed on
the “front end.”
Next it was determined that in classic
“peer review”, cases simply fell off and
issues were never closed or casually
investigated. There was no accountability
for closure of many significant issues.
104
FOCUSED REVIEW
The purpose:
– Initial assessment competence of all new
physicians or new privileges regardless of
experience.
– Conduct intensive, planned and “focused”
investigations when adverse events occurred
(trigger events).
– Conduct intensive, planned and “focused”
investigations when ongoing performance
measurement indicated undesirable
performance.
105
Focused Review: New Privileges
Goal: To be conducted as rapidly as possible.
“Volume” of review defined by the medical
staff and departments.
Individual plans should be developed to allow
the medical staff to know when the review
has concluded.
Each provider may warrant a tailored plan.
Some departments are completely uniform.
106
Focused Review: New Privileges
Should be conducted in a time frame that
is too short for rate based performance
measurement: data collection would not
be statistically significant for short term.
Evaluation of privilege must be realistic:
chart review versus direct observation.
All requirements defined in a plan.
TOP Medical Staff Standard RFI in 2009.
107
The Standard: MS.08.01.01
The organized medical staff defines the
circumstances requiring monitoring and
evaluation of a practitioner’s professional
performance.
- Initial Appointment (new privileges)
- New mid-cycle privilege
- Trigger events
- Variant data
108
The Standard: MS.08.01.01
The focused evaluation process is defined by
the organized medical staff. The time period of
the evaluation can be extended, and/or a
different type of evaluation process assigned.
Information for focused professional practice
evaluation may include chart review, monitoring
clinical practice patterns, simulation, proctoring,
external peer review, and discussion with other
individuals involved in the care of each patient
(e.g., consulting physicians, assistants at
surgery, nursing or administrative personnel).
109
The Standard: MS.08.01.01
Relevant information resulting from the
focused evaluation process is integrated
into performance improvement activities,
consistent with the organization’s policies
and procedures that are intended to
preserve confidentiality and privilege of
information.
110
The Standard: MS.08.01.01
1: A period of focused professional
practice evaluation is implemented for all
initially requested privileges.
111
The Standard: MS.08.01.01
2: The organized medical staff develops
criteria to be used for evaluating the
performance of practitioners when issues
affecting the provision of safe, high quality
patient care are identified. (D means
Plan)
112
The Standard: MS.08.01.01
3: The performance monitoring process is
clearly defined and includes each of the
following elements:
- Criteria for conducting performance monitoring
- Method for establishing a monitoring plan
specific to the requested privilege
- Method for determining the duration of
performance monitoring
- Circumstances under which monitoring by an
external source is required
113
The Standard: MS.08.01.01
4: Focused professional practice
evaluation is consistently implemented
in accordance with the criteria and
requirements defined by the organized
medical staff.
114
The Standard: MS.08.01.01
5: The triggers that indicate the need for
performance monitoring are clearly
defined.
Note: Triggers can be single incidents or
evidence of a clinical practice trend.
115
The Standard: MS.08.01.01
6: The decision to assign a period of
performance monitoring to further assess
current competence is based on the evaluation
of a practitioner’s current clinical competence,
practice behavior, and ability to perform the
requested privilege.
Note: Other existing privileges in good standing
should not be affected by this decision.
116
The Standard: MS.08.01.01
7: Criteria are developed that determine
the type of monitoring to be conducted. (D
means this has to be in the plan).
117
The Standard: MS.08.01.01
8: The measures employed to resolve
performance issues are clearly defined. (D
means it must be in the plan).
118
The Standard: MS.08.01.01
9: The measures employed to resolve
performance issues are consistently
implemented.
119
Scoring
All of the medical staff standards on these
issues are “A” meaning 100% compliance
is required
Focused Review: 16% of hospitals cited
Ongoing Review: 15% of hospitals cited
Problems with no or low volume providers
Changes to privileges based on data
120
Restraints
PC.03.05.03
The organization uses restraint or
seclusion safely.
122
PC. 03.05.03
Elements of Performance
1-DI, A: The hospital implements restraint or
seclusion using safe techniques identified by the
hospital’s policies and procedures in accordance
with law and regulation.
2-M, C: The use of restraint and seclusion is in
accordance with a written modification to the
patient's plan of care.
123
PC. 03.05.05
The organization initiates restraint or
seclusion based on an individual order.
124
PC. 03.05.05
Elements of Performance
3-A: The attending physician is consulted as
soon as possible (immediately), in
accordance with hospital policy, if he or she
did not order the restraint or seclusion.
125
PC. 03.05.05
4-M, C: Unless state law is more restrictive, orders
for the use of restraint or seclusion used for the
management of violent or self-destructive behavior
that jeopardizes the immediate physical safety of
the patient, staff, or others may be renewed within
the following limits:
• 4 hours for adults 18 years of age or older
• 2 hours for children and adolescents 9 to 17
years of age
• 1 hour for children under 9 years of age
126
PC. 03. 05. 05
Elements of Performance
5-DI, A: Unless state law is more restrictive, every
24 hours, a physician or other authorized licensed
independent practitioner primarily responsible for
the patient’s ongoing care sees and evaluates the
patient before writing a new order for restraint or
seclusion used for the management of violent or
self-destructive behavior that jeopardizes the
immediate physical safety of the patient, staff, or
others in accordance with hospital policy and law
and regulation.
127
PC. 03.05.05
Elements of Performance
6-DI, A: Orders for restraint used to protect
the physical safety of the nonviolent or
non-self-destructive patient are renewed
in accordance with hospital policy.
128
PC. 03.05.07
The organization monitors patients who
are restrained or secluded.
129
PC. 03.05.07
1-DI, A: Physicians or other licensed
independent practitioners or staff who have
been trained in accordance with 42 CFR
482.13(f) monitor the condition of patients in
restraint or seclusion. (See PC.03.05.17, EP
3)
130
PC. 03.05.09
The organization has written policies
and procedures that guide the use of
restraint or seclusion.
131
PC. 03.05.09
Elements of Performance
1-D, A: The hospital’s policies and procedures
regarding restraint or seclusion include the
following:
• Physician and other authorized licensed
independent practitioner training
requirements
• Staff training requirements
• The determination of who has authority to
order restraint and seclusion
132
PC. 03.05.09
Elements of Performance
1-D, A: The hospital’s policies and procedures regarding
restraint or seclusion include the following
The determination of who has authority to discontinue the
use of restraint or seclusion
The determination of who can initiate restraint or
seclusion
The circumstances under which restraint or seclusion is
discontinued.
The requirement that restraint or seclusion is discontinued
as soon as is safely possible
133
PC. 03.05.09
Elements of Performance
The hospital’s policies and procedures regarding
restraint or seclusion include the following:
• A definition of restraint in accordance with 42
CFR 482.13(e)(1)(i)(A-C)
• A definition of seclusion in accordance with 42
CFR 482.13(e)(1)(ii)
• A definition or description of what constitutes
the use of medications as a restraint in
accordance with 42 CFR 482.13(e)(1)(i)(B)
134
PC. 03.05.09
Elements of Performance
The hospital’s policies and procedures regarding
restraint or seclusion include the following:
• A determination of who can assess and
monitor patients in restraint or seclusion
• Time frames for assessing and monitoring
patients in restraint or seclusion
135
PC. 03.05.09
Elements of Performance
2-DI,A: Physicians and other licensed
independent practitioners authorized to
order restraint or seclusion (through hospital
policy in accordance with law and
regulation) have a working knowledge of the
hospital policy regarding the use of restraint
and seclusion.
136
PC. 03.05.11
The organization evaluates and
reevaluates the patient who is
restrained or secluded.
137
PC. 03.05.11
Elements of Performance
1-D, A: A physician or other licensed independent
practitioner responsible for the care of the patient
evaluates the patient in-person within one hour of the
initiation of restraint or seclusion used for the
management of violent or self-destructive behavior
that jeopardizes the physical safety of the patient,
staff, or others. A registered nurse or a physician
assistant may conduct the in-person evaluation within
one hour of the initiation of restraint or seclusion; this
individual is trained in accordance with the
requirements at PC.03.05.17, EP 3.
138
PC. 03.05.11
Elements of Performance
2-DI, A: When the in-person evaluation
(performed within one hour of the initiation
of restraint or seclusion) is done by a
trained registered nurse or trained
physician assistant, he or she consults
with the attending physician or other
licensed independent practitioner
responsible for the care of the patient as
soon as possible after the evaluation, as
determined by hospital policy.
139
PC. 03.05.11
Elements of Performance
3-DI, A: The in-person evaluation, conducted within one
hour of the initiation of restraint or seclusion for the
management of violent or self-destructive behavior that
jeopardizes the physical safety of the patient staff or others,
includes the following:
• An evaluation of the patient's immediate situation
• The patient's reaction to the intervention
• The patient's medical and behavioral condition
• The need to continue or terminate the restraint or
seclusion
140
PC.03.05.13
The organization continually monitors
patients who are simultaneously
restrained and secluded.
141
PC. 03.05.13
1-DI, A: The patient who is
simultaneously restrained and secluded
is continually monitored by trained staff
either in-person or through the use of
both video and audio equipment that is
in close proximity to the patient.
142
PC. 03.05.15
The organization documents the use of
restraint or seclusion.
143
PC. 03.05.15
Elements of Performance
1-M, C: Documentation of restraint and seclusion
in the medical record includes the following:
• Any in-person medical and behavioral
evaluation for restraint or seclusion used to
manage violent or self-destructive behavior
• A description of the patient’s behavior and
the intervention used
• Any alternatives or other less restrictive
interventions attempted
144
PC. 03.05.15
Elements of Performance
1-M, C: Documentation of restraint and seclusion
in the medical record includes the following:
• The patient’s condition or symptom(s) that
warranted the use of the restraint or
seclusion
• The patient’s response to the intervention(s)
used, including the rationale for use of the
intervention
• Individual patient assessments and
reassessments
• The intervals for monitoring
145
PC. 03.05.15
Elements of Performance
1-M,C: Documentation of restraint and seclusion in
the medical record includes the following:
•
•
•
Revisions to the plan of care
The patient’s behavior and staff concerns
regarding safety risks to the patient, staff,
and others that necessitated the use of
restraint or seclusion
Injuries to the patient
146
PC. 03.05.15
Elements of Performance
1-M, C: Documentation of restraint and seclusion in the
medical record includes the following:
•
•
•
•
•
Death associated with the use of restraint or
seclusion
The identity of the physician or other licensed
independent practitioner who ordered the restraint
or seclusion
Orders for restraint or seclusion
Notification of the use of restraint or seclusion to
the attending physician
Consultations
147
PC. 03.05.17
The organization trains staff to safely
implement the use of restraint or
seclusion.
148
PC. 03.05.17
Elements of Performance
2-M, C: The hospital trains staff on the use
of restraint and seclusion, and assesses
their competence, at the following
intervals:
• At orientation
• Before participating in the use of
restraint and seclusion
• On a periodic basis thereafter
149
PC. 03.05.17
Elements of Performance
3-M, C: Based on the population served, staff
education, training, and demonstrated knowledge
focus on the following:
• Safe application and use of all types of
restraint or seclusion used in the hospital,
including training in how to recognize and
respond to signs of physical and
psychological distress (for example,
positional asphyxia)
• Clinical identification of specific behavioral
changes that indicate that restraint or
seclusion is no longer necessary
150
PC. 03.05.17
Elements of Performance
3-M, C: Based on the population served, staff education,
training, and demonstrated knowledge focus on the
following:
•
Monitoring the physical and psychological wellbeing of the patient who is restrained or secluded,
including but not limited to respiratory and
circulatory status, skin integrity, vital signs, and
any special requirements specified by hospital
policy associated with the in-person evaluation
conducted within one hour of initiation of restraint
or seclusion
151
PC. 03.05.17
Elements of Performance
3-M, C: Based on the population served,
staff education, training, and demonstrated
knowledge focus on the following:
• Use of first aid techniques and
certification in the use of
cardiopulmonary resuscitation,
including required periodic
recertification
152
PC. 03.05.17
Elements of Performance
4-A: Individuals providing staff training in
restraint or seclusion have education,
training, and experience in the techniques
used to address patient behaviors that
necessitate the use of restraint or seclusion.
153
PC.03.05.17
Elements of Performance
5-M, D, C: The hospital documents in
staff records that restraint and
seclusion training and demonstration of
competence were completed.
154
CMS Restraint Changes
155
Reporting Restraint-Related
Deaths
Restraint-Related Deaths: Replaces the
requirement that hospitals report deaths
related to soft, 2- point restraints, with a
requirement that hospitals maintain a log (or
other system) that will be made available to
CMS if requested.
156
Reporting Restraint-Related
Deaths
Log: The Log is internal to the hospital and
the name of the practitioner responsible for
the care of the patient may be used in the
log in lieu of the name of
the attending physician if the patient was
under the care of a non-MD practitioner.
157
Reporting Restraint Deaths
Section 482.13 is amended by a) revising
paragraphs (g)(1) through (3) and b) adding
paragraph (g)(4). The revisions and addition
read as follows: With the exception of deaths
described under paragraph (g)(2) of this
section the hospital must report the
following information to CMS by telephone,
fax or electronically as determined by CMs
no later than the close of next business day
158
CMS Restraint Changes
(g) (i) Each death that occurs while a
patient is in restraint or seclusion
(g) (ii) Each death that occurs within 24
hours after that patient has been removed
from restrain or seclusion
159
Reporting Restraint-Related
Deaths
(g) (iii) Each death known to the hospital
that occurs within 1 week after restraint or
seclusion where it is reasonable to
assume that use of restraint or placement
in seclusion contributed directly or
indirectly to the patient’s death, regardless
of the type (s) of restraint used on the
patient during this time.
160
Reporting Restraint-Related
Deaths
(2) When no seclusion has been used and
when the only restraints used on the
patient tare those applied exclusively to
the patient’s wrist(s), and which are
composed solely of soft, non-rigid, clothlike materials, the hospital staff must
record in an internal log or other system,
the following information:
161
Internal Restraint Log
Components
(i) Any death that occurs while a patient is
in restraints
(ii) Any death that occurs within 24 hours
after a patient has been removed from
such restraints.
162
Internal Restraint Log
Components
(3) The staff must document in the
patient’s medical record the date and time
the death was:
– Reported to CMS for deaths described in (g)
(1) of this section or other systems for deaths
described in paragraph (g) (2) of this section.
For deaths described in paragraph (g) 2 of
this section entries into the internal log or
other system must be documented as
follows:
163
Internal Restraint Log
Components
(ii) The information must be made
available in either written or electronic
form to CMS immediately upon request.
164
Internal Restraint Log
Components
(i) Each entry must be made not later than
7 days after the date of death of the
patient.
(ii) Each entry must document the patient’s
name, date of birth , date of death, name
of attending physician or other LIP who is
responsible for the care of the patient ,
medical record number and primary
diagnosis(es)
165
Patient Flow Standards
LD 04.03.11
The hospital manages the
flow of patients throughout
the hospital.
LD.04.03.11
EP # 1
– The hospital has processes that support the flow of
patients throughout the hospital.
EP # 2
– The hospital plans for the care of admitted patients
who are in temporary bed locations, such as the
post-anesthesia care unit or the emergency
department.
EP # 3
– The hospital plans for care to patients placed in
overflow locations.
LD. 04.03. 11
EP # 4
– Criteria guide decisions to initiate ambulance
diversion.
EP # 5
– The hospital measures and sets goals the
components of the patient flow process including:
The available supply of beds
The throughput of areas where patients receive
care, treatment, and services ( such as inpatient
units, laboratory, operating rooms, telemetry,
radiology and PACU.
LD. 04.03.11
EP. # 5 (Continued)
– The safety of areas where patients receive
care, treatment and services
– The efficiency of the non-clinical services that
support patient care and treatment (such as
housekeeping and transportation).
– Access to support services (such as case
management and social work)
LD. 04.03.11
EP # 6
– Effective January 1, 2014
– The hospital measures and sets goals for mitigating
and managing the boarding of patients who come
through the emergency department.
– Note: Boarding is the practice of holding patients in
the emergency department or a temporary location
after the decision to admit or transfer has been
made. The hospital should set its goals with
attention to patient acuity and best practice; it is
recommended that boarding timeframes not exceed
4 hours in the interest of patient safety and quality of
care.
LD. 04.03.011
EP # 6 (Cross-referenced standard)
– NPSG. 15.01.01., EP’s 1 & 2, PC.01.01.01 EP’s 4 & 9
PC. 01.02.03, EP 3, PC. 02.01.19, EP 1 & 2
NPSG. 15.01.01 EP # 1
Conduct a risk assessment that identifies
specific patient characteristics and
environmental features that may increase
or decrease the risk for suicide.
LD. 04.03.11
NPSG. 15.01.01. EP # 2
Address the patient’s immediate safety needs
and most appropriate setting for treatment.
PC.01.01.01
The hospital accepts the patient in the care,
treatment, and services based on its ability to
meet the patient’s needs.
LD. 04.03.11
PC. 01.01.01
EP # 4 Hospitals that do not primarily provide
psychiatric or substance abuse services have a
written plan that defines the care, treatment and
services or the referral process for patients who
are emotionally ill or suffer the effects of
alcoholism or substance abuse
LD. 04.03.11
PC. 01. 01. 01
EP # 24 If a patient is boarded while awaiting for
emotional illness and/or the effects of alcoholism
or substance abuse, the hospital does the
following:
– Provides for a location for the patient that is safe,
monitored, and clear of items that the patient could
use to harm himself or herself or others.
– Provides orientation and training to any clinical and
non-clinical staff caring for such patients in effective
and safe care, treatment, and services.
– Conducts assessments, and reassessments, and
provides care consistent with the patients’ identified
needs.
LD. 04.03.11
PC. 01.02.03 EP # 3
Each patient is reassessed as necessary
based on his or her plan for care or changes in
his or her condition.
Note: Reassessments may also be based on
the patient's diagnosis; desire for care,
treatment, and services; response to previous
care, treatment, and services; and/or his or her
setting requirements.
LD.04.03.11
PC. 02.01.19 EP # 1
The hospital has a process for recognizing and
responding as soon as a patient’s condition
appears to be worsening.
PC. 02.01.19 EP # 2
The hospital develops written criteria describing
early warning signs of a change or deterioration
in a patient’s condition and when to seek
further assistance.
LD. 04.03.11
EP # 7
The individuals who manage patient flow
processes review measurement results to
determine that goals were achieved.
Cross-referenced standard NR. 02.02.01 EP #
4
The nurse executive, registered nurses, and
other designated nursing staff write: Nursing
standards of patient care, treatment, and
services.
LD. 04.03.11
EP # 8
Leaders take action when patient flow
goals are not achieved.
Cross-referenced standard PI. 03.01.01,
EP #4
The hospital takes action when it does
not achieve or sustain planned
improvements.
LD. 04.03.11
Note for EP # 8.
At a minimum, leaders included medical
staff and governing body, the chief
executive officer and other senior
managers, the chief nurse executive,
clinical leaders, staff members in
leadership positions within the
organization.
LD. 04.03.11
EP # 9
Effective January 1, 2014
When the hospital determines that it has a
population at risk for boarding due to
behavioral health emergencies, hospital
leaders communicate with behavioral health
providers and/or authorities serving the
community to foster coordination of care for this
population
Cross-referenced standards LD. 03.04.01 EP’s
#3 &6
LD. 04.03.11
LD. 03. 04. 01
EP # 3
Communication is designed to meet the
needs of internal and external users.
EP # 6
When changes in the environment occur,
the hospital communicates those
changes effectively
Leadership
LD.04.03.09
Care, treatment, and services
provided through contractual
agreement are provided safely
and effectively.
184
LD.04.03.09
1-A: Clinical leaders and medical staff
have an opportunity to provide advice
about the sources of clinical services to be
provided through contractual agreement.
2-D,A: The hospital describes, in writing,
the nature and scope of services provided
through contractual agreements.
185
LD.04.03.09
3-D,A: Designated leaders approve
contractual agreements.
186
LD.04.03.09
4-A: Leaders monitor contracted services by
establishing expectations for the performance of
the contracted services.
5-D,A:Leaders monitor contracted services by
communicating the expectations in writing to the
provider of the contracted services.
Note: A written description of the expectations
can be provided either as part of the written
agreement or in addition to it.
187
LD.04.03.09
6-A: Leaders monitor contracted services
by evaluating these services in relation to
the hospital's expectations
188
LD.04.03.09
7-A: Leaders take steps to improve contracted
services that do not meet expectations.
Note: Examples of improvement efforts to
consider include the following:
- Increase monitoring of the contracted services.
- Provide consultation or training to the
contractor.
- Renegotiate the contract terms.
- Apply defined penalties.
- Terminate the contract.
189
LD.04.03.09
8-DI,A: When contractual agreements are
renegotiated or terminated, the hospital
maintains the continuity of patient care.
10-D,A: Reference and contract laboratory
services meet the federal regulations for
clinical laboratories and maintain evidence
of the same.
190
Contract Principles
TJC does not require organizations to manually verify
each contract employee file.
If the contracting entity is Joint Commission
accredited there is no requirement to request the
information on the employee
Full hospital orientation is not required
Orientation to key areas such as emergency
preparedness, infection control, safety, and security is
critical.
191
Contract Principles
If specified in the contract, the contracting
organization can rely on the contract staff
provider to complete annual in-service
training, many topics of which are the
same as those required by the customer
(such as, infection control, populationspecific health care, cultural diversity,
proper lifting techniques, and so forth).
192
Contract Principles
Contracts must be in writing.
The organization must define the expectations of
the contract, including human resource
expectation.
The contract should specify that the contracted
organization will provide only staff who are
qualified in relation to their education, training,
licensure, and competence as defined by the
contracting organization.
193
Contract Principles
The contracted organization has the
responsibility to verify orientation,
performance evaluations, health status,
background checks, and any applicable
references.
194
Contract Principles
The contract should include the following:
Define within the contract the required
qualifications for the contracted staff
Review the personnel practices of the
contracted organization to assess
compliance with its own and Joint
Commission requirements (for example,
who will complete competence
assessments)
195
Contract Principles
If the contracted organization’s practices
are acceptable, the organization can
accept those practices for the provided
contracted personnel.
If the contracted organization’s practices
are not acceptable, the organization can
define in the contract the specific
requirements or perform the requirements
itself.
196
Human Resources
Competence Assessment
Activity
Competence Assessment
10-12 Personnel Records
Contract Personnel based on list provided
Agency Staff
Bring Hospital Orientation curriculum
Education Requirements (see handout)
Make sure department manager of requested
employee is present for the activity.
198
2013 Education Requirements
Arranged by Chapter in Joint Commission
Manual
Annually means every 12 months, different
than yearly
Ongoing is surveyed as every 3 years or
so
At orientation-is before being independent
199
HR.01.02.01
The hospital defines staff qualifications
Job Descriptions
200
HR. 01.02.05
7-DI, A: Before providing care, treatment,
and services, the hospital confirms that
non-employees who are brought into the
hospital by a licensed independent
practitioner to provide care, treatment, or
services have the same qualifications and
competencies required of employed
individuals performing the same or similar
services at the hospital.
201
Human Resources
Non-advanced practice employees of
physicians
– Equivalent process, orientation safety,
department, primary source verification
– Initial competency determined
– Annual competence determined
Physician employed advance practice
personnel ( CRNA, CNM, PA, ARNP)
202
HR.01.04.01
The hospital provides orientation to staff.
203
HR.01.04.01
3-A: The hospital orients staff on the
following: Relevant hospital-wide and
unit-specific policies and procedures.
Completion of this orientation is
documented.
204
HR. 01.04.01
7-M,C:The hospital orients external law
enforcement and security personnel on the
following:
– How to interact with patients
– Procedures for responding to unusual clinical
events and incidents
– The hospital’s channels of clinical, security,
and administrative communication
– Distinctions between administrative and
clinical seclusion and restraint
205
Problematic Human
Resources Standards
HR. 01.06.01 Staff Competence
Positions of one--An individual with the
educational background, experience, or
knowledge related to the skills being
reviewed assesses competence.
Performance evaluations (HR. 01.07.01)
Frequency/Measurement/Delinquency (C)
206
Frequently Cited Standards
207
Frequently Cited Standards
RC.01.01.01: 55%
– Dating, timing
LS.02.01.20: 54%
– Means of egress, hall clutter
IC.02.02.01: 47%
– Instrument processing, sterilization, high level
disinfection
208
Frequently Cited Standards
EC.02.05.01: 46%
– Air pressure differentials
LS.02.01.01: 45%
– Fire ratings of walls and penetrations
EC.02.03.05: 40%
– Fire safety equipment and fire safety features
LS.02.01.30: 39%
– Protection of hazardous areas
209
Frequently Cited Standards
EC.02.06.01: 35%
– Humidity 35-60% or get waiver 20-60%
MM.03.01.01: 35%
– Medication Security, controlled substances
– Vaccine storage
LS.02.01.35: 34%
– Sprinklers and Fire Extinguishers
210
QUESTIONS??
211
212