2015
Joint Commission Hospital
Accreditation Update
Roberta Fruth
RN, MS, PhD, FAAN, CJCP
Senior Consultant
Joint Commission Resources
© Joint Commission Resources
Laurel McCourt, MD
Consultant
Joint Commission Resources
Cell Phones and PDAs……
Thank you.
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Please turn off audible
ringers as a courtesy to
other participants.
Disclosure Statement
The following staff and speakers have disclosed that they do
not have any financial arrangements or affiliations with
corporate organizations that either provide educational grants
to this program or may be referenced in this activity:
– Laurel McCourt
– Roberta Fruth
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Furthermore, each of the previously named speakers has also
attested that their discussions will not include any unapproved
or off-label use of products.
Joint Commission Resources
Disclaimer
 These slides are current as of December 16, 2014. Joint
Commission Resources reserves the right to change the content
of the information, as appropriate.
 These slides are copyrighted and may not be further used, shared
or distributed without permission of the original presenter or Joint
Commission Resources.
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 These slides are only meant to be cue points, which were
expounded upon verbally by the original presenter and are not
meant to be comprehensive statements of standards
interpretation or represent all the content of the presentation.
Thus, care should be exercised in interpreting Joint Commission
requirements based solely on the content of these slides.
Objectives
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 Translate the changes related to the Joint Commission’s
standards and survey process for 2015 into your organization’s
ongoing survey readiness activities
 Apply appropriately the relationship between The Joint
Commission and the Centers for Medicare and Mediciaid
Services (CMS) as to distinguish between accreditation and
deemed status in your healthcare setting(s)
 Incorporate the use of tracers to analyze your organization’s
systems and processes
 Implement strategies for complying with new and challenging
standards in your practice setting(s)
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The Survey Process
(I think)
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Change is good…
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…but how do I keep up with all of the changes?
Resources
TJC Website
Perspectives
E-Alerts
Quick Safety
Simplified Guest Access for Joint Commission
Connect for staff
 NEW! Patient Safety Systems Chapter
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Quick Safety
.
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 Quick Safety is a monthly newsletter that
outlines an incident, topic or trend in health
care that could compromise patient safety.
 Quick Safety helps Joint Commissionaccredited organizations recognize potential
safety issues they may encounter
© Joint Commission Resources
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New in 2014: Simplified Guest Access
to Joint Commission Connect™
 Informs and educates hospital leaders on the
importance and the structure of an integrated
patient safety system.
 There are no new requirements.
 The chapter serves as a road map for hospital
leaders to use existing requirements to
improve patient safety.
 The chapter will be included on E-dition and in
the 2015 Comprehensive Accreditation
Manual for Hospitals.
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Patient Safety Systems Chapter
 Consistent excellence is the vision
 Leadership + safety culture + RPI
 All Joint Commission programs and activities are aligning
around this aim:
– Accreditation, performance measurement
– JCR education, publication, consulting
– Center-developed improvement solutions
 Help customers improve no matter where they are on the
journey to high reliability
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The Joint Commission and High Reliability
The Survey Process
 Objectives:
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1. External validation of standards compliance
2. System analysis to identify
strengths/vulnerabilities
3. Education of staff/leaders to enhance partnership
with organization
1. Methodology for assessing standards compliance:
individual tracer methodology and system tracer
methodology
2. User friendly process with participation encouraged by
all
3. Focus is on systems, not on individual
4. Risk Standards
5. Onsite activity influenced by Prior TJC Reports, ICM
Profile and Client Value Assessment Tool (NEW! –
used to have Priority Focus Areas and Clinical
Service Groups)
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Key Elements of the Survey Process
Risk Icon
Risk
• Proximity to patient
• Probability of harm
• Severity of harm
• Number of patients at risk
 Integrated into the Manuals, E-dition, AMP, & FSA Tool
 All products will display a single icon at the EP level
for three risk-focused categories:
1. National Patient Safety Goals
2. Accreditation program-specific risk area standards
3. Selected direct/indirect impact standards
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 In addition, the FSA Tool will use the R icon to identify
the fourth risk category:
4. RFI standards from current cycle survey events.
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ICM Profile
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ICM Profile
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ICM Profile
Client Value Assessment Tool
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 Onsite visit activities and findings add value to
improving the quality of health care.
 The Joint Commission demonstrates a collaborative
approach during interactions with my organization.
 Surveyors demonstrated professionalism.
 Surveyors address patient safety and quality of care.
 Accreditation standards reflect current practice and
science.
 You use a JCR consultant as a part of your
program for continuous accreditation
readiness. During the course of the
consultation, you realize that the consultant is
a friend of several TJC surveyors. You become
concerned that information about your
organization will be relayed to these surveyors.
Does the survey team have access to JCR
reports about an organization? What should
you do?
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Question for thought…
 Effective October 1, 2009, a minimum number
of records must be reviewed during the
course of the survey. This number is based on
the hospital’s average daily census.
 10% of average daily census OR
 30 records OR
 20 records where ADC < 20
Your last ADC was: XX Is this correct?
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Chart Review Process
Report Changes
 Statement of Conditions
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– The number of open PFIs will be referenced in
preliminary report on site; the final report ten days
later will have all open PFIs listed with completion
dates.
– All PFIs should be related to Life Safety chapter.
Report Changes
 Statement of Conditions
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– If open PFIs are not resolved within 6 months post
the completion date, the standards interpretation
group engineers will get a notice and will call the
organization to follow up and determine if the delay
is warranted.
– The possibility of an onsite revisit exists if deemed
necessary.
 There will be a new section on the report
called:
“Opportunities for Improvement”
 This section will consist of any “C” category
element of performance with only one
observation.
 There is no requirement to submit an ESC for
any findings in this section.
 No clarification
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Report Changes
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Accreditation Decision Changes
Revisions – Accreditation/Certification
Decision Rules – All Programs
 Contingent Accreditation now includes the failure
to successfully address all Requirements for
Improvement (RFIs) in submitting an Evidence of
Standards Compliance (ESC) or Measure of
Success (MOS). 1/2014
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 The Accreditation Committee will determine if the
organization’s corrective action is sufficient to
change the decision from Preliminary Denial of
Accreditation (PDA) to Contingent Accreditation.
1/2014
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Systemic patterns, trends and repeat findings
Possible fraud
Failure to address RFIs in 45/60 days
Failed onsite ESC
Failure to meet timely submission of
data/information
Condition level deficiency
Failed MOS
Scope of practice/licensure issues
Failure to make sufficient progress (e-SOC) or
failed to implement interim life safety measures
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Accredited/Certified
with Follow-Up Survey – Examples
 Successfully abated an immediate threat to life
situation
 Fails to successfully address all requirements of
the AFS decision
 Shows some evidence of engaging in possible
fraud or abuse
 Demonstrates patterns or trends of noncompliance
at an initial survey
 Is not recommended for certification by the CMS
after undergoing its first Joint Commission survey
for deemed status or Medicare recognition
purposes
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Contingent Accreditation/Certification –
Examples
Preliminary Denial of Accreditation –
Examples
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 an ITL or health for patients or the public;
 submission of falsified documents or
misrepresented information
 lack of a required license or similar issue
 failure to resolve the requirements of a
Contingent Accreditation status
 significant noncompliance with Joint
Commission standards
ICM/FSA Goals
 Identify risk and proactively manage risk to
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– Focus activities on identifying risk points in health care
organizations
– Manage risk throughout the accreditation cycle
– Provide health care organizations with tools/
resources/solutions for addressing their risk points
Some things to consider…
– Did you identify the issues the survey team found
during your last two ICMs? If you did, why didn’t your
plan of correction stick?
– When you completed the ICM did you really look at
your organization’s compliance with the standards or
did you complete it based on what you think your
compliance is?
– Have you accessed the tools that can be found in the
ICM and utilize them?
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 How do you use the Intracycle Monitoring (ICM)
process?
 Do you have a team approach or is one person
responsible?
 Do you do what you need to do to “make it go away” or are
the issues analyzed to determine why the non compliance
is present?
 Do you use this standard ESC response: “We have reeducated the “Fill In The Blank”?”
 Have you looked at patient safety events and near
misses/close calls in relation to non compliance identified
during your survey?
 Have you considered what the short term and long term
impact will be if you are unsuccessful in correcting the
RFIs?
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What is your approach to ESC?
 Do you develop generic ESC or are your ESC specific to
the root causes of the RFIs?
 Does the safety culture in your organization encourage
staff and medical staff to identify system and process
problems so they can be addressed quickly or do you wait
until something happens or a surveyor finds it?
 When you develop your ESC do you find a way to
incorporate it into daily activities and processes or do you
lay it on top of everything else staff have to do?
 Is the culture in your organization one that allows the
importance of the ESC to fade after a few months or is
patient safety and compliance embedded in your
mission/vision?
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What is your approach to ESC?
Bottom Line!
If you don’t address the
issues the first time you will
be continually doing rework
and patient safety and
quality suffer!
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What is your approach to ESC?
Survey Process Tips
(From a former surveyor)
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Individual Tracers, System Tracers,
2nd Generation Tracers
Surveyor Planning Session
 Conference Room Tips
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– Access to Quality Department Staff: either phone or
proximity
– Internet access will be via Verizon air card if wifi not
an option
– Check connectivity with an air card if available prior
to survey. If a room traditionally has poor
connectivity, probably better to find another room if
available.
Surveyor Planning Session
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 Binder with pertinent information to get survey
team started.
 In addition to standard information (org. chart,
etc.), it would be helpful to have a list of
acronyms (esp. any new ones) that survey
team might encounter.
 As documents are available, please take them
in
Surveyor Planning Session
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 If there are specific individuals responsible for
specific service lines, it is helpful to have those
individuals meet with the surveyors ASAP.
This includes if there is one individual
responsible for ambulatory sites.
 When providing the patient census, it is
important to include diagnosis, admission date,
and age of patient.
Opening Conference
 OK to use a Powerpoint to give a brief
presentation (no more than 15 minutes) about
the organization.
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 Always helpful to give the team any recent
changes or issues that have occurred within
the organization.
Individual Tracers
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 The most helpful “adult supervision” is a scribe
and a guide. If more individuals are with the
surveyors, it tends to become disruptive to the
units
 Important to let your staff shine; managers
should refrain from “rescuing” them
 Typically done as an adjunct to an individual
tracer: such as Cleaning, Disinfection, and
Sterilization second generation tracer starts
during the first OR tracer. Then continues
wherever the processes occur.
 Can be handed off to another surveyor
 Other second generation tracers: OPPE/FPPE,
Dietary, Patient Flow, etc…
 Risk Areas in ICM
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Second Generation Tracers
Special Issue Resolution
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 If you are getting two or more “messages” from
the members of the survey team
OR
 If the survey team is getting two or more
messages from your staff.
Daily Briefing
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 Observations relayed with applicable
standards and EP’s
 Just because it is discussed and is currently in
the report doesn’t mean it stays there
 IOU’s are documents or clarifications we have
asked for but not yet received
 The surveyor who facilitates this will discuss
during opening conference
 The required data elements will be reviewed in
documents provided
 Survey teams now looking for how the
organization looks at risk proactively and how
they use data to do so
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Data Use System Tracer
Data Use System Tracer
 This session is designed to look at
performance improvement organization-wide;
the more recent the example, the better
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 It is helpful to have front line staff available
during this session.
Data Use System Tracer
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 Does not include medication management or
infection control data review as this is covered
in separate system tracers (except in small
organizations)
Medication Management System
Tracer
 This session is made up of a didactic session
and a “walk around” session
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 Sometimes the “walk around” happens prior to
the session and sometimes during the session
Medication Management System
Tracer
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 This session’s purpose is to review how the
organization identifies risk in its own processes
and how it responds to it
 It is very helpful if front line staff are available
as well as the representatives from nutrition
services and respiratory therapy
Infection Control System Tracer
 Infection control plans including risks, goals,
and evaluations for the three years since the
last survey should be available to review prior
to the session
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 Usually only the core group responsible for
infection prevention is asked to attend
Infection Control System Tracer
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 This tracer is also designed to be part didactic
and part an individual tracer done on the unit
with a patient currently in some type of
infectious disease precaution
HR/Competency Review
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 Files can be reviewed electronically, you
should not be asked to print them out
 Need to review HR file, education file,
competency file, and employee health
file…however, some of this is accomplished
during individual tracer activity.
HR/Competency Review
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 Usually looking at files with HR director and a
couple of key resource people. The last half of
the session is with managers to discuss the
competency assessment portion in more
general terms
Medical Staff Credentials Session
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 Review of credentials files to include actual file
with primary source verification, etc.; employee
health (if employed); FPPE and OPPE data
 It seems to flow better when it is all done at the
same time, however, can be divided based on
physician leaders’ availability to discuss
process.
Environment of Care Session
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 Should have all of the seven management
plans and the annual evaluations of them
available for review prior to this session. All of
the years since your last survey should be
included.
 Often done by LSCS, but can be another
surveyor
Environment of Care Session
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 Attendees are the individuals who are
responsible for each of the plans and can
speak to their implementation across the
organization.
 Discussion about environment of care rounds
and the composition of the team that performs
them
Emergency Management Session
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 The focus of this session is primarily focused
on the concepts of preparation and mitigation
 HVA will be reviewed by the facilitating
surveyor prior to the session. If there are
distant sites, need an HVA for all of them
 Also can be LSCS or other surveyor
 The focus of this session is to review how the
organization functions from the top down;
board members welcome and encouraged to
attend, even if only by phone, but not
required.
 The process by which the senior leadership of
the organization can be made aware of
patient or staff safety concerns and their
response.
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Leadership Session
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CMS Update
 Hospital Program deeming authority renewed
for six years
 Some editorial language changes in the clinical
standards required by CMS
 Can be found in the CAMH update and the
E-dition
 Can also be found in the June 2014
Perspectives
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Standards Revisions Related to
Medicare Deeming Authority
 HR.01.01.01—qualified dietician on full-time,
part-time or consultative basis
 HR.01.02.01—reference to Note 3 regarding
the qualifications of staff in accordance with
national standards of practice
 LD.01.03.01—governing body responsible for
making sure PI activities reflect complexity of
organization, involve all departments and
services including those provided by contract
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Clinical Standards Changes
 MM.03.01.01—maintain records of receipt and
disposition of radiopharmaceuticals
 MS.03.01.03—patients admitted only on decision of
licensed independent practitioner permitted by state to
admit patients
 MS.06.01.05—surgical services maintains current
roster listing each practitioner’s surgical privileges
(can be paper or electronic)
 NR.02.03.01—an RN assigns nursing care for each
patient to other nursing personnel according to patient
needs and qualifications and competency of staff
available
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Clinical Standards Changes
 PC.01.02.03—added discharge planning needs to the
reasons for reassessment in the Note
 PC.02.01.01—RN supervises and evaluates the
nursing care for each patient
 PC.03.01.01—who can administer anesthesia,
clarified that anesthesiologist who supervises the
anesthesiologist’s assistant is immediately available if
needed
 PC.04.01.01—clarified that the list of home care
agencies that is included in the discharge plan
requested to be on the list
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Clinical Standards Changes
 RC.02.01.01—clarified that the medical record
needs to include any complications and
hospital-acquired infections
 RI.01.01.01—added a note that each patient,
or his/her family is informed of patient rights in
advance of furnishing or discontinuing patient
care whenever possible
 RI.01.02.01—added family to those the
patient wants notified of his or her admission
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Clinical Standards Changes
Other CMS Standards Changes Related to
Efficiency, Transparency, and Burden Reduction
Part II
– They address:
• Practitioners not on MS who order outpatient
services
• MS structure in multihospital systems
• Addition of several requirements for hospitals
with swing beds which allows the swing beds to
be surveyed by Joint Commission as part of
deemed status surveys
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 Effective September 29, 2014
 PC.02.01.03: Note added that allows for practitioners
not on the MS to order outpatient services as long as
they meet criteria: responsible for patient, licensed in
that state, acting within scope of license, authorized
according to state law and organization policy to order
those services
 MS.01.01.01 and MS.01.01.05: Changes at several
EPs address the need to ensure that each facility’s
MS has a vote in the decision to unify, that unique
circumstances and concerns of each facility MS are
considered and localized issues are addressed.
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Other CMS Standards Changes Related to
Efficiency, Transparency, and Burden Reduction
Part II
NEW! – September 2014
 For hospitals that use Joint Commission accreditation
for deemed status purposes: When a multihospital
system has a unified and integrated medical staff, the
bylaws describe the process by which medical staff
members at each separately accredited hospital (that
is, all medical staff members who hold privileges to
practice at that specific hospital) are advised of their
right to opt out of the unified and integrated medical
staff structure after a majority vote by the members to
maintain a separate and distinct medical staff for their
respective hospital.
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 MS.01.01.01 EP 37
NEW! – September 2014
 MS.01.01.05
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For hospitals that use Joint Commission
accreditation for deemed status purposes:
Multihospital systems can choose to establish
a unified and integrated medical staff in
accordance with state and local laws.
Other CMS Standards Changes Related to
Efficiency, Transparency, and Burden Reduction
Part II
– HR.01.02.01 defines qualifications for various roles
– HR.01.02.05 verifies qualifications
– LD.04.02.03 ethical business practices re: charges and
notification of charges
– PC.02.02.01 coordination of care
– PC.02.02.09 residents participate in social and recreational
activities according to abilities and interests
– PC.04.01.03 notice regarding discharge
– PC.04.01.07 meeting criteria prior to transfer or discharge
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 The addition of swing bed requirements appear in the
following standards:
Other CMS Standards Changes Related to
Efficiency, Transparency, and Burden Reduction
Part II
– RC.02.04.01 required documentation of patient’s discharge
information
– RI.01.06.05 resident’s right to environment that preserves dignity
and contributes to positive self-image
– RI.01.06.09 resident’s right to choose medical, dental and other
licensed independent practitioner care providers
– RI.01.06.11 resident’s right to communicate with those chosen
providers
– RI.01.07.05 resident’s right to receive and restrict visitors
– RI.01.07.07 hospital protects rights of residents who work for or on
behalf of hospital
– RI.01.07.13 resident’s right to transportation
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 The addition of swing bed requirements appear in the
following standards (cont):
 Several changes discussed in September 2014
Perspectives; update coming in February 2015
Perspectives with a link to a scorecard
 Will discuss top challenging standards in next
session
 Ultimate decision on equivalencies will be at CMS
regional office, posted in eSOC in History Audit
Trail surveyor will review when on site.
 Don’t have to apply for categorical waiver use;
must let LSCS know when survey team arrives on
site
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Environment of Care Standards
Diagnostic Imaging
– EC.02.01.01; EC.02.02.01; EC.02.04.01;
EC.02.04.03; EC.02.06.05;
– HR.01.02.05; HR.01.05.03
– MM.06.01.01
– PC.01.02.15; PC.01.03.01
– PI.01.01.01; PI.02.01.01
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 Can be found on www.jointcommission.org
prepublication standards section
 The new EPs can be found in the following
chapters:
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Questions?
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Leadership
(LD)
 Organizational structure to support
mission/vision
 Organizational relationships, communication
and conflict management
 Promoting a culture of safety
 Availability of resources to provide care,
treatment, services
 Competence of staff and other caregivers
 Evaluation and improvement of performance
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Leadership (LD)
LD.03.01.01–LD.03.06.01
Culture of Safety
 Regular evaluation of the culture of safety
 Process for managing behaviors that
R
undermine a culture of safety
R
 Effective communication
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 Leaders use data to guide decisions
 2nd Generation Tracer
 Clinical leaders and medical staff have input as to
source for outsourced services
 Written description of scope and nature of
outsourced services in contract
 Expectations for performance provided by hospital
according to defined measures provided to provider
 Performance is monitored
 Steps taken to correct identified performance
problems
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Contracted Services
LD.04.03.09
Process of Developing Contracts
Contract
Development
Continue to Monitor
Administration
Clinical Experts
Medical Staff
Risk Management
Legal
Representatives
Move to Corrective
Action if Indicators
Are Not Being Met
Increasing Monitoring
Provide consultation or training
Renegotiate the contract terms
Apply defined penalties
Terminate the contract
Clinical Indicators
Identified and
Included in Contract,
Identify Who Will
Have Specific
Contract Oversight,
Determine Indicator
Reporting Schedule
Monitor Indicator
Reports,
Seek Clarification
as Needed
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Team Input
Monitoring Contract Quality
Direct observation
Audit of documentation
Review of incident reports
Review of periodic reports
Input from staff and patients
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Collection of data
 Clinical Contracts are not formally approved by
designated leaders
 The nature and scope of service is unclear
 Lack of documentation of monitoring of
performance outcomes
 Contracts do not contain defined performance
metrics
 Unclear steps taken to improve performance
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Typical Findings
Tips
 Create a table that identifies key elements
necessary in every contract
Contract Management
Name of
Contract
Exp date Org Owner Contract Indicators
of
Contact and Due
Contract
Dates
Indicators
due to
this
individual
or area
Comment
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Date
Patient Flow – Not Just ED
Inpatient
Bed
Assignment
Surgery
Procedural
Areas
ED
Patient
Registration
Lab
Diagnostic
Imaging
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Inpatient
Discharge
LD.04.03.11 EP 5
Create Hospital-wide Patient Flow Team
COO, VP
Nursing,
CMO, Chief
Emergency
Medicine
ED
Chief EM, Director ED, IS,
Clinical Manager, Quality
Manager, CNS, Business
Analyst, Asst Medical Director
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Inpatient
VP Nursing, CMO, Nursing Director,
Nurse Manager, Housekeeping
Supervisor, Admitting Director,
Inpatient Attending, Inpatient
Medical Director, Director of
Patient Access Services
 Identify key inpatient units and support services to
include in patient flow improvement effort
– Limit # units included to keep efforts focused
 Develop key input, throughput, and output measures
– Identify existing data collection
 Populate spreadsheet with current performance data
– Use monthly data points
 Review draft scorecard with individual unit leaders to
solicit feedback
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LD.04.03.11 EP 5
Creating an Overall Flow Scorecard
LD.04.03.11 EP 5
Creating an Overall Flow Scorecard
– available supply of patient beds
– throughput of areas where patients receive care
(inpatient units, lab, OR, telemetry, radiology, &
PACU)
– safety of areas where patients receive care,
treatment and services
– efficiency of non-clinical services that support
patient care (e.g. housekeeping and transportation)
– access to support services (such as case
management & social work)
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 Example Data Points/Elements:
Metric
Goal
Actual
Average occupancy rate
88%
82%
ICU occupancy rate
94%
98%
Telemetry occupancy rate
90%
99%
Medical/Surgical occupancy rate
86%
73%
ED Overcapacity: time patients exceeded
treatment spaces/24 hours
Planned admissions/Available bed ratio
0
3.2
≤ 1.0
1.2
Off-service placements
10%
18%
87
© Joint Commission Resources
Available Supply of Beds
Metric
Goal
Actual
Median time: arrival to bed placement
≤ 5 min
8 min
Median time: arrival to first seen by provider
≤ 25 min
65 min
Disposition decision to departure (discharged
patients)
≤ 10 min
20 min
Disposition decision to departure (admitted
patients)
≤ 60 min
96 min
Median visit time all patients
≤ 1.8
3.2 hours
Median visit time discharged patients
≤ 60 min
100 min
Median visit time admitted patients
3.2 hours 5.2 hours
Median visit time per triage severity
classification
XX
XX
88
© Joint Commission Resources
Throughput Where Patients Receive
Care, Treatment and Services - ED
Metric
Goal
Actual
Average Length of Stay (ALOS)
≤ 3.2 days
3.6 days
Expected LOS to Actual LOS
≤ 1.0
1.12
Predicted discharge accuracy (predicted vs. actual
date)
≥ 40%
32%
OR time surgery end to patient transferred from room
≤ 10 min
14 min
OR time room vacated to time available for next case
≤ 18 min
22 min
PACU: meets Aldrete score for discharge from PACU
to depart PACU (admission and/or discharge)
≤ 15 min
32 min
Telemetry: delays from initial order to available
0 min
60 min
ICU: order to transfer out to departure from ICU
60 min
122 min
Direct admission: arrival to in bed time
≤ 15 min
25 min
89
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Throughput Where Patients Receive
Care, Treatment and Services - Other
Metric
Goal
Actual
Radiology: mean time initial order to completion chest
x-ray (ED, inpatient routine, stat)
xx
xx
Radiology: turnaround time chest x-ray complete to
results available (ED, inpatient routine, stat)
xx
xx
CT: initial order to results reported (intracranial bleed,
pulmonary embolism)
≤ 45 min
32 min
Lab: turnaround time initial order to results available
(ED, inpatient, stat) e.g. troponin, H&H, potassium,
BS
xx
xx
OP Physician Clinic: next available appointment (ED
discharge)
≤ 3 days
4 days
OP Thoracentesis: initial order to completion
≤ 3 days
3 days
90
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Throughput Where Patients Receive
Care, Treatment and Services - Other
Metric
Goal
Actual
Left prior to completion of treatment
≤ 1.5 %
6.8 %
- Left without being seen (LWBS)
≤2%
8.5 %
- Left against medical advice (AMA)
≤1%
4%
Time of initial medication order to time of medication
administration
≤ 10 min
21 min
Arrival to heart treatment (thrombolytic or vessel
opened)
≤ 30 min
36 min
Arrival to first pain intervention for long bone fracture
– ice, medication, reduction
≤ 10 min
16 min
91
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Safety of Areas Where Patients Receive
Care, Treatment & Services - ED
Safety of Areas Where Patients Receive
Care, Treatment & Services - Other
Metric
Goal
Actual
Falls (IP, OP, radiology, perioperative)
Medication errors
Elopements
Admission assessment completion time:
inpatients, boarded patients
Admission medication reconciliation time from
decision to admit: inpatients, boarded patients
92
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Admission orders received time from decision to
admit: inpatients, boarded patients
Metric
Goal
Actual
Transportation: time of request to response
(admission, discharge, inter-department)
xx
xx
Transportation # requests/needs during hours not
available/24 hours
0
26
Environmental Services: inpatient
discharged/transferred to department notified
≤ 7 min
13 min
Environmental Services: department notified to
inpatient bed clean and available
≤ 30 min
38
93
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Efficiency of Non-Clinical Services
that Support Care & Treatment
Metric
Goal
Actual
Care manager/Social worker total monthly hours
worked/discharged patient
xx
xx
Hours/week without onsite care manager and/or social
worker
≤ 72
88
# Episodes social worker needed for ED patient
continuum of care and not available/month
≤1
3
ED patients placed in observation until home care
services could be arranged
≤1
5
94
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Access to Support Services
Boarded Patients – BHC
 Location (soothing, supportive, promote
healing)
95
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– Alternative area crisis stabilization observation unit
(24-48 hours) – determine if patient meets medical
necessity for inpatient admission
– Space within ED designed or converted to eliminate
environmental safety risks and promote care and
treatment
Boarded Patients – BHC
 Staffing
ED or staff psychiatrist
Psychiatric APN
Dedicated BHC staff
Dedicated ED staff with special training
Social worker
Counselor
96
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–
–
–
–
–
–
Boarded Patients – BHC
–
–
–
–
–
–
–
–
–
Physicians, nurses, non-clinical staff
Initial & on-going continuing education
Psychiatric triage system
De-escalation, negotiation techniques
Psychiatric diagnoses
Psychiatric medications
Restraints & seclusion
Suicidal, homicidal risk assessments & precautions
Medical clearance exam & checklist
97
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 Education & Training
R
 Processes to support flow of patients
 Plans for care in temporary locations and overflow
locations
 Criteria guide diversion
 Measures and sets goals for components of flow
process: beds, efficiencies, safety access to
support services
 Data provided to management
 Data reported to leaders
 Data guides improvements
98
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LD.04.03.11 Patient Flow
(Second Generation Tracer)
Patient Flow LD.04.03.11
– Measures and sets goals for mitigating and
managing boarding of patients through the ED
(recommended 4 Hours) (effective January 2014)
– Review to determine if goals were achieved
– Take action when goals not achieved
– Leadership communication with behavioral health
providers and authorities to enhance coordination of
care.(effective January 2014)
99
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 LD.04.03.11 Revisions address the
following:
The staff are holding their morning huddle to review
patient placement. The ED is full and four patients
have been waiting since the previous evening for
beds. One of the four is very unstable.
The charge nurse from the PACU states that the
patients can be boarded as long as the patients are
not behavior health patients and the PACU patients
can take priority for placement. She adds that the
behavior health patients are the only patients who
cannot be boarded.
100
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Scenario: True or False?
LD 04.04.01 Priorities for PI
 Leaders set priorities for PI
 PI is hospital-wide
– Review of annual EM planning reviews
– Review of evaluations of emergency exercises and
responses to actual emergencies
– Determine which improvements are priorities for
implementation
New 2014
101
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 EP 25 Senior leaders direct PI in EM based on:
 Hospital-wide program R
 One or more individuals manage program R
 Scope of program includes full range of safety
issues R
 All departments, programs, and services
participate R
 Hospital creates procedures for responding to
system failures R
 Encourages use of blame-free reporting R
102
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LD.04.04.05
Patient Safety Program
LD.04.04.05
Patient Safety Program
103
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 Defines sentinel event and communicates R
 Conducts credible Root Cause Analysis (RCA)
Support systems for staff R
 Proactive risk assessment every 18 months R
 Analyzes information about failures R
 Disseminates lessons learned to staff R
LD.04.04.05
Patient Safety Program
– All system or process failures
– The number and type of sentinel events
– Whether the patients and the families were informed of
the event
– All actions taken to improve safety, both proactively and
in response to actual occurrences
– a determined number of distinct improvement projects to
be conducted annually
– All results of the analyses related to the adequacy of
staffing
104
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 Provides governance written reports annually,
including:
Testing the Audience…
True or False:
105
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Effective January 2014, Emergency Departments
will only be allowed to board patients up to 4
hours.
106
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Patient Safety Puzzle
Complicated
107
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 Containing intricately combined or involved
parts
Complicated
108
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 Containing intricately combined or involved
parts
Complex
 Containing many interactive elements or parts
that can influence or be incorporated into the
process or action
 Non-linear
 Chaotic behavior
– Relocating a service or individual
 Fat-tailed behavior
 Adaptive behavior
– Work-arounds
109
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– Rounding values up or down especially in series
110
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Complex Adaptive Systems (CAS)
111
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Complex Adaptive Systems (CAS)
Patient Safety
112
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Prevention of
errors and adverse events
to patients
that are associated with health care.
Patient Safety Systems
Assist health care
organizations to
improve quality and
patient safety
processes
Encourage
proactive methods
and strategy to
build culture of
patient safety
Guiding Principles for Patient Safety Systems
113
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Align Joint
Commission
standards with daily
work to promote
patient safety
Patient Safety Systems
114
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 New Chapter
 No new or additional standards or elements of
performance
 Scored in the chapter of their origin
 Focus on integration to create High Reliability
Organizations (HRO)
Strategies to Patient Safety
Reduce
variation
Reduce
risk
115
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Improve
quality
An Integrated Approach to
Patient Safety
Create a Safety Culture
Validated methods to improve processes
Safely integrated technologies
116
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Standardized ways for interdisciplinary
teams to communicate and collaborate
Staff and Leaders
Eliminate complacency
Treat each other with respect and
compassion
Promote collective mindfulness
117
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Learn from patient safety events and close
calls
 Promoting learning
 Motivating staff to uphold a fair and just safety
culture
 Providing a transparent environment
 Modeling professional behavior
 Removing intimidating behavior
 Providing resources and training necessary to
move to improvement initiatives.
118
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Role of Hospital Leaders
Qualities that Support a
Culture of Safety
Collective
Mindfulness
Transparency
accountability
mutual respect
Behavior to
support culture
of patient safety
First priority
Patient Safety
Culture of Safety
119
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Strong
patterns of
error
reporting
Learning
from patient
safety
errors
Data Use
Identify problems
Prioritize issues
120
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Developing solutions
Analyze Data
Variation within a system
Determine if process will
function as expected
according to specifications
121
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Identify variation within a
system and find indicators of
why variation occurred
Using Data to Drive Improvement
Information is shared
Time, resources, and
opportunities needed
for improvement are
provided
Opportunities for
improvement are
clearly articulated
Improvements are
recognized
122
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Presented in a clear
manner
Proactive Risk Reduction
Identification of actionable common
causes
Avoidance of unintended
consequences
Identification of system solutions
123
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Identification of commonalities
across departments/services/units
Proactive Risk Reduction
 An analysis of the related systems and
processes
– Preconditions
– Supervisory influences
– Organizational influences
124
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 Required by standards at least every 18
months
Encouraging Patient Activation
Patients and families
Partnerships
Disclosure to patient or family of
unanticipated outcomes
125
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Patient and family centered care
verifiable and rewarded
Encouraging Patient Activation
Disclose harm, express sympathy and apologize
(suggested)
Sufficient staffing levels
Staff have necessary tools and skills
Staff and LIPs fully engaged in patient- and familycentered care
126
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Focus on measurement, learning, and
improvement
127
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Patient Safety Puzzle
© Joint Commission Resources
128
129
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Rights and Responsibilities
of the Individual
(RI)
Rights and Responsibilities(RI)
Informing patient of their rights
Helping patients understand their rights
Respecting patient values, beliefs, preferences
Informing patients of their responsibilities
Communicating right to effective
communication, participation in care decisions,
informed consent, end of life care decisions
131
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




RI.01.03.01
Consents R
Written policy
Identifies services that require consent
Describes exceptions
Describes process
Describes documentation
Identifies when surrogate consents
Process includes discussion about care, 3
treatment, and, services
3
 Includes discussion of potential benefits, risks,
side effects, likelihood of achieving goals and
potential problems
132
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






RI.01.03.01
Consents (cont’d)
R
133
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 Includes discussion of alternatives to care
treatment and services and those risks
benefits and side effects of alternatives and
risks of not receiving care treatment and
services 3
 Discussion of circumstances of disclosing
patient information
RI.01.03.01
Consents (and RC.02.01.01, EP 4)
R
134
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 Note: The properly executed informed consent is
placed in the patient’s medical record prior to surgery,
except in emergencies. A properly executed
informed consent contains documentation of a
patient’s mutual understanding of and agreement
for care, treatment, or services through written
signature, electronic signature, or, when a patient
is unable to provide a signature, documentation of
the verbal agreement by the patient or surrogate
decision maker.
RI.01.05.01 Decisions
About End of Life Care
R
LIP/staff are aware of advance directive
Honor right to formulate or revise advance directive
Hospital honors advance directives (law/regulation) 3
Document patient’s wishes regarding organ donation
Hospital honors patient’s wishes concerning organ
donation
 Existence or lack of AD does not determine the
patient’s right to access, care, treatment, and service
 The hospital defines how it obtains and documents
permission to perform an autopsy*
*Effective January 1, 2010
135
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



136
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Patient-Provider
Communication Standards
Patient-Provider
Communication Standards
 RI.1.01.01 EP 2—expands the informing
patient requirement
– Visitation rights include the right to receive the
visitors designated by the patient, including, but not
limited to, a spouse, a domestic partner (including a
same-sex domestic partner), another family
member, or a friend.
137
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– Note: The hospital informs the patient (or support
person, where appropriate) of his or her visitation
rights.
Patient-Provider
Communication Standards
138
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 Addresses:
– Patient access to chosen support individual
(RI.01.01.01 EP 28)
• Allowed to be present with the patient for
emotional support during course of stay
–Unless the presence infringes on rights
of others or is medically or
therapeutically contraindicated
Patient-Provider
Communication Standards
139
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– Non-discrimination in patient care
(RI.01.01.01 EP 29)
• Prohibited based on age, race, ethnicity,
religion, culture, language, physical or
mental disability, socioeconomic status,
sex, sexual orientation, and gender
identity or expression
 RI.01.01.03 EPs 2
– Providing language services
• Can include:
–Hospital employed language
interpreters
–Contract interpreters
–Trained bilingual staff
–May be provided in person or via
telephone or video
140
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Patient-Provider
Communication Standards
 HR.01.02.01 EP 1
– Qualifications for language interpreters
• Can be met through language proficiency
assessment, education, training and
experience
 RI.01.01.03 EP 3
– Identifying patient communication needs
• Includes need for personal devices such
as hearing aids or glasses, language
interpreters, communication boards, etc.
141
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Patient-Provider
Communication Standards
Patient-Provider
Communication Standards
142
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 PC.02.01.21 EPs 1 and 2, RI.01.01.03 EP 2
– Providing language services
• The hospital determines which translated
documents and languages are needed
based on its patient population
Question for thought?
The physician comes to the ED treatment room
to do informed consent for surgery. The family
says, “Dad only understands Spanish but you
can explain it to us and we will sign for him.”
143
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What should the physician and staff do?
143
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Human Resources
(HR)
Human Resources
 HR.01.02.05 EP 1
– Primary Source Verification
• License
• Certification
• Registration
144
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 At time of hire and prior to expirations
 HR.01.02.05 EP 7
 Before providing care, treatment, and services,
the hospital confirms that nonemployees 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.
145
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Human Resources
Human Resources
146
© Joint Commission Resources
 HR.01.02.07
– EP 1 License (Situational Decision
Rule)
– EP 2 Scope of Practice (Situational
Decision Rule)
Human Resources
147
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 HR.01.04.01 EP 4
– Their specific job duties, including those
related to infection prevention and control
and assessing and managing pain.
Completion of this orientation is
documented.
148
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Questions?
ENVIRONMENT OF CARE
(EC)
149
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LIFE SAFETY
(LS)
Environment of Care (EC)
 Promoting a safe, functional and supportive environment
 Safety of building or space to protect patients, staff, visitors
 Equipment
 People who minimize risks-staff competence
 5 written plans to manage risks
 Qualified individual to manage and monitor environmental
risks
 Time frames to ensure compliance and safety
150
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 Leased space
 Individual to manage the EC program
 Individual to intervene when environmental conditions
immediate threat to life, health, and property
 Written plan with six components:
R
1. *Environmental safety
2. *Security
3. *Hazardous materials and waste R
4. *Fire safety
R
5. Medical Equipment
6. *Utilities
R
151
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EC.01.01.01 Plans
EC.02.01.01
Managing Safety and Security
 Identifies safety and security risks
 Take action to minimize risks
3
R
 Maintains grounds and equipment
 Identifies individuals
 Controls access to security sensitive areas
3
R
 Written procedures in the event of a security incident
3
 Product notices and recalls
152
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 Follows its identified procedures
EC.02.01.01: Typical Findings
 Lack of key control to sensitive areas
 No clear policy of determining staffs need for certain
levels of access
 Identified risks not followed through or identified
 Policy for making and limiting/collecting keys not
153
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implemented
EC.02.02.01
Labeling Hazardous Materials
 Written inventory of hazardous materials and waste
 Written procedures for response to spills
3
R
 Minimizes risks with handling radioactives
3
 Minimizes risks with using hazardous energy sources
R
3
154
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 Implements procedures
EC.02.02.01
Labeling Hazardous Materials
 Written inventory of hazardous materials and waste
 Written procedures for response to spills
3
R
 Minimizes risks with handling radioactives
3
 Minimizes risks with using hazardous energy sources
R
3
Top Standards Compliance Issue for 2013
155
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 Implements procedures
EC.02.02.01
Labeling Hazardous Materials
 Minimizes risks with med disposal
3
 Minimizes risks with gas disposal
 Has permits, licenses, manifest, and MSDS
3
R
156
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 Monitors levels of gases for safe range
EC.02.02.01
Hazardous Material and Waste
 EP’s 3 – 5: Personal Protective Equipment and the
process to manage hazardous materials and waste
handling and exposures
 EP’s 6 – 7: Hazardous energy sources
157
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– Escorts to Hot Lab based on organization policy
• Perspectives, July 2012
EC.02.03.01
Managing Fire Risk
 Minimize potential for harm
3
R
 Minimize fire potential IF patients allowed to smoke
 Maintain free/unobstructed access to all exits
3
3
 Written fire response plan
 Specific roles of staff/licensed independent
practitioners are described in the fire response plan
there are 550-650 surgical fires
158
© Joint Commission Resources
In the United States every year,
EC.02.03.01
Typical Findings
 Fire Safety
– Open junction boxes
– More than 300 cu ft of nonflammable medical gases
(i.e., oxygen) open to the egress corridor
 Fire Plan
159
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– Lack of fire safety training as per fire plan
• Surgical site fires
EC.02.03.05 Maintain Fire Safety Equipment and
Building Features
 List of testing requirements and frequency
 All testing must be documented
 Reference the NFPA 72, 1999 edition
 Tests visual and audible fire alarms annually
 Test fire pumps under pressure annually
160
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 Tests automatic smoke-detection shutdown devices annually
EC.02.03.05 Maintain Fire Safety Equipment and
Building Features
 Documentation of Maintenance, Testing and Inspections for fire
alarm and water-based fire protection systems:
Name of activity
Date of activity
Required frequency of activity
Name and contact information of who performed activity
NFPA standard(s) referenced for activity
Results
161
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–
–
–
–
–
–
Does Every mean Every?
 EC.02.03.05
– EP 13 Every 6 months the hospital inspects any
automatic fire extinguishing systems in a kitchen. The
completion date of the test is documented.
• Every 6 months +/- 20 days
– EP 12 Every 12 months the hospital tests visual and
audible alarms, including speakers. The completion date
of the test is documented.
• Every 12 months +/- 30 days
• Tested within the calendar month
162
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– At least monthly the hospital inspects portable fire
extinguishers. The completion dates of the inspections
are documented.
EC.02.03.05 Typical Findings
 During survey specific documentation is reviewed
 If the documentation for a specific EP is not available a
finding is written as non-compliant for that EP
– The documentation should be readily available
– Also, LD.04.01.05 EP 4 is scored
– Joint Commission Engineers will review and
evaluate compliance
– LD.04.01.05 EP 4 remains
163
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 If the organization clarifies after survey:
EC.02.03.05: Typical Findings
 Organization outsources testing of certain fire safety
features/devices but fails to obtain the documentation
that it was actually performed and the results of the
testing.
 Fire doors not closing properly
 Fire extinguishers not checked monthly
 Failure to ensure fire and smoke dampers fully close
164
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 Failure to test audible fire alarm
EC.02.05.01
Risks with Utility Systems
 Designs and installs utility systems
 Inventory of all systems
 Defines inspection and maintenance activity
 Defines intervals for inspecting
 Ventilation system is appropriate
R
3
 Responds to utility system disruptions
3
3
165
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 Minimizes pathogenic agents in water systems
Maintaining Utilities Equipment
 Inventory is populated based on one of two strategies:
– All equipment inclusion
– Based on physical risks for
• Infection
• Occupant needs
• Systems critical to patient care
 All life support equipment is included
166
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 All new types of equipment is evaluated for inclusion
EC.02.05.01, EP 3
 The hospital identifies, in writing, inspection and
maintenance activities for all operating components of
utility systems on the inventory.
167
© Joint Commission Resources
(See also EC.02.05.05, EPs 3–5; EC.02.05.09, EP 1)
EC.02.05.01, EP 3
 Hospitals may use different approaches to
168
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maintenance. For example, activities such as
 predictive maintenance,
 reliability-centered maintenance,
 interval-based maintenance,
 corrective maintenance,
 metered maintenance
EC.02.05.01, EP 4
 The hospital identifies, in writing, the intervals for
inspecting, testing, and maintaining all operating
components of the utility systems on the inventory, based
on criteria such as
– Manufacturer‘s recommendations
– Risk levels
– Hospital experience
169
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(See also EC.02.05.05, EPs 3–5)
EC.02.05.01
Typical Findings
 EC.02.05.01 EP 1: Improper system design
– Inability of the mechanical system to achieve
required results
 EC.02.05.01 EP 4: Lack of written inspection, testing &
maintaining frequencies
170
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– Continuous monitoring by a building automation
system (BAS) is acceptable
EC.02.05.01
 EC.02.05.01 EP 6: Ventilation system is unable to
provide appropriate pressure relationships, air-exchange
rates and filtration efficiencies
3
R
– Specific areas lack
• negative or positive pressures in relationship to adjacent
areas
– i.e. Endoscopy Processing Room should be negative to the
egress corridor
– MERV = minimum efficiency reporting value
171
© Joint Commission Resources
• the correct number of air changes per hour
• Improper filtration
EC.02.05.03
Emergency Electrical Power Source
 Alarm System
3
 Exit routes and exit sign illumination
3
 Emergency communication systems
3
 Elevators (at least one for non-amb)
3
R
 Areas that could result in patient harm 3
– Operating rooms, recovery rooms, nurseries etc.
172
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 Equipment that may cause patient harm when it fails
– Life-support systems, blood, bone and tissue
storage etc.
EC.02.05.05 Utility Systems
 Tests before use
 Inspects life support utility systems
R
3
 Inspects infection control utility systems
3
R
173
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 Inspects non-life-support utility systems
EC.02.05.07
Emergency Power Systems
 At 30 day intervals, test battery-powered lights
 Every 12 months perform functional test of batterypowered lights or replace all batteries
 Regular testing of emergency generator
3
R
load
3
R
174
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 Regular emergency generator testing with dynamic
EC.02.05.07
Emergency Power Systems
 Monthly testing of automatic transfer switch
3
R
 36 month testing of emergency generator 30%
nameplate rating for 4 continuous hours
3
R
 36 month emergency generator testing with dynamic
load
R
3
failures
3
175
© Joint Commission Resources
 Implement measures in emergency power system
EC.02.05.07: Typical Findings
 Inconsistent generator testing and documentation
 Inconsistent battery powered light checks with limited
documentation
 Missed transfer switches
 Not all transfer switches tested
 Missed Generator & Automatic Transfer Switch (ATS) Tests
 Twelve (12) times per year between 20 & 40 days
 Each emergency generator must be tested with a load of at least
 Each ATS must be tested
176
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30% of nameplate
EC.02.06.01
Safe Functional Environment
 Interior spaces meet needs of patient population
 Space for recreation and social interaction
 Storage space to meet patients’ needs
 Suitable lighting
 Space accommodates the use of equipment
3
 Emergency access to all locked spaces
3
R
 Furnishings and equipment safe and in good repair
177
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 Areas clean and free of offensive odors
EC.02.06.01
 EP 13 The organization maintains ventilation, temperature
services provided
• Ventilation:
– i.e. doors held open by air pressure; odors
• Temperature:
– Hot / Cold calls
• Humidity
– Primary concern is for areas >60% RH mold
growth is possible
– <25% RH static electricity is possible
178
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and humidity levels suitable for the care, treatment and
EC.02.06.01 Typical Findings
 Exposed plumbing (suicide risk)
 Torn carpet (tripping hazard)
 E-cylinders not secure
 Furnishings (bedside table) not working or falling apart
 Patient (unit) lounge being used by staff
makes room cramped
 Wheelchairs with missing parts (feet rests, stop
handles)
179
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 Necessary equipment does not fit in patient room or
EC.02.06.05
Manages Construction
 Hospital uses design criteria
 Conducts preconstruction risk assessment
3
R
180
© Joint Commission Resources
 Takes action to minimize risks during construction
EC.03.01.01 Roles/Responsibilities
 Staff/ licensed independent practitioners
– Can describe/demonstrate methods to
eliminate/minimize physical risks
– Can describe/demonstrate actions to take
– Can describe/demonstrate how to report
181
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• “What is your role if …?”
EC.04.01.01 Collect Data to Monitor
Conditions in the Environment
 Establishes process to monitor
R
 Reports and investigates issues
 Conduct environmental rounds in patient areas
 Conducts rounds in nonpatient areas
months
3
R
182
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 Evaluates each EOC management plan every 12
What Triggers ITL
(Immediate Threat to Life)
 Significantly compromised fire alarm system
 Significantly compromised sprinkler system
 Significantly compromised emergency power supply
system
 Significantly compromised exits
extreme danger
183
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 Other situations that place patients, staff or visitors at
What Triggers ITL
(Immediate Threat to Life)
 PDA01
– An Immediate Threat to Health or Safety exists for
patients or the public within the hospital.
 CONT01
184
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– The Immediate Treat to Health or Safety has been
successfully abated and verified through the direct
observation or other determining method.
Life Safety (LS)
 NFPA Life Safety Code (LSC) Occupancies drive
requirements
– Safe design and building construction
– Egress
– Protection by doors, stairs, corridors, smoke
barriers
– Suppression systems i.e., sprinkler systems
– Building services i.e., elevators, chutes
– Decorations, furnishings, portable heaters
185
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 It’s all about ‘FIRE’ protection
LS.01.01.01 Designs and Manages Physical
Environment
 Assign an individual
– Assess compliance with Life Safety Code®
– Completes statement of conditions (e-SOC)
– Manage resolution of deficiencies
 Maintain current electronic Statement of Conditions (SOC)
 Meet deficiencies within time frame identified on Plan for
Improvement (PFI)
3
R
or local fire control agencies
2
186
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 Maintain documentation of inspections/approvals by state
LS.01.02.01
Interim Life Safety Measures (ILSM)
 Notifies fire dept. if alarm is out of service more than 4
3
R
 Posts signage with location of alternative exits
 Written ILSM policy
2
R
 Inspects areas on daily basis based on ILSM
3
 Provides additional firefighting equipment
3
 Conducts education of safety issue
R
3
 Provides temp fire alarm/detection system
 Trains staff
3
R
3
3
187
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in 24 hours
LS.02.01.10 Building and Fire Protection Features
 Meeting requirements for height and
construction type
3
 Automatic sprinkling systems
3
 Fire rated walls
 Fire rated door requirements
 Ducts and dampers
 Patching penetrations
188
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– Functioning hardware
– Protective plates
– Signage
LS.02.01.10: Typical Findings
 Fire walls altered on the construction plans
 Unapproved PVC material was used to repair sprinkler
system
 Fire rating plate on fire door painted over
189
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 Penetrations patched incorrectly or not at all
LS.02.01.20 Maintains Integrity of Means of Egress
 The hospital maintains the integrity of the means of
egress
– EP 1 Doors unlocked in means of egress
– EP 12 Projections
– EP 13 Corridor Clutter
3
 Also scored
– EPs 16 – 22 Suites issues
– > 5000 square feet
190
© Joint Commission Resources
• Boundaries & Size defined
Corridor Storage
 “If the corridor looks cluttered, it probably is”
 Corridor clutter is not a PFI issue
 Carts Allowed:
– Crash Carts
– Isolation Carts
– Chemo Carts
 The following carts are not allowed:
 Anything in the egress corridor more than 30 minutes
is storage
191
© Joint Commission Resources
– Linen Hampers
– Latex Carts
Corridor Storage
 Dead end corridors may be used for storage
– Less than or equal to 50 sq ft space
 Converting patient room:
192
© Joint Commission Resources
– Long term include door closure
– Facilities team should be aware and approve of
room use
LS.02.01.20: Typical Findings
 Exit doors not clearly marked
 Exit egress obstructed
 Doors to stairwells unable to close—propped open
 Inconsistent signage in stairwells (5 or more stories
193
© Joint Commission Resources
high)
LS.02.01.30 Provides, Maintains Building Features to
Protect Individuals
 25 Elements of Performance
194
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 Fire rating requirements
– Hazardous areas protected by walls and doors
– Gift shop requirements
– Finishing on walls ceilings and floors
– Requirements for corridors
– Smoke compartment requirements
– Smoke barrier/damper requirements
LS.02.01.30: Typical Findings
 Linen chutes (on patient care units) not latching when
the door closed
 Removal of door closure units (to keep door open)
 Storage along walls too high—preventing sprinkler
system effectiveness
 Soiled linen bag pile up preventing chute from closing
 Gift shop displays
195
© Joint Commission Resources
 Inappropriate fire rated walls
LS.02.01.35
 There are 18” or more of open space maintained
below the sprinkler deflector to the top of storage.
196
© Joint Commission Resources
– NOTE: Shelving around perimeter wall OK
NFPA 13-1999, 5-6.6
Perimeter
Shelving
Perimeter
Shelving
18” rule
Ceiling
18”
18”
Wall
OK
Wrong
OK
OK
197
© Joint Commission Resources
Wall
NFPA 101-2012
1. Means of Egress Enhanced
– Patient lift & transport equipment may be stored in
the Means of Egress, provided that:
198
© Joint Commission Resources
• 5 ft clear corridor width is maintained
• Fire plan addresses management of storage
• Accommodates current “equipment in use”
NFPA 101-2012
2. Fixed seating permitted
199
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– provided 6 ft clear width
– < 50 sq ft with 10’ between groupings
• Groupings must be on same side of the egress
corridor
NFPA 101-2012 Corridor Cooking
3. Cooking Facilities
 One cooking area may be open to the egress corridor per
• Any additional cooking areas must be in
protected room similar to hazardous areas
• Provisions:
• No deep fat fryers
• Safety equipment to de-activate fuel supply
• Grease baffles installed
• No solid fuel (i.e. charcoal)
200
© Joint Commission Resources
smoke compartment
NFPA 101-2012 Fireplaces
4. Fireplaces in smoke compartments with patient
sleeping rooms
201
© Joint Commission Resources
– Section 18/19.5.2(2), (3) and (4)
• Allow the installation of direct vent gas fireplaces
• In smoke compartments containing patient
sleeping rooms
• Installation of solid fuel burning fireplaces in
areas other than patient sleeping areas
NFPA 101-2012 Decorations
5. Allow the use of Furnishings, Mattresses, and
Decorations including Section 18/19.7.5
202
© Joint Commission Resources
– Allows the installation of combustible decorations
on
• Walls
• Doors
• Ceilings
– LSC Section 18/19.7.5.6
© Joint Commission Resources
203
204
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National Patient Safety Goals
(NPSG)
None of the NPSGs made the list of the Top 20
most challenging standards…
205
© Joint Commission Resources
Great Job!!
207
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NATIONAL PATIENT SAFETY
GOAL
 More and more devices and alarms
 More patients connected to alarms or alarmbased devices
 150-400+ alarms per patient per day in a
typical critical care unit
 Alarm-based devices are not standardized in
many organizations
 Inconsistent use of alarms due to flexible
alarm setting features
208
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The Alarming Problem
© Joint Commission Resources
209
© Joint Commission Resources
210
 In Phase I (beginning January 2014)
Hospitals will be required to:
– (by 7/14) establish alarms as an organization
priority
– (during 2014) identify the most important alarms to
manage based on their own internal situations.
• Input from medical staff and clinical depts
• Risk to patients due to lack of response,
malfunction
• Are specific alarms needed or contributing to
noise/fatigue
• Potential for patient harm based on internal
incident history
• Published best practices/guidelines
211
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NPSG on Alarm Management
NPSG on Alarm Management
Hospitals will be expected to:
– develop and implement specific components of policies
and procedures that address at minimum:
• Clinically appropriate settings
• When they can be disabled
• When parameters can be changed
• Who can set and who can change parameters and
who can set to “off”
• Monitoring and response expectations
• Checking individual alarm signals for accurate
settings, proper operation and detectability
– educate those in the organization about alarm system
management for which they are responsible
212
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 In Phase II (as of January 2016)
 Have you identified clinical alarm safety as a
priority?
 Who is on the team addressing the NPSG?
 How far along are you in identifying the most
important alarm signals to manage?
 What is your biggest challenge?
 Remember that the entire goal must be fully
implemented by January of 2016!
213
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Questions to Consider
THE TOP 20 ISSUES
214
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2013/2014
CHALLENGING
STANDARDS/
NPSGS
2013 Non
Compliance
EC.02.05.01
LS.02.01.20
EC.02.06.01
47%
52%
39%
2014 Non
Compliance 1st 6
months
53%
52%
51%
EC.02.03.05
IC.02.02.01
45%
46%
50%
50%
LS.02.01.10
48%
49%
RC.01.01.01
LS.02.01.30
LS.02.01.35
EC.02.02.01
52%
45%
36%
34%
49%
46%
44%
36%
© Joint Commission Resources
Standard/NPSG
2013 Non
Compliance
MM.03.01.01
PC.01.03.01
EC.02.05.09
35%
27%
22%
2014 Non
Compliance 1st 6
months
32%
29%
27%
PC.02.01.03
MM.04.01.01
22%
22%
27%
24%
PC.03.01.03
20%
24%
LD.01.03.01
LD.04.01.05
EC.02.05.07
MM.05.01.01
19%
14%
23%
16%
23%
22%
21%
20%
© Joint Commission Resources
Standard/NPSG
 Ventilation system is unable to provide appropriate
pressure relationships, air-exchange rates and
filtration efficiencies
– Specific areas lack
• negative or positive pressures in relationship to
adjacent areas
– i.e. Endoscopy Processing Room should be
negative to the egress corridor
• the correct number of air changes per hour
• Improper filtration
– MERV = minimum efficiency reporting value
217
© Joint Commission Resources
#1 EC.02.05.01 EP 6
(Now EP 15) 53%
 Tissue test: only to be used as a pre-screening tool to
evaluate if further investigation needs to occur
– To perform the flutter test take a tissue and let it hang just
off the floor near the bottom edge of a door
– If the tissue indicates incorrect air flow, stabilize the area
by closing doors and windows, wait a few minutes and retest
– If the organization presents a Testing & Balancing report
the following questions should be asked
– when was the balancing done (seasonal issues)
– are any specific requirements (such as keeping a
door closed) needed to achieve satisfactory results
218
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Screening
 EC.02.05.01 EP 6 (NOW EP 15) will generate a CLD
– If the organization can repair the process that led to
non-compliance the LSCS may review
– Following LSCS review, the LSCS may contact the
Central Office to discuss the possibility of reducing
the CLD to SLD, with no change to the finding
– Resolution should include the area affected by the
equipment identified as non-compliant, not just the
identified room/area
• i.e. ensure zone is balanced
• Is there an ongoing process to assess
219
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Survey Process
#2 LS.02.01.20 EP 13
52%
 The hospital maintains the integrity of the means
of egress
 Anything in the egress corridor more than 30
minutes is storage
 Dead end corridors may be used for storage
– Less than or equal to 50sqft space
– Crash Carts
– Isolation Carts
– Chemo Carts
220
© Joint Commission Resources
 Carts Allowed:
“If the corridor looks cluttered…it
probably is”
 Educate Staff
221
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– What is the Risk?
• Patient movement
• Staff movement
• Additional Staff responding to
emergency patient care
#3 EC.02.06.01 EP 1 & 13
51%
– The organization must provide a safe
environment
• Unsecured oxygen cylinders
• Outdoor safety is scored at
EC.02.01.01 EP 5
222
© Joint Commission Resources
 EP 1 Interior spaces meet the needs of the
patient population and are safe and suitable to
the care, treatment and services provided
 EP 13 The organization maintains ventilation, temperature
and humidity levels suitable for the care, treatment and
services provided
• Ventilation:
– i.e. doors held open by air pressure; odors
• Temperature:
– Hot / Cold calls
• Humidity
– Primary concern is for areas >60%RH
» Mold growth is possible
 EP 20 Patient care areas are clean and free of
offensive odors
223
© Joint Commission Resources
EC.02.06.01 EP 13
#4 EC.02.03.05
50%
 The hospital maintains fire safety equipment and fire
safety building features.
224
© Joint Commission Resources
– Features of fire protection
• Inventory required to ensure all devices are tested
• Documentation of testing is required
 EC.02.03.05 EP 1 – 20:
– Each device that is required to be tested must be documented
in an inventory
• If x devices were tested last year, and x-1 were tested this
year, which device was missed?
– Each device must be on the inventory to identify which
device was missed
– Total number of devices (quantity) is not adequate
– Lack of an inventory (written, electronic or other) results in a
finding at the EP
• Findings solely for lack of inventory is not scored at
EC.02.03.05 EP 25
225
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Need for Inventory
EC.02.03.05
EPs 1 -20:
– Missing documentation: score the EP as non-compliant
• Also write a finding at EP 25 for documentation not being
readily available
– If acceptable documentation appears, finding at EP 1 – 20
might be removed during survey
– EP 25 remains
– If 3 or more findings at EC.02.03.05 EP 1 – 20
226
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 LD.04.01.05 EP 4: Staff held accountable
 During survey specific documentation is reviewed
 If the documentation for a specific EP is not
available a finding is written as non-compliant for
that EP
– The documentation should be readily available
 If the organization clarifies after survey:
– Joint Commission Engineers will review and
evaluate compliance
– LD.04.01.05 EP 4 remains
227
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EC.02.03.05
#5 IC.02.02.01
50%
• EP 4: when storing medical equipment, devices and
supplies
• Also consider EP 1: cleaning and performing low level
disinfection
• EP 3: disposing of medical equipment, devices and
supplies
228
© Joint Commission Resources
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies--implements infection prevention
and control activities
 The hospital reduces the risk of infections associated with
medical equipment, devices, and supplies--implements
infection prevention and control activities
– Issues:
• Competency and training
• Failure to update/follow procedures/policies
• Inadequate supervision
• Individual responsible for IC program
• Can result in an Immediate Threat to Health and
Safety!
– CoP Infection Control 482.42
– CoP Surgical Services 482.51(b)
229
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#5 IC.02.02.01
#6 LS.02.01.10 EP 5 – 7 & 9
49%
 Building and fire protection features are
designed and maintained to minimize the
effects of fire, smoke, and heat.
– EPs 5 – 7 Door issues
– EP 9 Fire Barrier Penetrations
230
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 Barrier Management
Barrier Management Symposium
231
© Joint Commission Resources
. . .at no cost to the attendee . . .
Barrier Management Symposium
 Program Developers:
– Joint Commission
– Firestop Contractors International Association
– Underwriters Laboratories
–
–
–
–
–
American Society for Healthcare Engineering
AWCI & Gypsum Institute
Fire Damper Industry
Fire Rated Glazing Industry
National Concrete Masonry Association
232
© Joint Commission Resources
 Participating Organizations:
#7 RC.01.01.01
49%
– Problematic EPs:
• EP 19: all entries are timed
• EP 11: all entries are dated
• EP 8: information that promotes continuity of
care among providers
– Issues:
• Stamps
• Buy-in
– CoP 482.24 Medical Records 482.24(c)(1)
233
© Joint Commission Resources
 The hospital maintains complete and accurate
medical records for each individual patient
#8 LS.02.01.30
46%
 The hospital provides and
maintains building features to
protect individuals from the hazards
of fire and smoke.
– EP2 Hazardous Areas
• Primarily door issues
234
© Joint Commission Resources
– EPs 16 – 23 Smoke Barriers & Doors
44%
 EP 4: Piping for the AASS is not used to
support any other item
 EP 5: Sprinkler heads are not damaged and
are free from corrosion, foreign materials, and
paint
 EP 14: Meets all other Life Safety Code
automatic extinguishing requirements related to
NFPA 101-2000
235
© Joint Commission Resources
#9 LS.02.01.35
LS.02.01.35 EP 14
Ceiling tiles misplaced in rooms
Blocked access to fire extinguishers
Missing signage required in NFPA 13-1999
Quick response sprinklers mixed with other
types in patient sleeping smoke compartments
236
© Joint Commission Resources




#10 EC.02.02.01 EP 3 – 5 36%
– Escorts to Hot Lab based on
organization policy
• Perspectives, July 2012
– Lead aprons
237
© Joint Commission Resources
 EPs 3 – 5: Personal Protective Equipment and
the process to manage hazardous materials
and waste handling and exposures
 EPs 6 – 7: Hazardous energy sources
 Score Eye Wash issues at EC.02.02.01 EP 5
 Risk assess location / application based on OSHA
recommendation to
– reduce the risk of injury from contact with caustic and
corrosive materials in areas such as
• Power Plant
• Lab
– Placed so that the eyewash is within 10 seconds or 55
feet from where the corrosive chemicals is used
 Weekly flush until clear is required
 Annual inspection to ensure the system is fully functional
 Mixing valve recommended to achieve tepid
– Risk assess potential exposure to determine if cold water
only would be acceptable
238
© Joint Commission Resources
Eye Wash Station
Federal Requirements: OSHA
32%
 The hospital safely stores medications
– Problematic EPs:
• EP 2: medications are stored according to
manufacturer’s recommendations
– Pharmacy bulk packages (contrast)
• EP 3: all medications and biologicals are stored in
secure area to prevent diversion and locked when
necessary, in accordance with law and regulation
– Complaints re: failure to address diversion
– http://www.cdc.gov/injectionsafety/drugdiversion/in
dex.html
• EP 6: the hospital prevents unauthorized individuals
from obtaining medications in accordance with law and
regulation
–
(cont)
239
© Joint Commission Resources
#11 MM.03.01.01
– EP 8: removes expired, damaged, and/or contaminated
meds/stores separately
Other issues:
– EP 7: stored meds and components used are labeled
with contents, expiration date and applicable warnings
• FAQs published July, 2010 re: MDV
• Use of single dose vials—SEA #52
• Storage of MDV
• Insulin pens
– EP 10: most ready to administer form
• Splitting pills
• Bulk OTC
– CoP Pharmaceutical Services 482.25(a),
– 482.25 (b)
240
© Joint Commission Resources
MM.03.01.01 (cont.)
29%
 The hospital plans the patient’s care
– Problematic EPs:
• EP 1: hospital plans the patient’s care based on needs
identified by the patient’s assessment, reassessment, and
results
• EP 5: written plan of care is based on patient’s goals and
time frames required to meet goals
– Psych hospitals deemed status: short- and long-term
goals
• EP 22: based on goals established, staff evaluate patient
progress
• EP 23: revises plans and goals based on patient’s needs
– CoP 482.23(b)(4) Nursing Services
241
© Joint Commission Resources
#12 PC.01.03.01
27%
 Medical Gas Systems
– EP 1: Inspection Testing and Maintaining
– EP 2: Test when modified, installed or repaired
– EP 3: Obstructions
– EP 3: Labeling
• Contents of piping
• Areas served
–Accuracy
242
© Joint Commission Resources
#13 EC.02.05.09 EP 3
#14 PC.02.01.03
27%
– Problematic EPs for organizations that use Joint
Commission for deemed status:
• EP 1: prior to providing care, tx, sx, obtains or
renews orders…in accordance with professional
standards of practice, law and regulation,
hospital policies, MS bylaws and rules and regs
• EP 7: provide care, tx, sx, using the most recent
patient order(s)
243
© Joint Commission Resources
 The hospital provides care, treatment, and
services as ordered or prescribed, and in
accordance with law and regulation
#15 MM.04.01.01
24%
 Medication orders are clear and accurate
244
© Joint Commission Resources
– Problematic EPs:
• EP 13: the hospital implements its policies for
medication orders
• EP 8: prohibits blanket reinstatement orders
#16 PC.03.01.03
24%
– Problematic EP:
• EP 1: presedation / preanesthesia patient
assessment
– Other EPs:
• EP 2: assess patient’s anticipated needs in order to
plan for postprocedure care
• EP 7: licensed independent practitioner plans or
concurs with plan for sedation or anesthesia
• EP 8: immediate reassessment
• EP 18: preanesthesia eval completed/documented
within 48 hours prior to surgery (N/A to DoD)
245
© Joint Commission Resources
 The hospital provides the patient with care before
initiating operative or other high-risk procedures,
including those that require the administration of
moderate or deep sedation or anesthesia
#17 LD.01.03.01
23%
 The governing body is ultimately responsible
for the safety and quality of care, treatment
and services
– Problematic EP:
– EP 2: Governing body provides for organization
management and planning
246
© Joint Commission Resources
• This EP is scored when Medicare Conditions of
Participation (CoPs) are out of compliance at the condition
level
#18 LD.4.01.05
22%
– Problematic EP:
– EP 4: Staff are held accountable for their
responsibilities
• Used when leadership has allowed non
compliance to exist without correction
• Sometimes used when situation is serious but
does not warrant a “decision rule”
247
© Joint Commission Resources
 The hospital effectively manages its programs,
services, sites, or departments
21%
EPs 4 – 7
 Missed Generator & Automatic Transfer Switch
(ATS) Tests
– Exercise monthly
• Each emergency generator must be tested
with a load of at least 30% of nameplate
• Each ATS must be tested
 Missed triennial 4 hour test
248
© Joint Commission Resources
#19 EC.02.05.07 EP 6
#20 MM 05.01.01
20%
249
© Joint Commission Resources
 A pharmacist reviews the appropriateness of all medication
orders for medications to be dispensed in the hospital
– Problematic EPs:
– EP 1: Before dispensing or removing medications from
floor stock or from an automated dispensing machine, a
pharmacist reviews all medication orders unless:
– a LIP controls the ordering, preparation, and
administration of the medication
• Exception for ED and radiology
– when a delay would harm the patient in an urgent situation
(including sudden changes in a patient’s clinical status)
• The organization determines what qualifies as an
urgent situation
MM 05.01.01 continued
– Emergency department: An LIP is not required to
remain at the bedside when the medication is
administered. However, an LIP must be available to
provide immediate intervention should a patient
experience an adverse drug event
– Radiology: Pharmacist review of contrast orders
(including radiopharmaceuticals) is exempted.
However, the hospital is expected to define, through
protocol or policy, the role of the LIP in the direct
supervision of a patient during and after IV contrast
media is administered
250
© Joint Commission Resources
 Exceptions:
continued
– EP 8: No review for therapeutic duplication
– Multiple PRN medications without clear guidelines
when each is to be selected over another.
• Multiple pain medications/narcotics
• Multiple antiemetics
• Multiple antihistamines for itching/hives
• Multiple benzodiazepines for anxiety
– EP 11: After the medication order has been reviewed
all concerns, issues, or questions are clarified with the
individual prescriber before dispensing
251
© Joint Commission Resources
MM 05.01.01
Question for thought…
251
© Joint Commission Resources
 The TJC survey team scores several EC/LS
findings during the course of your survey that
were scored in your previous survey. This
results in not only a CLD, but an Accreditation
with Follow-Up Survey Decision. How do you
deal with this in your organization?
252
© Joint Commission Resources
Questions?
254
© Joint Commission Resources
Performance Improvement
(PI)
Performance Improvement (PI)
 Role of leadership in Performance Improvement
 Collection of data foundation of PI
 Data collection of required measures
 Analysis of data for trends, patterns
 Making improvements based on analysis
254
© Joint Commission Resources
 Evaluating improvements
PI.01.01.01
Collect/Monitor Data
 Collects data on the following:
–
–
–
–
Leaders priorities (scorecard)
Operative or other procedures that place patients at risk
Discrepancies between pre and post op diagnoses
Adverse events related to using moderate or deep
sedation or anesthesia (ECT)
– Results of resuscitation
– Behavior management and treatment
255
© Joint Commission Resources
– Significant medication errors
PI.01.01.01
Collect/Monitor Data
 Collects data on the following:
256
© Joint Commission Resources
– Significant adverse drug reactions
– Patient perception of the safety/quality of
care/treatment and services
– Falls
– Effectiveness of RRT
– Disease management outcomes (PCMH)
– Access to care within time frame (PCMH)
PI.01.01.01
Collect/Monitor Data
 National Patient Safety Goals
 Leadership
– Contract quality indicators (LD.04.03.09)
– Patient flow (LD.04.03.11)
– Adequacy of staffing (LD..04.04.05)
• Annual report to the board
 Provision of Care, Treatment and Services
257
© Joint Commission Resources
– Restraints (PC.03.03.01)
PI.02.01.01
Data Management
258
© Joint Commission Resources
Use statistical tools and techniques to analyze and
display data.
259
© Joint Commission Resources
Data Use:
Strategies
 Benchmarking
– Comparing data to external target goals
– Goals established by leading organizations or
professional groups
– Structured report
– Tracks selected indicators
– Financial and nonfinancial
260
© Joint Commission Resources
 Scorecard
PI.02.01.03
Improves Performance on ORYX
Accountability Measures
 Achieve a composite performance rate of at least 85%
on the ORYX accountability measures
 Scored prior to the survey
 Refer to the PM chapter (Performance Measurement)
– Four required
AMI, HF, PN, SCIP
Births 1,100 or > must collect PC (perinatal care)
Sixth measure at discretion of hospital
Not qualify for PC then another measure
261
© Joint Commission Resources
1.
2.
3.
4.
Joint Commission Top Performers
 2011: 620 hospitals
 2012: 1099 hospitals
 2014: 1224 hospitals
262
© Joint Commission Resources
 44 hospitals recognized voluntarily collecting and
reporting data on more core measure sets than required
 Increase in academic medical centers (35)
 Increase in government owned hospitals (138)
Joint Commission Top Performers
Heart attack
Inpatient psychiatric services
Heart failure
Venous thromboembolism
Pneumonia
Stroke
Surgical care
Perinatal care
Pediatric Asthma
Immunizations
263
© Joint Commission Resources
10 Specific Treatment Areas
Joint Commission Top Performers
Achieve cumulative performance
of 95% or above across all
reported accountability measures
At least one core measure
set with a composite rate
of 95% or above
264
© Joint Commission Resources
Achieve performance of 95% or above on every
reported accountability measure for which
there were at least 30 denominator cases
Scenario
 During tracers the surveyors noted data posted on the
units. When asked about quality improvement efforts on
the units the nurses consistently took the surveyors to the
display and explained specific unit based PI projects and
265
© Joint Commission Resources
the progress.
Scenario
A. This is not a good idea since the staff are expected to
know the data without props such as unit displays.
B. This reinforces the staff-level participation in PI
activities
improvement
266
© Joint Commission Resources
C. This is acceptable as long as the data demonstrate
267
© Joint Commission Resources
Joint Commission Center for Transforming Healthcare
© Joint Commission Resources
TST Hand Hygiene: First Initiative
269
© Joint Commission Resources
JC Center for Transforming Health Care
270
© Joint Commission Resources
Projects:
271
© Joint Commission Resources
Projects:
272
© Joint Commission Resources
Hand off Communications
273
© Joint Commission Resources
Participating Institutions Hand Off Communications
© Joint Commission Resources
274
275
© Joint Commission Resources
Medication Management
(MM)
276
© Joint Commission Resources
What’s New?
Polling Question
 The changes regarding sample medications
reflect an increase in Joint Commission
requirements.
278
© Joint Commission Resources
– True?
– False?
 EPs Became effective July 1, 2014
 Are indicated by the following:
– Note: This element of performance is also
applicable to sample medications
 49 EPs are so noted
 Are found in 13 of the 20 Medication Management
standards
 The Joint Commission Perspectives, January, 2014
 Found in the 2014 Update 1 to Comprehensive
Accreditation Manuals
279
© Joint Commission Resources
Sample Medications
Polling Question
– True?
– False! The identification of specific EPs in the
Medication Management chapter actually reflect a
decrease in applicable EPs. Previously, the entire
Medication Management chapter was applicable to
sample medications
280
© Joint Commission Resources
 The changes regarding sample medications
reflect an increase in Joint Commission
requirements.
280
© Joint Commission Resources
Compliance Tips for the MM
Standards in the Top Ten
MM 03.01.01 Typical Findings
 Medication security
– Carts not located in secure areas or locked up
– Medications which are unsecured
– Policy which directs who has access to medications
 Controlled substances not reconciled
282
© Joint Commission Resources
– Organizational policy is usually strongest
requirement
– Discrepancies not resolved
– Special care in areas not automated
MM 03.01.01 Typical Findings
 Refrigerator temperatures out of range and no
actions taken
 Using date opened (or wrong date) on MDVs
 Expired medications
 Not keeping most ready-to-administer form of
drug in floor stock (unit dose, pre-filled syringe,
premix bag) if commercially available
283
© Joint Commission Resources
 Unlabeled medications
MM.03.01.01: Compliance Tips
 Understand definitions of levels of security
 Conduct knowledgeable rounds by
pharmacists
 Determine organization policy is consistent
with law and regulation
 Risk assess
 Review policy and prevent diversion
 Provide access to labels
284
© Joint Commission Resources
– Incidents, ADRs, events, errors
MM.04.01.01: Typical Findings
 Continued/inappropriate use of verbal orders
– Scribing for a physician
– The use of computerized order entry
– Range orders
– Standing order sheets not completed correctly
– Titrating medications
 Policies too broad
– Inconsistent implementation
»
285
© Joint Commission Resources
 Indications for required medications
 Preprinted order sets not reviewed/updated
 Policies do not cover types of medication orders
used within the organization
MM.04.01.01
 Problematic EPs:
286
© Joint Commission Resources
– EP 7: the hospital reviews and updates preprinted
order sheets, within the time frames it identifies or
sooner if necessary based on current evidence and
practice
MM.04.01.01
 Problematic EPs:
– EP 13: the hospital implements its policies for
medication orders
Failure to clarify unclear, illegible and incomplete orders
Lack of consistency in interpreting range orders
Lack of indication on PRN orders
Lack of special precautions for ordering LASA
medications
287
© Joint Commission Resources




MM.04.01.01: Compliance Tips
Clear verbal order vs. telephone order policy
Policies address patient population
Implementation of policies
Medication Tracers—multiple processes
Preprinted order sets (include templates) —
design process for review and approval
– Frequency of review
– Education of medical staff
288
© Joint Commission Resources





MM 05.01.01 Typical Findings
288
© Joint Commission Resources
 Lack of pharmacy review of orders other than
ED, Radiology…most common: PACU
 If pharmacy not open 24 hours; lack of
pharmacy review of orders
 Therapeutic duplication risk review lacking
 Lack of clarification of unclear order with
prescriber
289
© Joint Commission Resources
More Medication Management…
MM.03.01.03
Emergency Medications




List of emergency supplies and meds
Readily accessible 3 R
Unit dose, ready to administer
Resupply after use 3
 Code Carts
291
© Joint Commission Resources
 Checks
 Age-appropriate
 Defibrillator pads
MM.05.01.07
Pharmacy Preparation of IV Admixtures
– In areas where pharmacy is not on site, e.g. offsites
– Pharmacy is not open 24 hours
292
© Joint Commission Resources
 Intent: To move IV admixture preparation out
of the nursing unit
 Consider where IV admixtures might be
prepared outside the pharmacy: admixture
competency and preparation site
 Pharmacy should consider ways to make IV
admixtures available when needed without
admixture by nurses
Typical Findings
 Pill splitters/crushers not cleaned
 Admixing without competency
293
© Joint Commission Resources
 Admixing being done outside of pharmacy
during regular pharmacy hours
294
© Joint Commission Resources
Medication Standards Compliance
in the Operating Room
Top Findings in the Operating Rooms
Labeling in ORs
Handling of controlled substances
Automated dispensing anesthesia carts
Pre-op/PACU and medication order review
Stashes of medication
Is your OR really secure?
Controlled substances
– Practices consistent with your policies
– Minimize risk of diversion
295
© Joint Commission Resources







Labeling of Medications
 NPSG 03.04.01 Label all medications,
medication containers, and other solutions on
and off the sterile field in perioperative and
other procedural settings
EP 1: Labeling medications and solutions that are not
immediately administered, even if only one
EP 2: Timing of labeling
EP 3: Contents of label: med name, strength, quantity,
diluent/volume if not apparent, expiration
date/time when necessary
296
© Joint Commission Resources
– Problematic EPs:
Question for thought…
297
© Joint Commission Resources
You are doing a patient tracer in the cardiac
catheterization laboratory and notice that all of
the syringes and basins on the sterile field are
labeled even if they are empty. Is this OK?
Labeling of Medications
298
© Joint Commission Resources
Answer: Yes, IF your policy is written to
explicitly detail the process.
NPSG.03.06.01
Reconciling Medication Information
 Collecting information on the home
medications
– “Good faith” effort
– Reconciliation with medications ordered in the
hospital
– No longer specifically part of this NPSG
– Update medications in medical record part of
RC.01.01.01 and RC.02.01.01
299
© Joint Commission Resources
 Transfer of patient – and reconciliation of
medications
NPSG.03.06.01 (continued)
Reconciling Medication Information
 Discharge process
– Provide discharge medication information to patient
– Added responsibility of patient to maintain list and to
communicate to Primary Care Physician
– No requirement for the hospital to provide list to
next provider of care
 Non-24 hour settings
• Allows tailoring process for specific settings
300
© Joint Commission Resources
– Organizations can define the medication information
they require to be collected
 Identify high-alert and hazardous medications
 Managing high-alert and hazardous
medications
 Implements its process for managing high-alert
and hazardous medications 3 R
 Reporting abuses and losses of controlled
substances according to law and regulation, to
the individual responsible for the pharmacy
and the CEO if determined by the hospital
301
© Joint Commission Resources
MM.01.01.03
High-Alert Medications
High Alert Medication Strategies
 How have you defined these?
 How have you defined strategies for reducing
risk?
 How have you disseminated information about
risks and new processes
302
© Joint Commission Resources
 Recommendation: Address the specific risks
of each high alert medication on your list
Hazardous Medications
–
–
–
–
PPE
Other Primary engineering controls
Processes
Training
303
© Joint Commission Resources
 Requirements are included in MM.01.01.03;
EC.01.01.01, EC.02.02.01, EC.04.01.01, as
well as LD, LS, and EM references
 Need a list! (MM.01.01.03)
 Defined by NIOSH - revised 2010
 Strategies to protect those who come in
contact
MM.01.02.01
Look-Alike/Sound-Alike
 Develops list of LASA
 Takes action to prevent errors in interchange
3
R
The Institute for Safe Medication Practice (ISMP) list is
one source of look-alike/sound-alike medications
304
© Joint Commission Resources
 Annually reviews and revises
Look Alike Sound Alike
Medication Strategies
305
© Joint Commission Resources
 Consider why you have multiple
concentrations of the same medication
 Have you defined policy on ordering LASAs?
 Recommendation: Address display of LASA
via Tallman lettering, use of brands or
indications; address storage via restriction,
separation, labeling
305
© Joint Commission Resources
Questions?
Provision of Care,
Treatment, and Services
(PC)
Transplant Safety
(TS)
306
© Joint Commission Resources
Waived Testing
(WT)
Challenging Standards
PC.01.02.03
• Assessment and reassessment
PC.01.03.01
• Plans of care
PC.01.02.07
• Pain Management
307
© Joint Commission Resources
PC.03.01.03
• Anesthesia care
PC.01.02.03
 The hospital assesses and reassesses the
patient and his or her condition according to
defined time frames
– EP findings:
308
© Joint Commission Resources
• EP 2: within defined time frame
• EP 4: the patient receives a medical history and physical
examination no more than 30 days prior to, or within 24
hours after registration or inpatient admission but prior to
surgery or procedure requiring anesthesia services
(MS.01.01.01)
PC.01.02.03
 EP findings:
– EP 5: update to the H&P documenting any changes
is done within 24 hours of admission (MS.01.01.01)
– All other EPs are Risk Related
• EP 1: defining timeframes in writing
• EP 3: patients reassessed based on POC or changes
• EP 6: RN completes nursing assessment within 24 hours
309
© Joint Commission Resources
• EPs 7 & 8: functional and nutritional screening
PC.01.02.05
 Professionals Assess and Reassess
310
© Joint Commission Resources
– Based on initial assessment an RN determines
patient’s need for nursing care
PC.01.02.07
16%
 Pain Management
Comprehensive pain assessment
Assess considering patient’s age
Responds to pain and reassesses
Treats pain
311
© Joint Commission Resources
–
–
–
–
312
© Joint Commission Resources
PC.01.02.07
16%
PC.01.02.08
 Fall Prevention Management
– Assesses risk for falls
– Implements interventions to reduce risk
313
© Joint Commission Resources
Is fall management in
the Plan of Care?
PC.01.02.09
 Abuse and Neglect
Written criteria
Community resources that are available
Educates staff
Use the criteria
Assesses or refers
Reports per law and regulation
314
© Joint Commission Resources
–
–
–
–
–
–
PC.01.03.01
 The hospital plans the patient’s care
– EP findings:
315
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• EP 1: Plans the patient’s care based on needs identified by
the patient’s assessment, reassessment, and results
• EP 5: Written plan of care is based on patient’s goals and
time frames required to meet goals
• EP 22: Based on goals established, staff evaluate patient
progress
• EP 23: Revises plans and goals based on patient’s needs
PC.02.01.03
 Physician orders
316
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– Obtains or renews orders
– Use the most recent orders
– Read back orders
PC.02.01.21
 Change in patient’s condition
Process to recognize
Written criteria to describe early signs
Staff seek additional assistance
Informs patient and family how to seek assistance
317
© Joint Commission Resources
–
–
–
–
PC.02.01.21
 Communication
318
© Joint Commission Resources
– Identifies oral and written communication needs
– Identifies preferred language for discussing health
care
– Communicates during care in manner that meets
patient needs
PC.02.02.01
 Coordinates patient’s care, treatment and
services
319
© Joint Commission Resources
– Process for hand-off
– Coordinates care, treatment and services
PC.02.02.03
 Food and nutrition
320
© Joint Commission Resources
– Accommodates special needs and special diets
– Accommodates cultural, religious or ethnic
preferences unless counter indicated
– Stores food and nutrition products including those
brought in by family
PC.02.02.07
 Academic education
321
© Joint Commission Resources
– Arranges for child or youth to receive academic
education based on his or her length of stay and
condition of patient
PC.02.03.01
 Patient Education
Learning needs assessment
Provides patient and family education
Interdisciplinary participation
Evaluates understanding
Teach how to communicate concerns about patient
safety
322
© Joint Commission Resources
–
–
–
–
–
PC.03.01.03
19%
 The hospital provides the patient with care
before initiating operative or other high-risk
procedures, moderate or deep sedation or
anesthesia
– EP findings:
• EP 1: pre-sedation / pre-anesthesia patient assessment
323
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• EP 2: assess patient’s anticipated needs in order to plan for
post procedure care
PC.03.01.03
19%
 The hospital provides the patient with care
before initiating operative or other high-risk
procedures, moderate or deep sedation or
anesthesia
• EP 7: licensed independent practitioner plans or concurs
with plan for sedation or anesthesia
• EP 8: immediate reassessment
• EP 18: pre-anesthesia evaluation completed/documented
within 48 hours prior to surgery
324
© Joint Commission Resources
– EP findings:
PC.03.01.05
 During procedures and anesthesia
325
© Joint Commission Resources
– Patient’s oxygenation, ventilation, and circulation
are monitored continuously
– Appropriate for age
PC.03.02.07
 After procedure and anesthesia
Immediately after
Continues to monitor after the procedure
Discharge by LIP or criteria
Postanesthesia evaluation completed within 48
hours post anesthesia
326
© Joint Commission Resources
–
–
–
–
Scenario
327
© Joint Commission Resources
 The patient order was written at 0400 in the
ED to admit the patient to ICU. The patient
was transferred to the ICU at 1200 and the
nurse performed the admitting patient
assessment profile at 1400. Does this meet the
Joint Commission standards?
Scenario
328
© Joint Commission Resources
A. Yes it does.
B. It may if the hospital policy supports the
profile must be completed within 24 hours.
C. It does not meet the standard.
Scenario
329
© Joint Commission Resources
 During a tracer the CRNA explained that the
anesthesia team routinely uses the last vital
signs recorded from the holding area as the
pre-induction assessment. Does this meet the
Joint Commission standards?
Scenario
330
© Joint Commission Resources
 A patient complains of pain on the 0-10 scale
at 8. The patient is treated and reassessed
one hour later and the pain is reported as a 7.
The pain medication order was a stat order.
What would you expect the nurse to do next?
Scenario
A. Take vital signs and give the patient more
time to respond to the medication.
B. Call the LIP with the information and
additional orders for pain management.
331
© Joint Commission Resources
C. Repeat the medication one time to seek relief.
PC.03.01.08
 Tissue Specimens
Collecting
Preserving
Transporting
Receiving
Reporting
Where is
that
specimen
report?
332
© Joint Commission Resources
–
–
–
–
–
Restraints
 Not using Joint Commission for deemed status
– PC.03.02.01 to PC.03.03.31
 Using Joint Commission for deemed status
333
© Joint Commission Resources
– PC.03.05.01 to PC.03.05.19
PC.04.01.05
 Patient discharge and education
334
© Joint Commission Resources
– Provides written discharge instruction in a manner
that patient and family can understand
Elements needed for safe transitions of care
Leadership support
Multidisciplinary collaboration
Early identification of patients/clients at risk
Transitional planning
Medication management
Patient and family action/engagement
Transfer of information
Source: The Joint Commission, Transition of care: The need for collaboration across entire care continuum. Hot
Topics in Health Care, Issue #2. 2013.
335
© Joint Commission Resources
Safe Transitions of Care
Scenario
336
© Joint Commission Resources
 The patient is at high risk for falls. Fall
management includes a yellow name band, a
falling star on the door, and yellow socks. The
patient does not ambulate and the staff do not
use the socks. The patient is transported to
ultrasound. Does this comply with the fall
management protocol?
Scenario
337
© Joint Commission Resources
 The patient food refrigerator temperature reads
about 8 degrees above the maximum
temperature. You would expect the staff
member to:
Scenario
338
© Joint Commission Resources
A. document the temperature and adjust the
thermostat
B. adjust the thermostat and reassess the
temperature in an hour
C. document the temperature, adjust the
thermostat and reassess in an hour
Waived Testing
Growing number of waived testing methods
Growth of ambulatory and office practices
Not performing system checks and calibrations
Manufacturer’s recommendations
Reporting of incorrect results
Inappropriate storage practices
339
© Joint Commission Resources






Waived Testing (WT)
340
© Joint Commission Resources
 Waived tests are the lowest complexity level
classified by CLIA’88 and the most common by
caregivers, bedside or point of care
 Definition of policy and procedures
 Competency
 Quality control checks and documentation
Waived Testing
 Oversight by the director named on the
CLIA license
341
© Joint Commission Resources
– Make sure the individual knows and understands
role in oversight
– Can select a designee (and usually does)
WT.01.01.01
Policies and Procedures
Diagnosis and treatment vs. follow-up testing
Policies and procedures for waived testing
Manufacturers’ manuals/inserts enhanced
Policies/procedures for
– Initial use
– Periodically thereafter
– Changes in procedure occur
R
3
342
© Joint Commission Resources




WT.01.01.01
Policies and Procedures
Policies/procedures available during testing
Manufacturers’ instructions followed 3
Criteria for confirmatory testing 3
Clinical use of test results 3
343
© Joint Commission Resources




WT.03.01.01
Competent Staff and LIPs
344
© Joint Commission Resources
 Orientation and training
 Orientation is documented on hospital specific services
 Orientation is documented for tests authorized to
perform
WT.03.01.01
Competent Staff and LIPs
 Trained on use of instrument/use/maintenance
 At least 2 Methods of competency assessment are
R
used:
3
– Blind specimen
– Observation
– Monitoring
– Written test
New FAQ
345
© Joint Commission Resources
 Competence assessed at defined intervals
WT.04.01.01
Quality Control Checks
3
R
R
346
© Joint Commission Resources
 Written quality control plan
 Quality control rationale
 Non-instrument-based testing
– Frequency
– Number of levels
 Instrument-based testing 3
– Each instrument
– Manufacturers’ instructions
– Two QC checks if available
WT 04.01.01 Quality Checks
347
© Joint Commission Resources
 EP 4 no longer requires organizations to
perform quality control checks on each day of
testing. Organizations are now required to
perform quality control checks per
manufacturers’ instructions for instrumentbased waived testing.
Transplant Safety
– Tissue suppliers registered with FDA R
– Coordinates acquisition, receipt, storage, issuance
– Follows the tissue suppliers’ or manufacturers’
written directions 3 R
– Verifies package integrity and temperature range
upon receipt and documents
– Monitors and documents storage temperatures
unless room temperature
– Refrigerators, freezers, nitrogen tanks have alarms
3
R
348
© Joint Commission Resources
 TS.03.01.01 Managing Tissues
Transplant Safety
 TS.03.02.01 Bi-Directional
– Hospital records allow any tissue to be traced
donor
recipient or disposition
recipient or final disposition
donor
tissue supplier
recipient or disposition
recipient or disposition
tissue supplier
349
© Joint Commission Resources
• Documents temperatures, staff, preparation
• Keep all records for 10 years
© Joint Commission Resources
350
351
© Joint Commission Resources
Infection Prevention and Control
(IC)
 Annual Evaluation of Previous Year Plan
 Risk Assessment and Analysis for Previous
Year
 Risk Assessment and Analysis for Current Year
 Infection Prevention and Control Plan for
Current Year
 List of places using Cidex, Cidex OPA,
Matricide or similar products
352
© Joint Commission Resources
What Do You Need For Survey?
IC.01.01.01
 Responsibilities
– Clinical authority: program level
– Daily management of infection
353
© Joint Commission Resources
– Develops and implements policies and procedures
IC.01.02.01
 Resources
– Access to information
– Laboratory resources
– Equipment and supplies
354
© Joint Commission Resources
• Ventilation systems
• Negative pressure rooms
IC.01.03.01
 Risk Assessment
355
© Joint Commission Resources
– Geographic location, community, and population
served
– Care, services provides
– Analysis of surveillance activities
– Reviews and analyzes risks annually
– Prioritizes risks
IC.01.05.01
 Infection prevention and control plan
–
–
–
–
–
356
© Joint Commission Resources
Uses EB during plan development
Written
Process for investigation outbreaks
All components of the hospital are included
Method to communicate responsibilities to staff,
patients, families, visitors
– Includes hand and respiratory hygiene practices
IC.02.01.01
 Implements plan
Standard precautions including PPE
Implements transmission based precautions
Investigates outbreaks
Minimizes risk of infection when storing and
disposing of infectious waste
– Communicates responsibilities for preventing
transmissions to LIPs, staff, patients, families,
visitors
357
© Joint Commission Resources
–
–
–
–
IC.02.02.01
50%
358
© Joint Commission Resources
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies – implements infection prevention
and control activities
IC.02.02.01
50%
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies – implements infection prevention
and control activities
– Scopes, contamination issues
359
© Joint Commission Resources
– EP 1: low-level disinfection
– EP 2: intermediate and high-level disinfection and
sterilization of medical equipment, devices and
supplies (EC.02.04.03, EP 4)
IC.02.02.01
47%
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies – implements infection prevention
and control activities
360
© Joint Commission Resources
• EP 4: when storing medical equipment, devices and
supplies
• Also consider EP 1: cleaning and performing low level
disinfection
• EP 3: disposing of medical equipment, devices and supplies
IC.02.02.01
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies – implements infection prevention
and control activities
– Issues:
• Competency and training
• Failure to update/follow procedures/policies
361
© Joint Commission Resources
• Inadequate supervision
IC.02.02.01
 The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies – implements infection prevention
and control activities
– Issues:
• Can result in an Immediate Threat to Health and Safety!
362
© Joint Commission Resources
– CoP Infection Control 482.42
– CoP Surgical Services 482.51(b)
Scenario
363
© Joint Commission Resources
 The technician in endoscopy was observed
moving a contaminated scope from a
procedure room to the dirty utility room. The
scope was in a container without a cover. Is
this acceptable practice?
IC.02.04.01
 Influenza vaccination
364
© Joint Commission Resources
– Educates LIPs and staff
– Included in infection prevention plan
– 90% influenza vaccination by 2020
IC.03.01.01
 Evaluates plan
365
© Joint Commission Resources
– Evaluates at least annually
– Reviews prioritized risks
– Communicates annual review to patient safety
program
Compliance Issues
–
–
–
–
–
–
–
Process
Timeframes (Soak, Rinse, HLD)
Dilutions
Log books
Use of (Personal Protective Equipment) PPE
Storage
Safety
Competency Assessment
Process
366
© Joint Commission Resources
 Are you following your own policy for cleaning
and disinfection?
IC.02.02.01 Typical Findings
 Staff unable to identify key disinfection
processes throughout the organization
 “wet” or “dwell” time
 Inconsistent practice of policies
367
© Joint Commission Resources
– Helpfulness is not always helpful
– Cleaning items
© Joint Commission Resources
368
370
© Joint Commission Resources
Record of Care,
Treatment, and Services
(RC)
RC.01.01.01 Complete and
Accurate Medical Record
52%
 Components of complete medical record
 Information unique to the patient
 Information needed to support patient
 Information needed to justify care
 Information about the patient’s care that
promotes continuity among providers
R
3
370
© Joint Commission Resources
 Information documents course and results of
care
RC.01.01.01
Complete and Accurate Medical Record
 Standardized formats to document
 All entries are dated
 Tracks the location of all components of record
 Assembles or makes available in a summary
of information required to provide care to
patient
371
© Joint Commission Resources
 All entries are timed
 Entries not dated or timed
 Inconsistent documentation formats and
location of information
 Difficult to locate information to support care
(computerized entry and location)
 Staff unable to locate documentation from
other disciplines or locations
 eMR access limitations
372
© Joint Commission Resources
RC.01.01.01: Typical Findings
RC.02.01.01
Reflection of Patient’s Care
R
Medical record contains:
 EP 1 Demographic information
 NEW NOTE: new language and new note
– Medical Record contains demographic information:
NOTE: If patient is minor, incapacitated or has advocate,
communications needs are documented in MR
373
© Joint Commission Resources
• Name, address, DOB, sex, legal status of any patient
receiving behavioral care services
• Patient’s communication needs, including preferred
language for discussing health care
RC.02.01.01
Reflection of Patient’s Care
R
 EP 2 Medical Records contain clinical information
including:
– All orders
3
– Results of diagnostic/therapeutic tests and
procedures
– Discharge plan and discharge planning evaluation
374
© Joint Commission Resources
– Discharge diagnosis
RC.02.01.01
Reflection of Patient’s Care
R
– Any advance directives
– Any informed consent
– Any records of communication with patient (email or
phone)
– Any patient-generated information
– Note added: The properly executed informed
consent is placed in the patient’s medical record
prior to surgery, except in emergencies*
375
© Joint Commission Resources
 Medical record contains additional information
as needed to provide care (see list) 3
RC.02.01.03 Documentation of
Operative, High-Risk, and Sedation
– Physician, assistants, procedure performed (ECT),
description of finding and postoperative diagnosis
 Required operative note information
3
3
R
R
376
© Joint Commission Resources
 Document procedure/sedation/anesthesia R
 LIP documents provisional diagnosis before
procedure R
 H&P recorded prior to procedure 3 R
 List of required information to be in note
R
(7 items) 3
 Use of a post procedure note before transfer
RC.02.01.03 Documentation of
Operative, High-Risk, and Sedation
 Discharge documentation (LIP or criteria)
 Approved discharge criteria documentation
 LIP responsible for discharge R
R
R
377
© Joint Commission Resources
– Note: Postoperative summary may be considered
equivalent if all items are listed/included
RC.02.01.03: Typical Findings
 H&P past 30 days
 Post procedure note written prior to actual
procedure
 Post procedure note does not contain the
necessary elements
378
© Joint Commission Resources
 H&P does not contain the necessary elements
as set forth in Medical Staff Bylaws
A surveyor witnesses the proceduralist enter the
suite and wash their hands and then walk into a
completely draped patient that they had not
previously talked to that day and start the
procedure. When reviewing the documentation
later in the day, the update to the history and
physical is documented as being done prior to
the procedure. What will the surveyor do in this
case?
379
© Joint Commission Resources
Question for thought…
RC.02.03.07
Verbal Orders
13%
 Qualified staff receive and record verbal orders
– CoP Medical Records 482.24(c)(1)(i, ii, iii)
– Allowance for partners to sign—Continues!!!
– Problematic EP:
380
© Joint Commission Resources
• EP 4: verbal orders are authenticated within the time frame
defined by law and regulation
• CMS removed the 48 hour timeframe—now dependent on
state law and regulation!
– Make sure your policy is up to date
RC.02.03.07: Typical Findings
 No attempt to limit verbal orders
 Verbal orders not authenticated within time frame
 Date/Time not documented when verbal order
authenticated
381
© Joint Commission Resources
 Date/Time not documented when verbal order was
received
RC.02.04.01: Discharge Information
 Concise discharge summary
R
Reason for hospitalization
Procedures performed
Care, treatment, and services provided
Patient’s condition and disposition at discharge
Information provided to the patient and family
Provisions for follow-up care
382
© Joint Commission Resources
–
–
–
–
–
–
3
Information Management
383
© Joint Commission Resources
(IM)
Information Management (IM)
Are all of your policies and IM Plans updated
as the record and eMR changes?
384
© Joint Commission Resources
 Planning/maintaining system for internal and
external information
 Protecting privacy and security of data
 Ensures accuracy
 Ensuring accessibility among caregivers
IM.01.01.03 Continuity of
Information Management Process
R
 Written plan for managing interruptions in
process
 Plan is tested for effectiveness
3
385
© Joint Commission Resources
 Implements plan when needed
IM.02.02.03
Data Accessibility
R
 Policies to capture, display and retain patient
information
 Storage and retrieval system make clinical information
accessible to providers (navigation of the eMR)
386
© Joint Commission Resources
 Disseminates data in useful formats and defined
timeframes
Laurel McCourt, MD
JCR Consultant
Former TJC Surveyor: Hospital, Office Based Surgery,
and Special Survey Unit
388
© Joint Commission Resources
The TJC Medical Staff
Standards Update
2014
Objectives
389
© Joint Commission Resources
 Review the top standards in the medical staff
chapter that were scored in the first half of
2014
 Review of processes that have been used as
solutions to the “top ten”
 Review what’s new as of July 2014
 A look ahead to 2015
MS.01.01.01
390
© Joint Commission Resources
 EP 3: Most commonly scored EP, must be
scored if one of EPs 12-36 is scored
 EP 16: Most commonly scored EP of EPs 1236
– History, Physical and Updates defined at a
minimum of what is contained at PC
01.02.03 EPs 4,5
MS.01.01.01
391
© Joint Commission Resources
 EP 16 : The requirements for completing and
documenting medical histories and physical
examinations. The medical history and physical
examination are completed and documented by
a physician, an oralmaxillofacial surgeon, or
other qualified licensed individual in accordance
with state law and hospital policy.
MS.01.01.01
392
© Joint Commission Resources
 EP 16: Note 2:The requirements referred to in
this element of performance are, at a minimum,
those described in the element of performance
and Standard PC.01.02.03, EPs 4 and 5.
MS.01.01.01
393
© Joint Commission Resources
 EP 4: The medical staff bylaws, rules and
regulations, and policies, the governing body,
bylaws, and the hospital policies are compatible
with each other and are compliant with law and
regulation.
MS.01.01.01
394
© Joint Commission Resources
 EP 5: The medical staff complies with the
medical staff bylaws, rules, and regulations
MS.01.01.01
395
© Joint Commission Resources
 EP 10: The organized medical staff has a
process which is implemented to manage conflict
between the medical staff and the medical
executive committee on issues including, but not
limited to, proposals to adopt a rule, regulation,
or policy, or amendment thereto.
MS.01.01.01
396
© Joint Commission Resources
 EP 21: The process, as determined by
the organized medical staff and approved
governing body, for selecting and/or
electing and removing the medical
executive committee members
Associated standards . . .
397
© Joint Commission Resources
 EM 02.02.13 EP 2 The medical staff
identifies, in its bylaws, those individuals
responsible for granting disaster privileges
to volunteer licensed independent
practitioners.
Associated standards . . .
398
© Joint Commission Resources
 EM 02.02.13 EP 3 The hospital
determines how it will distinguish volunteer
licensed independent practitioners from
other licensed independent practitioners.
(Usually in the Emergency Operations
Plan)
Associated standards . . .
399
© Joint Commission Resources
 EM 02.02.13 EP 4 The medical staff describes,
in writing, how it will oversee the performance of
volunteer licensed independent practitioners who
are granted disaster privileges (for example, by
direct observation, mentoring, medical record
review).
Associated standards . . .
400
© Joint Commission Resources
 EM 02.02.13 EP 5 Before a volunteer
practitioner is considered eligible to function as a
volunteer licensed independent practitioner, the
hospital obtains his or her valid governmentissued photo identification (for example, a
driver’s license or passport) AND at least one of
the following:
 A current picture identification card from a health care organization that
clearly identifies professional designation
 Primary source verification of licensure
 Identification indicating that the individual is a member of a Disaster
Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the
EmergencySystem for Advance Registration of Volunteer Health
Professionals(ESAR-VHP), or other recognized state or federal response
organization or group
 Identification indicating that the individual has been granted authority by
a government entity to provide patient care, treatment, or services in
disaster circumstances
 Confirmation by a licensed independent practitioner currently privileged
by the hospital or by a staff member with personal knowledge of the
volunteer practitioner’s ability to act as a licensed independent practitioner
during a disaster.
 A current license to practice
401
© Joint Commission Resources
Associated standards . . .
Tips for Success
402
© Joint Commission Resources
 Take a copy of the bylaws and the standard
EPs 12-36 and tab where each of the EPs is
located
 If the details of any of EPs 12-36 are in other
areas such as the rules, regs, or policies, keep
these handy and updated.
 Keep these updated every time bylaws, etc.,
are revised
MS.08.01.03
403
© Joint Commission Resources
 EP 3 Information resulting from the
ongoing professional practice evaluation is
used to determine whether to continue,
limit, or revoke any existing privilege(s)
MS.08.01.03
404
© Joint Commission Resources
 EP 1: There is a clearly defined process
in place that facilitates the evaluation of
each practitioner’s professional practice
MS.08.01.03
405
© Joint Commission Resources
 EP 2 The type of data to be collected is
determined by individual departments and
approved by the organized medical staff.
Tips for Success
406
© Joint Commission Resources
 Develop a spreadsheet of all of your
practitioners and when their OPPE is due.
 Send a list to dept. chairs every month to
remind if you don’t have a current OPPE on file.
 Be sure to include allied health practitioners
Tips for Success
407
© Joint Commission Resources
 If you are using OPPE that includes activity
numbers, it is a good idea to have available the
case logs in case the credentials committee has
a question about the outcome
MS.03.01.01
 EP 16 For hospitals that use Joint
Commission accreditation for deemed status
purposes: The medical staff determines the
qualifications of the radiology staff who use
equipment and administer procedures.
408
© Joint Commission Resources
 Can now be done by the Radiology Medical
Director
MS.03.01.01
EP 17 For hospitals that use Joint Commission
accreditation for deemed status purposes: The
medical staff approves the nuclear services
director’s specifications for the qualifications,
training, functions, and responsibilities of the nuclear
medicine staff.
409
© Joint Commission Resources
 Can now be done by the Radiology Medical
Director
MS.03.01.01
410
© Joint Commission Resources
 EP 7 The organized medical staff
monitors the quality of the medical
histories and physical examinations.
MS.03.01.01
411
© Joint Commission Resources
 EP 2 Practitioners practice only within
the scope of their privileges as determined
through mechanisms defined by the
organized medical staff.
Tips for Success
412
© Joint Commission Resources
 Encourage medical staffs to develop
audit tool for H and P’s and review
these regularly and track data and
actions taken
 Check applications carefully for possible
omissions or oversights
 EP 1 A period of focused professional
practice evaluation is implemented for all initially
requested privileges
– Usually results from a lack of
documentation of the practitioner’s
performance in a timely manner
– Other reason for scoring is no evidence of
process for allied health practitioners
413
© Joint Commission Resources
MS.08.01.01
 EP 3 The performance monitoring process is
clearly defined and includes each of the
following elements:
– Criteria for performance monitoring
– Method for establishing a monitoring plan
specific to the requested privilege
– Method for determining the duration of
performance monitoring
– Circumstances requiring an external source
414
© Joint Commission Resources
MS.08.01.01
MS.08.01.01
415
© Joint Commission Resources
 EP 4 Focused professional practice
evaluation is consistently implemented in
accordance with the criteria and
requirements defined by the organized
medical staff.
 Establish the FPPE process during the
credentialing process.
 Send out an attached copy of the FPPE with
the practitioner’s board letter
 Keep a spreadsheet of all currently in FPPE,
reminders to reviewers
 Follow through on process and feedback in a
timely manner
416
© Joint Commission Resources
Tips for Success
416
© Joint Commission Resources
Telemedicine
Telemedicine
 Usually a contracted service
 Watch how the contract is written, be sure to include
written performance expectations
417
© Joint Commission Resources
– These can include verification of ID and OPPE for
the individual as long as it can be specific to your
site
Telemedicine
 MS.13.01.01
 Telemedicine Options
 Regardless of option chosen: must maintain a file.
– EP 1 Full Credentialing
419
© Joint Commission Resources
• This is traditional process
• Changed in response to cumbersome nature of
performing this process
Telemedicine
 MS.13.01.01 (con’t)
 Telemedicine Options
– EP 2 Use the information from distant TJC site to
put practitioners through their process
– EP 3 Use the decision from the TJC distant site
420
© Joint Commission Resources
• Must have in contract
• Must have access to and ability to provide quality data
The Medical Staff Standards
 MS.13.01.03
 Telemedicine
421
© Joint Commission Resources
– EP 1 What can be done through this medium
– EP 2 Quality should be industry standard
421
© Joint Commission Resources
Questions?
Medical Staff and Leadership:
PI and Quality
Survey Expectations
423
© Joint Commission Resources
 The two should not be mutually
exclusive nor functioning in silos.
Medical Staff and Leadership:
PI and Quality Survey Expectations
424
© Joint Commission Resources
 In order to show compliance with MS 05.01.01
the surveyors should be able to discern from
meeting minutes and discussion with physicians
that there is significant medical staff involvement
in performance improvement.
Medical Staff and Leadership:
PI and Quality Survey Expectations
425
© Joint Commission Resources
 From a leadership perspective, the
organization’s administration, in partnership with
the medical staff, should be able to show how
an organization-wide patient safety program has
been implemented as delineated in
LD.04.04.05. This will be assessed through the
review of minutes and the leadership session
426
© Joint Commission Resources
New Standards/EPs
July 2014
 Standard MS.03.01.03 The management and
coordination of each patient’s care, treatment,
and services is the responsibility of a practitioner
with appropriate privileges.
EP 13. For hospitals that use Joint
Commission accreditation for deemed status
purposes: Patients are admitted to the
hospital only on the decision of a licensed
practitioner permitted by the state to admit
patients to a hospital.
427
© Joint Commission Resources
NEW! – July 2014
 MS.06.01.05 The decision to grant or deny a
privilege(s), and/or to renew an existing
privilege(s), is an objective, evidence-based
process.
EP 15. For hospitals that use Joint
Commission accreditation for deemed status
purposes: The surgical service maintains a
current roster listing each practitioner’s
surgical privileges.
 Note: The roster may be in paper or
electronic format
428
© Joint Commission Resources
NEW! – July 2014
 PC.03.01.01 EP 10 For hospitals that use
Joint Commission for deemed status purposes:
In accordance with the hospital’s policy and state
scope-of-practice laws, anesthesia is
administered only by….
– An anesthesiologist’s assistant supervised
by an anesthesiologist who is immediately
available if needed.
429
© Joint Commission Resources
NEW! – July 2014
NEW! – September 2014
430
© Joint Commission Resources
 CMS Standards Changes Related to
Efficiency, Transparency, and Burden
Reduction Part II
– Practitioners not on MS who order
outpatient services
– MS structure in multihospital systems
 EP 1… Note: Outpatient services may be ordered by a
practitioner not appointed to the medical staff as long as
he or she meets the following:
- Responsible for the care of the patient
- Licensed in the state where he or she provides care to
the patient
- Acting within his or her scope of practice under state
law
- Authorized in accordance with state law and policies
adopted by the medical staff and approved by the
governing body to order the applicable outpatient
services
431
© Joint Commission Resources
PC.02.01.03
 MS.01.01.01 EP 37
 For hospitals that use Joint Commission accreditation
for deemed status purposes: When a multihospital
system has a unified and integrated medical staff, the
bylaws describe the process by which medical staff
members at each separately accredited hospital (that is,
all medical staff members who hold privileges to practice
at that specific hospital) are advised of their right to opt
out of the unified and integrated medical staff structure
after a majority vote by the members to maintain a
separate and distinct medical staff for their respective
hospital.
432
© Joint Commission Resources
NEW! – September 2014
NEW! – September 2014
 MS.01.01.05
433
© Joint Commission Resources
For hospitals that use Joint Commission
accreditation for deemed status purposes:
Multihospital systems can choose to establish a
unified and integrated medical staff in
accordance with state and local laws.
NEW! – September 2014
 MS.01.01.05 EP 1-4 all begin with the same
language:
434
© Joint Commission Resources
 If a multihospital system with
separately accredited hospitals
chooses to establish a unified and
integrated medical staff, the following
occurs:
 MS.01.01.05 EP 1
 Each separately accredited hospital within a
multihospital system that elects to have a unified and
integrated medical staff demonstrates that the
medical staff members of each hospital (that is, all
medical staff members who hold privileges to
practice at that specific hospital) have voted by
majority either to accept the unified and integrated
medical staff structure or to opt out of such a
structure and maintain a separate and distinct
medical staff for their hospital.
435
© Joint Commission Resources
NEW! – September 2014
NEW! – September 2014
 MS.01.01.05 EP 2
436
© Joint Commission Resources
 The unified and integrated medical staff takes
into account each member hospital’s unique
circumstances and any significant differences in
patient populations and services offered in each
hospital
NEW! – September 2014!
 The unified and integrated medical staff
establishes and implements policies and
procedures to make certain that the needs and
concerns expressed by members of the medical
staff at each of its separately accredited
hospitals, regardless of practice or location, are
given due consideration.
437
© Joint Commission Resources
 MS 01.01.05 EP 3
NEW! – September 2014
 MS 01.01.05 EP 4
438
© Joint Commission Resources
 The unified and integrated medical staff
has mechanisms in place to make
certain that issues localized to particular
hospitals within the system are duly
considered and addressed.
439
© Joint Commission Resources
On The Horizon….
What’s coming next….
440
© Joint Commission Resources
 Proposed new standards that completed field
review stage of evaluation.
 Once the field review comments were
compiled, TJC opted to delay implementation for
one year for review and revision
 Likely to be very similar to original format
since based on American Board of Radiology
requirements
 For hospitals that provide computed tomography (CT) services: At
the time of granting initial privileges, the hospital verifies and
documents that a radiologist who interprets CT exams is board
certified in radiology or diagnostic radiology by the American Board
of Radiology, American Osteopathic Board of Radiology, or an
equivalent source. If the radiologist is not board-certified, then the
hospital verifies and documents that he or she has achieved the
following qualifications and experience:
 Completed an Accreditation Council for Graduate Medical
Education (ACGME) or American Osteopathic Association (AOA)
diagnostic radiology residency
 Performance and interpretation of 500 CT examinations in the
past 36 months
441
© Joint Commission Resources
MS.06.01.03 EP 10
 For hospitals that provide computed tomography (CT) services:
Upon renewal of privileges, the hospital verifies and documents that
a radiologist who interprets CT examinations has the following
experience:
 The radiologist meets the Maintenance of Certification (MOC)
requirements of their certifying body.
 A radiologist reading CT examinations across multiple organ
systems has read 135 exams in the past 24 months.
 A radiologist reading organ system-specific CT examinations (for
example, abdominal, musculoskeletal, head), has read a minimum of
40 organ system specific CT examinations in the past 24 months. In
addition, he or she must have also read a total of 135 cross-sectional
imaging studies for MRI, CT, PET/CT and ultrasound in the past 24
months.
442
© Joint Commission Resources
MS.06.01.05 EP 16
MS.06.01.05 EP 17
443
© Joint Commission Resources
 For hospitals that provide computed tomography (CT) services:
Upon renewal of privileges, the hospital verifies and documents the
ongoing education of a radiologist who interprets CT examinations.
Ongoing education must include As Low As Reasonably Achievable
(ALARA), Image Gently, Image Wisely, and one of the following:
 Meeting the Maintenance of Certification (MOC) requirements of
their certifying body
 Completing 100 hours of relevant continuing medical education
(CME) in the past 24 months; this must include 50 hours of Category
1 CME
 Completing 10 hours CME in the past 24 months specific to the
imaging modality or organ system
Check your knowledge…
© Joint Commission Resources
 TRUE or FALSE…
 If you have a practitioner that begins actively
practicing in your organization in November and
your TJC survey is in March of the following year,
the surveyor will expect to see some data or
outcomes regarding the practitioner’s FPPE at
the time of survey.
444
© Joint Commission Resources
Questions?
Contact Information
 lmccourt@jcrinc.com
445
© Joint Commission Resources
 Phone: 630-854-6881
446
© Joint Commission Resources
Emergency Management
(EM)
Emergency Management (EM)
 Comprehensive approach to manage small/large
operational disruptions which adversely impact patient
safety and the provision of care, treatment or services
 EOP to respond and test (evaluate) effectiveness
 Mitigation, preparedness, response, recovery
 Communication, resources/assets, safety/security, staff
activities
447
© Joint Commission Resources
responsibilities, utilities, patient clinical and support
Acronyms
 EOP—Emergency Operation Plan
 ICS—Incident Command Structure
 DMAT—Disaster Medical Assistance Team
 MRC—Medical Reserve Corps
 ESAR-VHP—Emergency System for Advance
Registration of Volunteer Health Professionals
 EOC—Environment of Care
448
© Joint Commission Resources
 LSC—Life Safety Code®
Acronyms
 HRSA—Health Resources and Services Administration
 NIMS—National Incident Management System
 HICS—Hospital Incident Command System
 PPE— Personal Protective Equipment
 AHRQ—Agency for Healthcare Research and Quality
449
© Joint Commission Resources
 AHCA—American Healthcare Association
Classification Systems
 Emergencies classified many different ways
– Two category system
• Internal (damage infrastructure)
• External (beyond organization’s walls and most
likely overwhelm the organizations resources)
450
© Joint Commission Resources
– Three category system
• Natural disasters
• Technological disasters
• Sociological and public health disasters
Six Critical Functions
1. Communication
2. Resources and Assets
3. Safety and Security
4. Staff Responsibilities
5. Utilities Management
451
© Joint Commission Resources
6. Patient clinical and support activities
Two Most Common Systems
http://www.fema.gov/emergency/nims/index.shtm
452
© Joint Commission Resources
1. NIMS
– Created in 2004 by presidential declaration
– Umbrella approach unifying local, state, federal
– Not specifically designed for hospitals
– Seeking HRSA funding
– Implement 17 elements
– Intended to enhance relationship between:
• Hospitals, local government, public health, other
emergency response agencies
Two Most Common Systems
2. HICS
http://www.hicscenter.org
453
© Joint Commission Resources
– Revised August 2006
– Assists hospitals in improving their emergency
management planning, response, recovery
– Parallels the NIMS program
– HICS materials include a “tool box”
– Focuses on the Incident Command Structure
(ICS)
EM.01.01.01 Planning Activities
 HVA (Hazard Vulnerability Analysis)
– Not a one-time event—continuous process
– Identifies potential threats, risks, and emergencies
– Identifies potential impact
– Identifies events that could affect service demands
– Identifies likelihood of events occurring
– Identifies consequences of those events
 Planning for all emergencies not possible
454
© Joint Commission Resources
 Collaboration with community partners
EM.01.01.01 Planning Activities
 Do not limit HVA list to traditional disasters
– Internal events
– Man-made incidents
– Mass-casualty events
 Review community historical data
 Consider likelihood or probability of occurrence
 Apply the 4 phases of emergency management
455
© Joint Commission Resources
 Clear and well-defined ICS
EM.01.01.01 Planning Activities
 Preparedness
– Activities that will organize and mobilize essential
resources
– How to respond if a disaster occurs
– Checklist, checklist, checklist
456
© Joint Commission Resources
 Mitigation
– Designed to reduce risk of and potential damage
due to an emergency
• HVA is a mitigation activity
• Which mitigation activities to pursue
EM.01.01.01 Planning Activities
 Response
– Strategies and actions activated during an
emergency
• Treating victims
• Reducing secondary impact to the organization
• Controlling negative effects
• Back to business
• Specify recovery steps or stages
457
© Joint Commission Resources
 Recovery
– Involves restoring systems that are critical to
resuming normal services
EM.02.01.01
Emergency Operations Plan (EOP)
 Leaders participate in developing EOP
 Maintains written EOP
 EOP identifies hospital’s capabilities for 96 hours
 EOP describes recovery strategies
 Initiating and terminating the hospital's response and recovery
phases
 Authority to activate the response/recovery phases
 In an emergency response procedures are implemented
R
3
458
© Joint Commission Resources
 Alternative sites for care
EM.02.02.01
Communicating During Emergencies
 How staff/LIP are notified
 How to communicate with external authorities
 How to communicate with patients/family
 How to communicate with community and media
 How will communicate with suppliers
 How to communicate with other community
 Back up systems for communication
459
© Joint Commission Resources
organizations
EM.02.02.03
Managing Resources and Assets
 How organization will obtain and replenish supplies,
medications, etc.
 How organization monitor quantities of supply
460
© Joint Commission Resources
 Arrangements for transporting patients
EM.02.02.05
Safety and Security
 Internal safety and security arrangements
 Role of community security agencies
 Coordination of security (internal/external)
 Management of hazardous waste
461
© Joint Commission Resources
 Control of entrance, movement of individuals
EM.02.02.07
Managing Staff
 Roles and responsibilities of staff/licensed independent
practitioners for all 6 components
 Identifying who staff/licensed independent practitioners
report to
 Supporting staff needs: housing, transportation
 Managing family support needs: child care
 How to identify volunteers
462
© Joint Commission Resources
 Train staff for roles
EM.02.02.09
Managing Utilities
 Electricity
 Water for consumption
 Water for equipment
 Fuel
 Medical gas/vacuum
463
© Joint Commission Resources
 Essential systems: HVAC, steam for sterilization
EM.02.02.11
Managing Patients
 Managing ADT, scheduling, triage, assessment,
treatment
 Evacuation
 Increase in demand for vulnerable patients
 Personal hygiene and sanitation needs
 Mental health services
 Patient clinical information tracking
464
© Joint Commission Resources
 Mortuary services
EM.02.02.13/EM.02.02.15
Disaster Volunteers
 EM.02.02.13 LIP Volunteers
 EM.02.02.15 Non-LIP Volunteers
 Eligible to function as volunteer
3
R
•
•
•
•
•
•
Healthcare organization ID—professional designation
Current license, registration, certification
Primary source verification
Federal/State response organization
Granted authority in disaster circumstances
Confirmation by a LIP or hospital staff
EC News, December 2014
465
© Joint Commission Resources
– Must have valid government-issued photo ID
– One other document
EM.02.02.13 Volunteer Licensed Independent
Practitioners
 MS oversees performance of volunteer licensed
independent practitioner
 Within 72 hours continuing disaster privileges
• Reason could not be performed
• Demonstrated ability to provide care
• Evidence that the hospital attempted to perform
 Extraordinary circumstances
466
© Joint Commission Resources
 Primary source verification
– As soon as disaster is under control
– Within 72 hours
EM.03.01.01
Effectiveness of Planning
 Annual review of HVA and documents
 Annual review of EOP and documents
467
© Joint Commission Resources
 Annual review of its inventory and documents
Testing the EOP
 Enables the ability to assess Plan’s:
Appropriateness
Adequacy
Effectiveness of logistics
Effectiveness of human resources
Effectiveness of training
Effectiveness of policies/procedures/protocols
468
© Joint Commission Resources
–
–
–
–
–
–
Testing the EOP
 Should stress the limits
 Scenarios realistic and relevant
 Validate the effectiveness of the plan
469
© Joint Commission Resources
 Identify opportunities for improvement
Learner Check
Which of the following are the four phases of Hazard
Vulnerability Analysis (HVA):
A. Preparedness, response, recovery, mitigation
B. Mitigation, preparedness, response, recovery
D. Rescue, response, recovery, preparedness
470
© Joint Commission Resources
C. Mitigation, recovery, response, preparedness
© Joint Commission Resources
471