1. Joint Commission Readiness
John R. Rosing, MHA, FACHE
Vice President and Principal
Patton Healthcare Consulting

2. Institute the Action Plan Everyone in Position

3. WHATS NEW I SHOULD WORRY ABOUT?

4. Focus on the Priority Issues
The standards have ~1800 EPs that can be scored
The Joint Commission does >90% of its scoring on about 25 standards/NPSGs
Focus on the top scored
Focus on all NPSGs
Focus on any NEW standards/FAQ
Focus on previously scored issues

5. AND THEN THERE ARE THE MOST FREQUENTLY SCORED STANDARDS
Low hanging fruit, almost fall on surveyor
Learn from the mistakes of others
If the surveyors see it everywhere and score it everywhere, there is no chance they are going to look the other way at your hospital.
Focus on these issues and fix them long before survey.

6. TOP SCORED, STANDARD LEVEL 2012 Source: Perspectives April 2012
Complete/accurate medical record (RC – 66%)
Maintain egress (LS – 56%)
Fire Protection features maintained (LS – 52%)
Fire protection features maintained to protect patients (LS – 45%)
Maintain fire safety equipment (EC – 40%)

7. Top Scored TJC 2012 cont. Source: Perspectives April 2012
Medical Equip Infection Risk (IC – 36%)
Assess and reasses per timeframes (PC – 34%)
Medication Storage (MM – 33%)
Verbal orders (RC %)
Maintain system for extinguishing fire (LS – 31%)

8. Signing, Dating & Timing Medical Record Entries (RC.01.01.01 – 66%)
Hospital maintains a complete and accurate medical record
The author identified and authenticated. (EP 11)
Timing - Biggest Problem (EP 19)
Have you designed paper forms to enable success?
Every form has a time box
Multipurpose forms have time/date, signature for every section
Information needed to justify patient care (EP 6) **Legibility is scored here!
Consider using data for OPPE or HR evaluation process

9. MEANS OF EGRESS, USUALLY EXITS (LS.02.01.20) 56%
Hospital maintains means of egress
Easy to find issues, educate on:
Blocked or locked egress doors
Corridor clutter, storage in hallways
Linen carts and latex carts will be scored
Cart on Wheels can be plugged in but not parked for >30 minutes
OK stuff:
Crash carts are considered “in use”
Isolation carts outside occupied room also considered “in use”
Dietary cart while delivering
Med cart in use

10. Fire Protection Features (LS.02.01.10 - 52%)
Building & fire protection features minimize the effects of fire, smoke and heat.
32 elements of performance!
Fire and smoke doors labeled, correct type, close, label visible, under cut, door gaps, adhesive tape over latch
Penetrations are sealed with correct material

11. Fire Doors, cont Inspect and maintain fire doors
Appropriate fire rating on doors and frame
Door positively latches
Door had a closure
No gaps > 1/8 inch, or undercut >3/4 inch
Resulted in ITL if multiple problems

12. LS -Maintain Building Features (LS.02.01.30 – 45%)
25 elements of performance, 1 with its own 25 bulleted requirements.
Building features are provided and maintained to protect individuals from smoke
Label all Hazardous Areas (such as boiler rooms, laboratories, O2 tank supply rooms, flammable liquid storage rooms)
Limit access to hazardous areas
Self closing doors work as expected and designed

13. EC.02.03.05 FIRE PROTECTION EQUIPMENT 40%
21 elements of performance
More focused on testing, inspection and maintenance of fire protective features.
Testing alarms and strobes
Testing pumps and sprinklers
Testing dampers
And don’t forget the documentation requirement for the new EP 25 to include NFPA reference

14. Fire Protection Equipment (EC.02.03.05 – 40%)
Hospital inspects, tests & maintains
fire safety equipment.
Includes testing of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches & water flow devices.
If outsourced to a vendor keep the report, read the report and act on problems!
Make sure reports are tied to an inventory of devices and make sure the inventory doesn’t change every quarter
Check closed areas of the building as well when doing all tests.

15. Fire Extinguisher Dating (EC.02.03.05 EP 15)
Month, day, year and initials of inspector required per NFPA
They will review the tag
If bar coded, they will review documentation
Required monthly
Check closed areas of the building as well when doing all tests. – this means every 30 days!!!! Not during the month *** jkc check!!!

16. MEDICAL EQUIPMENT RISKS IC (IC.02.02.01 – 36%)
Cleaning, sterilizing, storing and disposing of medical equipment & supplies. C & 3
Problems or gaps with dating controls & biologicals
Store clean and dirty separately
Air handling
Flexible Scope Cleaning
Laryngoscope storage FAQ
Surveyors trained on AAMI standards for sterilization and disinfection

17. Reduce Risk of Infection, cont
Surveyors will observe staff as they process dirty equipment
Surveyors will check manufacturer instructions for use (IFU) for three things: the device/instrument, the sterilizer itself, and the packaging (i.e., blue wrap or flash pan.)
Check your policy, check staff understanding, and precision
Will observe proper use of PPE

18. ASSESS AND REASSESS PER POLICY (PC.01.02.03) 34%
Initial nursing assessment done on time.
If initial nursing assessment screened for dietary consult or other, it is done on time.
Reassessments are done per plan of care. If I+O is in POC, it is done.
H+P done or updated in 24 hours or updated prior to surgery
H+P isn’t more than 30 days old
H+P update language includes: I have reviewed the H+P, I have examined the patient and….

19. Safe Medication Storage (MM.03.01.01 – 33%)
Been a top 10 for years.
Largest problem was medication storage temps, this is now a C element!
Tackle both refrigerators and warmers
Warmers max and duration an issue
1 months log only if using paper
Always Document actions taken
Describe how you monitor on weekends in 5 day areas

20. Medication Storage, cont.
Clarified - Expired medications including multidose vials
Use BUD label, not date open label
Expire in 28 days or less, vaccines are exception
Policy addressing med storage by a provider after access and before administration (There are 19 MM chapter D’s)
Unauthorized access to medications – “do what you say” If housekeepers are permitted or prohibited.

21. Verbal Orders RC %
When required by law or regulation, verbal or telephone orders are authenticated within the specified timeframe. (48 hours)
And the authentication is timed
It’s a C element of performance, no MOS
It’s a criticality 4 so you have 60 days to fix it if scored
Consider data use for OPPE, consider hard-stops in your EHR
EHR is not foolproof on this issue

22. Provide/Maintain Fire Systems and Equip (LS.02.01.35)
Sprinklers
18 inch rule
Sprinkler pipes can not support other items like cables or wires
Sprinkler head clean and free of obstruction, collar flush
Ansul system shuts off gas, activates alarm, controls exhaust system.

23. NOT TOP 10, BUT FREQUENT FLYERS
Additional, problematic standards that are frequently scored on surveys.

24. Primary Source Verification (HR.01.02.05)
Photocopies of licenses have no validity in the Joint Commission process.
Primary source verification of licensure on time, prior to expiration
If the individual really was unlicensed for a period of time, risk of PDA/CON
Problem areas: Decentralized responsibility with lack of oversight
Special competencies or certifications required by the hospital are obtained according to hospital policy. ACLS, BLS

25. Assess & Reassess Pain (PC.01.02.07)
Sev. 3- Conduct a comprehensive pain assessment consistent with scope of care, Tx, services and patients condition.
Your policy spells out the depth of the assessment, the form, the timing.
Follow your policies or TJC RFI
Keep your policies simple, 90% minimum compliance?

26. Medical Gas (EC )
Hospital inspects, tests & maintains medical gas and vacuum systems.
No parking zone!
Get vendor reports, fix problems noted
Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when.
Alarms must be working. Has led to ITL

27. Document Operative & High Risk Procedures (RC.02.01.03)
H&P in MR before procedure (EP 3)
Post op, post procedure report is dictated is before transfer to next level (EP 5)
The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

28. NATIONAL PATIENT SAFETY GOALS
Must be evaluated by your surveyors
They are almost all criticality 3, so they count
Always a focus of surveyor training
They are complex because you have to know the requirements and the FAQ explanation of details.

29. GOAL 1, USE OF 2 PATIENT IDENTIFIERS
Nothing new here, just get staff to correctly verbalize what your two identifiers are.
Make sure staff really use those 2 identifiers on each patient interaction, even when they know the patient.
Be careful in amb care, hyperbaric, dialysis still need to use 2 ID

30. GOAL 2, CRITICAL TEST RESULTS
Do you have a goal or timeframe in which your staff are expected to reach the LIP?
Are you meeting that expectation?
Remember, the lab reaching a nurse is only step 1 in the process and timeline.
Do you expect something to be in the chart? Do you do a READ-BACK??
How do you monitor performance?

31. GOAL 3, IMPROVING THE SAFETY OF USING MEDICATIONS
Part 1 – label every medication or solution on a sterile field. This includes water, saline, chlorhexidine, propofol or one syringe.
Do staff have the tools they need to perform this function? Look at bedside procedures in ICU, OR and minor procedures in AHC settings.
“show me where you store your sterile labels”
“what is your process to make sure that proper labeling is performed?”

32. THE ONE ON THE LEFT IS FENTANYL, THE ONE ON THE RIGHT IS….

33. ITS WHITE, THEREFORE IT DOESN’T…..

34. TWO ARE LABELED, THEREFORE THE THIRD IS….

35. ITS ONLY WATER, ITS ONLY REFUSE, IT DOESN’T NEED A LABEL

36. GOAL 3, IMPROVING THE SAFETY OF USING MEDICATIONS
Part 2: Reduce harm from anticoagulation therapy. Do you have and do you use protocols for anticoagulants? Surveyors will trace anticoagulation patients so is it clear that protocols are being used?

37. GOAL 3, IMPROVING THE SAFETY OF USING MEDICATIONS
Part 3 Medication reconciliation
Is a list created for each inpatient or outpatient?
Does someone analyze the list to “identify and resolve discrepancies?”
Procedural settings can be simplified and made easy
Inpatient admission reconciliation is not easy. Discrepancies include omissions and changes.
Inpatient discharge reconciliation is not easy. Requires one complete list

38. GOAL 7 INFECTION PREVENTION
Part 1 – your hand hygiene program
You have a program, you have goals, you are improving.
Be prepared to discuss at IC system tracer and Data use tracer.
Will surveyors see your program implemented and working or significantly missed?
Reduce your vulnerability in ICU, ED, PACU, dialysis, infusion center by conducting tracer interview where less observation is possible.

39. GOAL 7 INFECTION PREVENTION
Part 2 – prevention of MDRO infections
Show me your risk assessment, and most recent update, EP 1
Lets ask staff, patients and LIP’s about your education or optionally lets look at some documentation. EP 2 and 3
Show me your measurement data from surveillance and how this was presented to leadership. EP 5,6
Show me which CPG’s you used. EP 7
Show me how you alert ICP to new cases. EP 8
Show me how you alert your ICP and staff to a readmission of an MDRO patient. EP 9

40. GOAL 7 INFECTION PREVENTION
Part 3 – central line infection prevention
Lets talk with patients, families, staff and LIP’s about your education, or optionally show me documentation. EP 1,2
Show me your CPG’s. EP 3
Show me your most recent risk assessment. EP 4
Show me the report you sent to leadership with the data analysis. EP 5
Show me you catheter insertion checklist. EP 6
Show me your standardized supply cart. EP 9
During tracers what will the surveyor see during and insertion relative to femoral vein, barrier precautions used, hand hygiene and antiseptic used? EP 7,10,11

41. GOAL 7 INFECTION PREVENTION
Part 4 – prevention of surgical site infection
Lets talk with staff, LIP’s and patients about the education you provided or optionally lets look at documentation.
Same CPG, risk assessment, measurement, report to leaders.
Hair removal technique and antibiotic prophylaxis in accordance with CPG’s.

42. GOAL 7 INFECTION PREVENTION
Part 5 – CAUTI
Have you implemented CAUTI in 2013?
What CPG are you planning to use?
What data are you going to collect and who is going to do it?

43. GOAL 15 IDENTIFY PATIENT SAFETY RISKS INHERENT IN THE POPULATION
Part 1: Conduct a risk assessment for the patient and the environment for features that may increase or decrease risk for suicide.
Each patient is clinically screened and a decision reached about their risk.
Environmental risks are identified and evaluated to determine if we can mitigate the risk or must eliminate the risk.
Part 2: do something about it
Part 3: upon discharge give each patient a list of resources such as crisis lines.

44. UNIVERSAL PROTOCOL Part 1: pre-procedure verification process
We have the right patient, procedure, plan and equipment present
Part 2: site marking by the surgeon
Part 3: Time out just prior to the procedure
Take a look at ambulatory and bedside procedures.
Make sure no one leaves the room after timeout.
Does your paperwork trail and timing make sense?

45. MISC UPDATES The One and Only campaign OR fire prevention
Scope cleaning and high level disinfection
Pressure relationships, OR’s, decontamination areas
Central supply adherence to manufacturers sterilization guidance.
Look at CMS tracer checklists for ideas.
Know that multi-dose vials are vulnerable
Closed Record Review is BACK! Stop, see Medical Record Review Tool

46. Tracer Tips For Staff
Its not a police interrogation, its not root canal
Be enthusiastic about how good we are
Focus on the excellent service and care we provide
Find a quiet room, out of main traffic path to review the medical record for the patient tracer
Before answering a question:
Take a deep breath
Make sure you understand the question
Or ask “Could you please rephrase that question…”
Talk about what you do, don’t over-think it
Offer to provide the answer later in the day
Stop talking once you have answered
Know where policies are kept & how to access them.
Make sure you have the right policy, screen

47. Tracer Tips For Staff, cont.
Never, never “fix” a chart to avoid an RFI
Never “make up” answers to please the surveyor
Don’t be intimidated by surveyors
Do not argue with the surveyor
Welcome surveyor suggestions
Know what improvements in patient care came from PI (performance improvement) activities
Help the surveyor navigate, tell the patient story
Don’t affirm the leading question…” this isn’t a very good process, is it?”

48. Role of the Escort/Note Taker
Upon arrival handle introductions and get the ball rolling ASAP
Gently coach struggling staff
Record offers to present support and record surveyor’s response
Record the “he said” “she said”
Record MR numbers
ID potential pitfalls, RFI’s, or potential disasters

49. TRACERS FOLLOW THE PATH OF THE PATIENT
Patient evaluated in the ED, and a decision made to admit the patient
Patient transferred to the inpatient medical surgical unit.
Patient sent to radiology the next morning for CT with contrast
Patient scheduled for surgical procedure
Patient sent post surgery to ICU
Patient transferred to med surg unit
Patient discharged to home.

50. TRACERS EVALUATE THE INTERFACES OF CARE
Each transfer of responsibility involves the transfer of critical information necessary to provide safe and effective services. (especially medications)
Communication breakdowns during these transfers are common root causes as identified by hospitals.

51. TRACER – EVALUATE EXECUTION OF YOUR POLICIES AND PROCEDURES
At the start of our patients episode of care in the ED, what can we evaluate?
Timeliness of triage, evaluation, treatment, transfer after decision to admit.
Depth, completeness and appropriateness of assessments
Staff knowledge of hospital assigned responsibilities
TAT of critical tests, results or treatments
Handoff to the unit
Issues about flow
Privacy and patient rights
Medication security and storage
Hand hygiene and IC in general

52. TRACER TECHNIQUE
Staff should be programmed to pick a room, get the chart, get the nurse, get other disciplines, get surveyor out of the hallway.
At the start, try to put staff at ease, consider their case load and timing of the visit, relieve staff of their assignment if possible.
Chart review, followed by oral interview, or vice versa, or tour first. Surveyors pick their most comfortable technique.
Concurrent oral interview and staff guided tour with presentation of key documents pertinent to the responses.
Surveyors listen to the responses and allow those responses to shape the next question.
Remember Peter Falk, Inspector Columbo?
They ask questions pertinent to the patient being traced.
They keep their checklist or form in the background

53. TRACER TECHNIQUE How do you do…..? What did you do……?
What would you do if…?
Can you show me where/how that is documented?
Are the responses consistent from staff person to staff person?
Are the responses consistent with hospital policies?
Can staff find policies?
Surveyor may validate staff responses prn with patient directly.
Surveyor may listen to and observe pertinent practices that may be taking place in the background.
Surveyors rarely ask about specific standards or safety goals, they ask only about what was done for the patient.

54. WHAT DO WE HOPE TO AVOID? Knowledge deficits
Process variation unit to unit, person to person and acceptance of the practice.
Listen carefully to response: “I do” vs. “Usually…”
Short cuts, work arounds, and personal belief systems
Policy deficits or non compliance with policy
Documentation defects
Fumbles

55. Patient Tracers Focus is on actual care practices.
The patient’s care drives assessment of compliance to standards not vice versa
Focus is on linkages, continuum of care, and communication among the healthcare team
Quality, timeliness, and completeness of the medical record drives compliance
Focused tracers will go into depth on the issue.

56. System Tracers
Interview Sessions, do mocks for these sessions also, practice!
Come ready to talk proudly and showcase
Hospital system tracers:
Medication Management
Data Use
Environment of Care – must have documents at your finger tips.
Emergency Management – make sure your plan addressed every EP
Competency Assessment - HR
Infection Control – make sure your plan addressed every EP

57. Picking the Patient Where will the surveyor visit:
All anesthesia and sedation areas
At least 50%-100% inpatient locations
Sample of outpatient sites
Picking an internal tracer patient:
Multiple units, enter through the ED, transfer from another facility, had surgery
Watch procedures everywhere all the time!
Can’t decide? Pick the fattest chart or at least a 2 day chart, procedure patients, restrained patients

58. Why Do they want to See a Med Pass?
Standards you can observe during a pain med pass
If med is drawn up prior to administration was the medication properly labeled
Two patient identifiers
EMAR, bar code compliance
Hand hygiene x2
Nursing 5 rights
Pain assessment and reassessment
Patient education on the medication

59. WHAT IS ASKED?
Tell me about the initial nursing assessment. What do you look for?
Fall risk screening and actions taken
Nutritional screening and timeliness
Abuse screening
Patient education
Decubiti screening
Pain assessment and reassessment process, right technique and adherence to policy.

60. WHAT ELSE?
Show me the H+P, is it done <24 hours, updated, legible, complete?
Does this H+P read like the same patient in the care plan?
Show me the pre-anesthesia assessment and immediate reassessment.
Show me the time out documentation
Unit staff, if not familiar with surgical area documentation SAY SO, but see if someone can help find.
Show me the consent; translator involvement?
Keep track of names, who was interviewed, who was the person that performed some task in the record.

61. WHAT ELSE ?
Show me the immediate post procedure note, all required elements? Time performed?
Show me the post anesthesia assessment < 48 hours after recovery
Show me the nursing care plan, does it read like the patient we just learned about?
Show me the restraint documentation, order renewal
Show me the lab work, any critical results? What is that process?
Lets look at medication orders, range, prn, anticoagulation?

62. FOLLOW UP QUESTIONS Do staff know how to navigate the chart?
Can staff find policies?
Were staff trained and competent?
Go to PACU, med orders, security
Go talk with anesthesia about med labeling and time out
Validate privileges or refer to colleague
Med Rec on admission and discharge?
Does the medical record tell the story?

63. Read the Book
4/15/2017 63

64. READ THIS NEWSLETTER Get it Distributed

65. And Look on the Website, Print All FAQ’s http://www. jointcommission

66. Standards Consist of Three Parts: Standard Statement
Rationale and/or Notes (not in the excel file)
Elements of Performance (EP)
These are the score-able elements

67. Scoring Sample The CAMH

68. How EP’s are Scored Category A
Relate to structural and process requirements, such as policy
Scored as either exist or not. Either compliant or not. All or nothing.

69. How EP’s are Scored Category C
Based on the number of times you do NOT meet a EP
Scored by the surveyors as:
0 = Insufficient Compliance = 3 or > instances of non-compliance
1 = Partial Compliance = 2 instances of non-compliance
2 = Satisfactory Compliance = 0 – 1 instance of non-compliance
For you…. Two observations is NON-COMPLIANT

70. Poor process design in first place Poor transfer of knowledge to users
Tracers reveal….. Failures, defects, workarounds or undesired variation…… Usually caused by one or more of the following……
Poor process design in first place
Poor transfer of knowledge to users
Poor validation of competency of users
Poor measurement of conformance to design
Poor management intervention to fix variation

71. 5 Steps to doing the Right Thing Well : Sustained Execution=Continuous Readiness
Measure conformance an ask...
Poor design?
Inadequate education
Ineffective competency validation
Variation due to work-arounds
Variation due to unit, day of week, time of day, FT/PT/agency staff, etc.
John R. Rosing, MHA, FACHE
Patton Healthcare Consulting
Management Intervention (appropriate action)
Manager
Measure conformance L I N E M A G R S
Manager
Validate competency
Staff dev.
Educate
PI team
Focus/PDSA/Rapid cycle design

72. Please visit and bookmark www.pattonhc.com
QUESTIONS?
Please visit and bookmark