1. Unannounced Visitors – You and The Joint Commission (TJC)
David Gourley, RRT, MHA, FAARC
Executive Director of Regulatory Affairs
Chilton Hospital
Pompton Plains, New Jersey

2. Unannounced Visitors - You and The Joint Commission (TJC)
Shared Visions – New Pathways
Periodic Performance Review
Unannounced Surveys
Priority Focus Process
Tracer Methodology
Patient Safety
Emergency Preparedness
Performance Measurement
Hot Topics for RT’s
Focus Conference - Fall 2013

3. Accreditation Why are we accredited? Accreditation options
Quality of patient
Patient safety
External validation
CMS requirement
Third party payors
Accreditation options
TJC AOA
DNV
Home care (10 accrediting bodies)
Focus Conference - Fall 2013

4. CEO’s Perspective on Environment
Affordable Care Act (ACA) requirements
Clinically integrated services
Team based models
Accelerated changes to provide evidence-based care
Pressures from physicians to affiliate with hospital
Increased costs (drugs, supplies, technology, staff)
Increased competition
Consumer interest in public scorecards
Decreased reimbursement
Focus Conference - Fall 2013

5. Intracycle Monitoring (ICM)
Goals of ICM
Improve/add value to PPR/FSA
Significant improvements in process and assessment tool
Valued, relevant, and efficient for customers and TJC
Identify and proactively manage risk
Focus on risk points throughout accreditation cycle
Proximity to patient
Probability of harm
Severity of harm
Number of patients at risk
Provide tools/resources/solutions
Focus Conference - Fall 2013

6. Intracycle Monitoring (ICM) (cont.)
Periodic Performance Review (PPR) changed to Focused Standards Assessment (FSA)
Completed annually
Required to complete “Risk” standards
Four options for completion of FSA
Full FSA (self evaluation)
Option I
Option II
Option III
Focus Conference - Fall 2013

7. Challenging StandardsRC
Hospital maintains complete and accurate medical record for each individual patient
All entries are timed
All entries are dated (10/05/13)
Information needed to justify the patient’s care, treatment, and services LS
Hospital maintains the integrity of the means of egress
Hallway clutter
Focus Conference - Fall 2013

8. Challenging Standards (cont.)
Hallway clutter
“If the hallway looks cluttered…. it probably is!”
Carts allowed:
Code Carts
Isolation Carts
Chemo Carts
Anything in egress corridor for more than 30 minutes is storage
Dead end corridors may be used for storage
Focus Conference - Fall 2013

9. Challenging Standards (cont.)LS
Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
Fire barrier penetrations
Fire door issues EC
The hospital maintains fire safety equipment and features.
Focus Conference - Fall 2013

10. Challenging Standards (cont.)IC
Hospital reduces risk of infections associated with medical equipment, devices, and supplies
Intermediate and high-level disinfection and sterilization
Storage of medical equipment, devices, and supplies
Contact time for disinfectants MM
Hospital safely stores medications
Medications stored according to manufacturer’s specifications
Medications are stored in secure area to prevent diversion
Expired meds are removed from stock
Focus Conference - Fall 2013

11. Challenging Standards (cont.)LS
Hospital provides and maintains features to protect from hazards of fire and smoke
Smoke barriers and doors
Door “chocks” LS
There is 18” or more clearance maintained below sprinkler head to the top of storage
Focus Conference - Fall 2013

12. Challenging Standards (cont.)EC
Interior spaces meet the needs of patient population and are safe for care, treatment, and services
Unsecured oxygen cylinders
Adequate ventilation, temperature, and humidity EC
Personal protective equipment (PPE) and process to manage hazardous materials and waste
Focus Conference - Fall 2013

13. Challenging Standards (cont.)PC
Hospital assesses and reassesses the patient according to defined time frames.
Initial assessment performed within defined time frame
H&P no more than 30 days prior to surgery or procedure
Updated H&P documenting any changes within 24 hours of admission RC
Qualified staff receive and record verbal orders
Verbal orders are authenticated within defined time frame
Focus Conference - Fall 2013

14. Challenging Standards (cont.)MM
Medication orders are clear and accurate
Hospital policy for medication orders are implemented
Hospital reviews and updates preprinted order sheets within identified time frame, based on current evidence and practice PC
Hospital plans for patient’s care
Based on assessment, reassessment, and results
Written care plan based on patient goals and time frames
Revises plan and goals, based on patient needs
Focus Conference - Fall 2013

15. Challenging Standards (cont.)EC
Medical gas systems
Inspection, testing, and maintenance
Labeling of medical gas shut-off valves
Contents of piping
Areas served PC
Hospital provides patient with care before initiating operative or other high-risk procedures
Pre-sedation/pre-anesthesia assessment
Immediate reassessment
Focus Conference - Fall 2013

16. Challenging Standards (cont.)EC
Fire safety
More than 300 cubic feet of non-flammable medical gas open to egress corridor
Lack of fire safety training as per fire plan PC
Hospital assesses and manages the patient’s pain
Conduct comprehensive pain assessment
Reassesses patient and responds to patient’s pain
Consider overmedicating as much of a problem as undermedicating
Focus Conference - Fall 2013

17. New for 2014 Clinical alarms
Originally one of the National Patient Safety Goals (NPSG)
Sentinel Event Alert # 50 (April 8, 2013)
NPSG for 2014
Incidents of alarms being silenced or shut off
Default settings
Incidents of inadequate staffing to support
No mechanisms for monitoring/responding
Incidents of “alarm fatigue”
Overuse, excessive number of alarms
Patient deaths have occurred
Focus Conference - Fall 2013

18. New for 2014 (cont.) Clinical alarms (cont.)
Effective 7/1/14, leaders establish alarm system safety as a hospital priority.
During 2014, identify the most important alarm signals to manage based on the following:
Input from medical staff and clinical departments
Risk to patients if alarm is not attended to or malfunctions
Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
Potential for patient harm based on internal incident history
Published best practices and guidelines
Focus Conference - Fall 2013

19. New for 2014 (cont.) Clinical alarms (cont.)
Effective 1/1/16, establish policies and procedures for managing alarms, at a minimum, address the following:
Clinically appropriate settings for alarm signals
When alarm signals can be disabled
When alarm parameters can be changed
Who has authority to set alarm parameters
Who has authority to change alarm parameters
Who has authority to turn alarm off
Monitoring and responding to alarms
Checking alarm signals for accurate settings, operation, and detectability
Focus Conference - Fall 2013

20. New for 2014 (cont.) Clinical alarms (cont.)
Effective 1/1/16, healthcare organizations must educate staff about purpose and proper operation of alarm systems for which they are responsible
Focus Conference - Fall 2013

21. Unannounced Surveys
Survey may occur anytime from 18 to 36 months from last survey date
Promote a positive culture regarding accreditation
Create perpetual state of readiness
Eliminate need for ramp-up
Integrate prep activities with management activities
Develop internal accreditation experts
Focus Conference - Fall 2013

22. Unannounced Surveys (cont.)
Arrival of surveyors on-site
Prepare information desk
Meet and greet surveyors
Notification of all key personnel
Notification of all staff
Secure conference rooms
notifications to appropriate staff
Focus Conference - Fall 2013

23. Unannounced Surveys (cont.)
Preparing your department
Educate back-up personnel
Needed documents:
Policy and procedure manual
PI data
Infection control data
Competency assessment data
Communicate with staff
Focus Conference - Fall 2013

24. Tracer Methodology “A Systems Approach to Evaluation”
Traces a number of patients through Healthcare organization’s entire process
Surveyor may identify performance issues in one or more steps of the process – or in interfaces between processes
Initially uses priority focus areas and clinical service groups
Process surveyors use during on-site survey to “trace” patient care throughout the organization
Focus Conference - Fall 2013

25. Tracer Methodology (cont.)
Follows course of care/service provided to patient
Assesses relationship among disciplines and important functions
Evaluates performance relevant to the individual
Comprises 50 – 60% of on-site survey
Approximately 90 minutes in length
Focus Conference - Fall 2013

26. Tracer Methodology (cont.)
Patient tracer selection criteria
Clinical service groups
Patients receiving complex services
Patients crossing different programs/ services
Patients related to systems tracers
Infection Control
Medication Management
Focus Conference - Fall 2013

27. Tracer Methodology (cont.)
Starts in setting where patient is located
May include sequential following of course of care
Includes evaluation of top 4 – 5 priority focus areas
Observation of care areas and environment of care issues
Focus Conference - Fall 2013

28. Tracer Methodology (cont.)
Patient tracer visits may include:
Observation of direct care
Observation of medication mgmt. process
Observation of care planning process
Patient or family interview
Review of medical record with staff
Staff level interaction
Review of policies and procedures
Staff level interaction includes:
Daily roles and responsibilities
Training and orientation
Performance measurement
Focus Conference - Fall 2013

29. Tracer Methodology (cont.)
Systems tracers
Medication Management
Data Use
Infection Control
Emergency Management
Environment of Care
Suicide Prevention
Patient Flow
Set of components working toward common goal
Evaluation of how well systems function
Addresses interrelationship of elements
Translates standards compliance into potential vulnerabilities
Medication Management
Use of data (ORYX and staffing effectiveness
Infection control
Staffing effectiveness
Patient safety
Focus Conference - Fall 2013

30. Patient safety Integrated patient safety program
National patient safety goals (NPSG)
Sentinel events
Failure mode and effects analysis (FMEA)
Focus Conference - Fall 2013

31. Patient safety (cont.) Integrated patient safety program
Managed by qualified individual or interdisciplinary team
Definition of scope of program oversight
Integrated throughout organization
Procedures for response
Systems for internal and external reporting
Defined responses to unanticipated events
Support systems for staff members
Annual reports on system/process failures and actions taken to improve safety
Oversight – ranging from “no harm” events (slips) to sentinel events with serious adverse outcomes
Procedures for responding: caring for affected individuals, containing risk, preserving factual information for analysis
Focus Conference - Fall 2013

32. Patient safety (cont.)
Focus Conference - Fall 2013

33. Patient safety (cont.)
National patient safety goals for hospitals (2014)
Improve accuracy of patient identification
Eliminate transfusion errors related to patient misidentification
Report critical results of tests and diagnostic procedures on a timely basis
Label all medications, med containers, and other solutions
Reduce patient harm from anticoagulant therapy
Accurately and completely reconcile medications across the continuum of care
Comply with CDC or WHO hand hygiene guidelines
Focus Conference - Fall 2013

34. Patient safety (cont.)
National patient safety goals for hospitals (2014) (cont.)
Implement evidence-based practices to prevent healthcare- associated infections from multidrug-resistant organisms
Implement evidence-based practices to prevent CLABSI
Implement evidence-based practices to prevent SSI
Implement evidence-based practices to prevent CAUTI
Identify patients at risk of suicide
Universal protocol
Focus Conference - Fall 2013

35. Patient safety (cont.)
Focus Conference - Fall 2013

36. Patient safety (cont.) Surveying and scoring NPSG
All accreditation programs
Must implement all relevant goals, or acceptable alternative
Surveyors evaluate actual performance, not just intent
Focus Conference - Fall 2013

37. Patient safety (cont.) Sentinel events Defining sentinel events
Reporting of sentinel events
Conducting root cause analysis
Creating risk reduction strategy
Root cause analysis – thorough and credible
Risk reduction strategy – creating, documenting, and implementing. Include action plan that measures effectiveness of process and system improvements to reduce risk
Focus Conference - Fall 2013

38. Patient safety (cont.) Failure mode and effects analysis (FMEA)
Pro-active program for identifying and reducing unanticipated adverse events
Select high risk process to be analyzed
One process to be analyzed annually
Based in part on Sentinel Event Alerts
Focus Conference - Fall 2013

39. Patient safety (cont.)
Failure mode and effects analysis (FMEA) (cont.)
Identify high-risk process and assemble a team
Diagram the process
Brainstorm potential failure modes and their effects
Prioritize failure modes
Identify root causes of failure modes
Redesign the process
Analyze and test the new process
Implement and monitor the redesigned process
Focus Conference - Fall 2013

40. Hot Topics for RT’s Orientation and Competency
How were you oriented to vent care?
How often is your competency evaluated?
What is your newest ventilator?
Did you get an in-service?
Was there a competency?
Do you intubate?
How is your competency assessed?
Are you ACLS or PALS certified?
Focus Conference - Fall 2013

41. Hot Topics for RT’s (cont.)
Clinical Practice
If two or three vent alarms are going off at once, how do you differentiate?
What is your role on the Code Team?
What is the criteria for restraints and vent patients?
How often are vents checked?
How often do you check alarms?
How often is tubing changed?
How often is PM done on vents?
Focus Conference - Fall 2013

42. Hot Topics for RT’s (cont.)
Clinical Practice
Where do you document treatments?
Are you evaluating missed treatments?
Are missed treatments considered med errors?
What is the most common reason for missed treatments?
What can be done about it?
Are you drilling down “refusals”
Do you track by shift, time of day, RT?
Focus Conference - Fall 2013

43. Hot Topics for RT’s (cont.)
Clinical Practice
Do you draw blood gases?
How do you label specimens?
How do you identify the patient?
What is your turnaround time?
How do you communicate critical values?
Have you had any needlesticks?
Do you have safety devices on your needles?
Focus Conference - Fall 2013

44. Hot Topics for RT’s (cont.)
Clinical Practice
Do you have weaning protocols?
Who weans patients?
Do you attend critical care rounds?
What measures are being taken to prevent VAP?
How are vents cleaned between patients?
How would you evacuate vent patients?
Can RTs transcribe verbal orders?
What are the “don not use” abbreviations?
Focus Conference - Fall 2013

45. Hot Topics for RT’s (cont.)
Assessment
What is included in your assessment?
What do you reassess after treatments?
Do you assess smoking status?
Staffing
How many RTs are here during the day?
How many RTs are here at night?
What is the RT staffing plan?
Focus Conference - Fall 2013

46. Hot Topics for RT’s (cont.)
Performance Improvement
What PI projects are you working on?
Do you track re-intubations?
What is your vent LOS?
How do you track VAP?
Focus Conference - Fall 2013

47. Hot Topics for RT’s (cont.)
Medication Management
How do you get meds for treatments?
Are RT meds on med profile?
Are RT meds reviewed by pharmacy?
Who pulls RT meds from Pyxis?
Are RT meds documented on MAR?
Do you have a “window of time” before or after a treatment is due to be considered late?
Focus Conference - Fall 2013

48. Questions???