2CURRENT NEW DIRECTIONS AND THEMES EC/LS heavily focused and scoredHigh level disinfectionOR temperature and humidityAir handling and pressure relationshipsMS gapsContract managementClosed record review to zero in on restraint issues and ICU sedation issuesThen there are the top 10
4GOOD IDEAS FOR TRACER INTERVIEW Be enthusiastic about how good you areTalk proudly about the excellent service and care you provideOffer data or other follow up to support compliance if available for areas cited by surveyorHave multiple staff (MD, pharmacist plus RN a BIG help) participate in the unit interviews, one person can forget, get intimidatedKnow what your EMR will display based on userid.Don’t think “what is the right answer” think about what you do day after day.Know where policies are kept & how to access them
5When They Are on Your Unit Know where to find your policies & “fast facts” or other tip toolHave two people in the patient record, a second person as back up looking for stuffOffer policies, describe educationUse your resources, you don’t need to memorizeCall on experts around you
6When They Leave… After the team leaves, find all “IOUs” Find the order Find the anesthesia record, the consent, etcCopy it, highlight the part the surveyor couldn’t findFind the surveyor, show them AND/ORBring a copy to the surveyor room during special issue resolution, escort should record this
7Role of the Escort/Note Taker With an electronic system consider a buddy system, have someone other than the nurse search the record for requested informationGently coachRecord offers to present support and record surveyor’s responseRecord the “he said” “she said”Record MR numbers
8GOOD IDEAS FOR TRACER INTERVIEW In the PACU or PreOp holding know that your surveyor is going to want to see:History and physicalUpdate to the H&PNursing assessmentConsultsOrdersHome medication list, reconciliation if inpatientIf surgical, pre anesthesia 1+2, time out,Post procedure note with all elementspost anesthesia note.Train escorts and scribes where to find these.
9Tracer Tips For Staff Before answering a question: Take a deep breath Make sure you understand the questionOr ask “Could you please rephrase that question…”Offer to provide the answer later in the dayStop talking once you have answeredIf your surveyor pauses after your answer, try to seek acknowledgement that you have fully answered the question don’t just restart talking.
10Tracer Tips For Staff, cont. Never, never “fix” a chart to avoid an RFINever “make up” answers to please the surveyorDon’t be intimidated by surveyors, or by your own management.Do not argue with the surveyorTake advantage of surveyor suggestionsKnow what improvements in patient care came from PI (performance improvement) activitiesDon’t affirm the leading question…” this isn’t a very good process, is it?”
11Focus on the Top 10 & NPSGsThe 2014 standards have 1700 EPs that can be scoredThe Joint Commission does >90% of its scoring on about 25 standards/NPSGsImplement the top scored and all NPSGsSpend you dollar here!
12The Top 10 Most Frequently Cited TJC Standards 2013 Medical Record EntriesRC EP 6, EP 11, EP %Information needed to justify the patient’s care, treatment, and services missingEntries are not dated, timed, signedIllegible hand writing
13The Top 10 Maintaining the Path of Egress LS.02.01.20 EP 13, 16-22 54% Corridors are not free of clutterExit door, exit signSuites are not designated and maintained
14Top 10 High Level Disinfectant IC.02.02.01 EP 1, EP 2, EP 4 47% High level disinfection and sterilization problemsStaff competency and staff supervision are focus areasPoor low level disinfection – Ø contact timePoor storage of equipment, devices, and suppliesHas resulted in Immediate Threat to Life and/or Condition Level Finding
15Top 10 Manage risks with Ventilation systems EC.02.05.01 46% Will lead to a Condition Level FindingNew to the top 10 in 2012, scored in the ORs & procedure areasPos/Neg air pressure relationshipsAir exchanges, correct # per hourFiltration problemsSurveyors can use Tissue TestImproper system design, orLack of inspection, testing, maintenance or performance problems
16Top 10 Maintain building features to prevent effects of fire, smoke LS %Penetrations in fire barriers and fire door issues are still a problem.Usually fire doors not latchingDoors undercut, gaps, rated
17Top 10 Maintenance of Fire Safety Equipment EC.02.03.05 EPs 1- 25 44% Inspection, testing and maintenance of each piece of fire safety device (smoke detector, fire pull station, magnetic door release)Documentation in not readily available for testing fire safety equipmentOften a double hit against leadership
18Top 10 Maintain building features to protect against fire and smoke LS %Primary issue is doors to hazardous areas that are propped openSmoke barrier penetrations, hazardous areas not protectedGaps under doors
19Top 10 Maintain fire extinguishing features LS.02.01.35 35% Sprinkler or fire extinguishment issuesHanging things from sprinkler pipe,18 inch rule, sprinkler head brokenAlso, scored here: ventilation, temperature and humidity problems.
20Top 10 Safe, functional environment EC.02.06.01 EP 1, EP 13 36% Safe, functional area, a catch all standard for ripped mattresses or stained ceiling tilesMaintain ventilation, temperature and humidityDoor held open by air pressure, hot/cold calls, humidity >60%RFAlso scored here: storage of oxygen cylinders
21Top 10 Safe medication storage MM.03.01.01 EPs 2, 3, 6, 7, 8 33% Unsafe/secure storage of medicationRefrigerator temperature not sustained/monitoredMeds unsecured – not locked or under constant surveillanceAccess by non-licensed is not approved by policyTerminated employee ADM access is not cut offImproperly labeled including Ø beyond-use dateExpired or damaged are not removed
22And the Runner-UpsEC EP 3 & Hazardous materials and eye wash station testingPC care plan can be interdisciplinary and customized.MM EP 13 Implementation of medication orders.EC Generator testing is not done on time, or for long enough.EC Problems with medical gas systems.
23And the Runner-UpsHR This standard made it back on the top 20 list! Primary source verification.PC EP 5 The most frequent problem is the update to the H&P.EC – This standard is a catch all for fire safety issues.MS – The biggest issue is that the requirement for completing the H&P is not specified in the medical staff bylaw.sPC The requirement for the pre-anesthesia and pre-sedation assessments
24Success Strategies: Survey Checklist Keep policies simpleMock Tracers to check complianceFix it or find another wayFocus on the top 10 & NPSGsBullet proof weak areasAvoid the Situational Rules
25STANDARDS THAT BECOME MORE CHALLENGING WITH EMR “Find me the pre-anesthesia assessment”“Show me the immediate reassessment just prior to induction”“Show me the immediate post procedure note”“Show me the documentation of time out”EMR will date and time these notes automatically so audit and evaluate how your records look.Make sure staff can even find these documents
26EMR AND TIMING 6:30 am, patient arrives, IV started H+P update 7 am Pre-anesthesia assessment 7:15 amPre-procedure medication orders and IV by anesthesia written at 7:30Pre-procedural verification by staff 7:45Time out 7:55Anesthesia record case ends 10 amImmediate post procedure note timed 7:30Post procedure orders timed 7:30
27EMR AND TIMINGIf you want to start post procedure notes prior to the case filling out demographic, diagnostic information, make sure the note has a final time documented electronically or by author.If you want to write post procedure medication orders, there must be a process to pend, and un-pend them which includes physician authorization
28WHAT REALLY ARE THE H+P REQUIREMENTS? Done within 24 hours of inpatient admissionDone before surgery or invasive procedureFollows your bylaws, R+R content expectationsIf done in the community it can be updated if less than or equal to 30 days oldUpdate note must state: “I have examined the patient, I have reviewed the H+P and there are/are not changes except as noted”.
30Alarm Fatigue Focus Issue A sentinel event alert was released in April ’13Focus of a new National Patient Safety Goal for 2014Alarms have led to Immediate ThreatAlarm being shut off or silencedNot resetting alarm after silencedNot trained on all equipmentResult in patient death
31Sentinel Event Alert Recommendations Leaders ensure there is a process for safe alarm management and response in high- risk areas.Prepare an inventory of alarm-equipped medical devices and identify the default alarm settings and appropriate alarm limits.The summit is to identify specifi actions
32Sentinel Event Alert Recommendations Establish guidelines for alarm settings. Define when alarms are not clinically necessaryEstablish guidelines for tailoring alarm settings and limits for individual patients (who can modify and when)Implement routine inspections and maintenance of alarm-equipped devices.Staff training on aboveThe summit is to identify specifi actions
33Sentinel Event Alert Recommendations Adhere to manufacturer instruction for use, eg: replace single use leads, replace batteriesAssess acoustics of alarm soundsSet as a leadership priorityEstablish a team to addressThe summit is to identify specifi actions
34New NPSG on Alarm Safety NPSG.06.01.01 Establish alarm safety as a priority (7/2014)Identify the most important alarm signals to manage (2014)Establish policies and procedures for managing clinical alarms. (1/2016)educate staff and LIP’s about the purpose and proper operation of alarm systems (1/2016)2): Identify the most important alarm signals to manage based on input from the medical staff and clinical departments and on the results of an analysis of alarm systems against TJC-speciNied criteria that include: the risk each alarm poses to the patient if overlooked, whether an alarm contributes to counterproductive noise and fatigue, the potential for harm based on internal incident history, and a review of the published best practices and guidelines.
35HIGH LEVEL DISINFECTION Identify every location performing HLD and make sure you have a standardized process.Visit every location performing HLD and make sure staff can precisely verbalize the process including dilutions, soak times, dating of chemicals, dating of test strips, documentation of testing.Make sure there is adequate separation of clean and dirty activities.Make sure scopes can hang freely, not touching the bottom, not loopingClose the scope storage cabinet
36HIGH LEVEL DISINFECTION Laryngoscopes, after HLD, must stay wrappedET tubes, and stylets, purchased or cleaned must stay wrappedIf you open a package for a case, discard the device or send for repeat cleaning and wrapping at the end of the case.If you use a blade to test a laryngoscope, there must be a process to keep it clean.Keep airway circuits wrapped, clean until ready for use
37HIGH LEVEL DISINFECTION The endoscopy scope cleaning room should be under negative pressure to remove contaminants and Cidex or other vaporsIn endoscopy, the decontamination door is to stay closed so that the negative pressure can work.The endoscopy procedural area should be under positive pressure to avoid contaminants leaking in.If you have new space for bronchoscopy, it should be under negative pressure.Obtain copies of your pressure reports to verify
38HIGH LEVEL DISINFECTION Surveyors will observe staff as they process dirty equipmentSurveyors 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 understand and follow both. Create a recipe bookWill observe proper use of PPE
39OR TEMP AND HUMIDITYThere should be a process to measure and record daily.Can be building automation or staff performed.Humidity expectation is below 60% (mold and bacteria concern) and has been greater than 35%, but CMS has just authorized greater than or equal to 20% (fire hazard concern)See S&C /19/13, must document use of their blanket waiver on low humidity
40AIR HANDLING AND PRESSURE RELATIONSHIPS OR’s, CSR, Endo, decontam, isolation roomsSurveyors will perform tissue tests, a crude approximation of air pressure relationship.Based on observations they will ask for your validated report.Many organizations have:Not performed the testCan’t find the testThe test failed, and no correctionThe test is old and the relationship no longer works
41MS.01.01.01 Required implementation April 2011 Open book test, no performance requirementAll you had to do is place required statements in medical staff bylaws and rules and regsMany organizations ignored the differentiation between bylaws and R+R.Bylaws are hard to changeR+R and somewhat easierTab a copy of your bylaws with EP’s identifiedIf gaps noticed, go back and add the content
42CONTRACT MANAGEMENTLD clinical contracts must be identified and a list provided to your surveyorEach contract must have:Performance expectationsPerformance evaluationInput from senior leadership/MSSurveyors will pick one or more of your contracts from you listChallenge is being able to identify them allPeople who perform patient care, clinical services that would otherwise be performed by an employed healthcare professional
43CONTRACTS OFTEN MISSED Off site pharmacy compounding in a licensed pharmacy (remember NECC)Nuclear isotope compounding in a licensed pharmacyPacemaker interrogation by contractorCustom orthotic fittings requested and paid for by the hospitalPhysician leaders, telemedicine contractor, anesthesia group, ED group
44CLOSED RECORD REVIEWWhen surveyors perform tracers, they see patients that your currently haveThey may miss the opportunity to see a restraint patient, an ICU sedation patient, an insulin sliding scale or drip patient, and anticoagulation adjustment patient, a blood transfusion, a death, an ED transfer out, a circumcision.Closed record review opens up all of theseMust be able to find these types of records
45PLANS OF CARE Review the H+P Review the initial nursing assessment Identify care issues to manageDoes the read of the care plan sound like the same patient you read about in H+P or initial nursing assessment?Must update care plan immediately if placed in restraint.
46MEDICAL GASESStaff can’t park anything in front of the gas shut off valveValve must be labeled correctly with room numbersNursing staff must know what to do in the event of a fireEngineering staff must have an inspection report on proper functioningDefects noted in the report must be corrected and the report annotated
47PAIN REASSESSMENTWe perform pain reassessment at the required intervalsWe perform pain reassessment within X minutes of giving a pain medTry to keep it simpleDocument the reassessment, be careful in EMR as it may document failure if the note is lateConsider late note process if using a flow sheet to document. If end of shift note is permissible, not necessary.
48Patient Flow New Standards for 2013/2014 Revisions to StandardsLD – hospital manages the flowPC – Hospital meets the needs of the patientPerspectives July, 2012A new R3 document was publishedAnother addition planned for 2014 re boarded patients
49Patient Flow New Standards for 2013/2014 LD – hospital manages the flowLeaders use dataManage throughput – Not just ED, this include PACUBehavioral Health communication (Jan 2014)PC – focus on BHC boarded patientsStaff trainingEnvironment safe and suitedPatient assessment, policies, community
50BEHAVIORAL HEALTHCARE 37% CTS Treatment planning reflect assessed needs, strengths, preferences and goals23% HR LIP privileges or clinical responsibilities15% CTS ** For non 24 hour settings: process for a requiring a medical history and physical15% HR Competency assessment for staff15% NPSG Suicide screen14% EC Safe, functional environment