4 Focus on the Priority Issues The standards have ~1800 EPs that can be scoredThe Joint Commission does >90% of its scoring on about 25 standards/NPSGsFocus on the top scoredFocus on all NPSGsFocus on any NEW standards/FAQFocus on previously scored issues
5 AND THEN THERE ARE THE MOST FREQUENTLY SCORED STANDARDS Low hanging fruit, almost fall on surveyorLearn from the mistakes of othersIf 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 recordThe author identified and authenticated. (EP 11)Timing - Biggest Problem (EP 19)Have you designed paper forms to enable success?Every form has a time boxMultipurpose forms have time/date, signature for every sectionInformation 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 egressEasy to find issues, educate on:Blocked or locked egress doorsCorridor clutter, storage in hallwaysLinen carts and latex carts will be scoredCart on Wheels can be plugged in but not parked for >30 minutesOK stuff:Crash carts are considered “in use”Isolation carts outside occupied room also considered “in use”Dietary cart while deliveringMed 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 latchPenetrations are sealed with correct material
11 Fire Doors, cont Inspect and maintain fire doors Appropriate fire rating on doors and frameDoor positively latchesDoor had a closureNo gaps > 1/8 inch, or undercut >3/4 inchResulted 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 smokeLabel all Hazardous Areas (such as boiler rooms, laboratories, O2 tank supply rooms, flammable liquid storage rooms)Limit access to hazardous areasSelf closing doors work as expected and designed
13 EC.02.03.05 FIRE PROTECTION EQUIPMENT 40% 21 elements of performanceMore focused on testing, inspection and maintenance of fire protective features.Testing alarms and strobesTesting pumps and sprinklersTesting dampersAnd 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 & maintainsfire 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 quarterCheck 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 NFPAThey will review the tagIf bar coded, they will review documentationRequired monthlyCheck 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 & 3Problems or gaps with dating controls & biologicalsStore clean and dirty separatelyAir handlingFlexible Scope CleaningLaryngoscope storage FAQSurveyors trained on AAMI standards for sterilization and disinfection
17 Reduce Risk of Infection, cont 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 understanding, and precisionWill 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 surgeryH+P isn’t more than 30 days oldH+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 warmersWarmers max and duration an issue1 months log only if using paperAlways Document actions takenDescribe how you monitor on weekends in 5 day areas
20 Medication Storage, cont. Clarified - Expired medications including multidose vialsUse BUD label, not date open labelExpire in 28 days or less, vaccines are exceptionPolicy 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 timedIt’s a C element of performance, no MOSIt’s a criticality 4 so you have 60 days to fix it if scoredConsider data use for OPPE, consider hard-stops in your EHREHR is not foolproof on this issue
22 Provide/Maintain Fire Systems and Equip (LS.02.01.35) Sprinklers18 inch ruleSprinkler pipes can not support other items like cables or wiresSprinkler head clean and free of obstruction, collar flushAnsul 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 expirationIf the individual really was unlicensed for a period of time, risk of PDA/CONProblem areas: Decentralized responsibility with lack of oversightSpecial 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 RFIKeep 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 notedGas 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 surveyorsThey are almost all criticality 3, so they countAlways a focus of surveyor trainingThey 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….
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 reconciliationIs 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 easyInpatient 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 programYou 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 infectionsShow me your risk assessment, and most recent update, EP 1Lets ask staff, patients and LIP’s about your education or optionally lets look at some documentation. EP 2 and 3Show me your measurement data from surveillance and how this was presented to leadership. EP 5,6Show me which CPG’s you used. EP 7Show me how you alert ICP to new cases. EP 8Show 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 preventionLets talk with patients, families, staff and LIP’s about your education, or optionally show me documentation. EP 1,2Show me your CPG’s. EP 3Show me your most recent risk assessment. EP 4Show me the report you sent to leadership with the data analysis. EP 5Show me you catheter insertion checklist. EP 6Show me your standardized supply cart. EP 9During 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 infectionLets 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 – CAUTIHave 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 itPart 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 presentPart 2: site marking by the surgeonPart 3: Time out just prior to the procedureTake 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 disinfectionPressure relationships, OR’s, decontamination areasCentral supply adherence to manufacturers sterilization guidance.Look at CMS tracer checklists for ideas.Know that multi-dose vials are vulnerableClosed Record Review is BACK! Stop, see Medical Record Review Tool
46 Tracer Tips For StaffIts not a police interrogation, its not root canalBe enthusiastic about how good we areFocus on the excellent service and care we provideFind a quiet room, out of main traffic path to review the medical record for the patient tracerBefore answering a question:Take a deep breathMake sure you understand the questionOr ask “Could you please rephrase that question…”Talk about what you do, don’t over-think itOffer to provide the answer later in the dayStop talking once you have answeredKnow 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 RFINever “make up” answers to please the surveyorDon’t be intimidated by surveyorsDo not argue with the surveyorWelcome surveyor suggestionsKnow what improvements in patient care came from PI (performance improvement) activitiesHelp the surveyor navigate, tell the patient storyDon’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 ASAPGently coach struggling staffRecord offers to present support and record surveyor’s responseRecord the “he said” “she said”Record MR numbersID 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 patientPatient transferred to the inpatient medical surgical unit.Patient sent to radiology the next morning for CT with contrastPatient scheduled for surgical procedurePatient sent post surgery to ICUPatient transferred to med surg unitPatient 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 assessmentsStaff knowledge of hospital assigned responsibilitiesTAT of critical tests, results or treatmentsHandoff to the unitIssues about flowPrivacy and patient rightsMedication security and storageHand hygiene and IC in general
52 TRACER TECHNIQUEStaff 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 systemsPolicy deficits or non compliance with policyDocumentation defectsFumbles
55 Patient Tracers Focus is on actual care practices. The patient’s care drives assessment of compliance to standards not vice versaFocus is on linkages, continuum of care, and communication among the healthcare teamQuality, timeliness, and completeness of the medical record drives complianceFocused tracers will go into depth on the issue.
56 System TracersInterview Sessions, do mocks for these sessions also, practice!Come ready to talk proudly and showcaseHospital system tracers:Medication ManagementData UseEnvironment of Care – must have documents at your finger tips.Emergency Management – make sure your plan addressed every EPCompetency Assessment - HRInfection Control – make sure your plan addressed every EP
57 Picking the Patient Where will the surveyor visit: All anesthesia and sedation areasAt least 50%-100% inpatient locationsSample of outpatient sitesPicking an internal tracer patient:Multiple units, enter through the ED, transfer from another facility, had surgeryWatch 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 passIf med is drawn up prior to administration was the medication properly labeledTwo patient identifiersEMAR, bar code complianceHand hygiene x2Nursing 5 rightsPain assessment and reassessmentPatient 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 takenNutritional screening and timelinessAbuse screeningPatient educationDecubiti screeningPain 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 documentationUnit 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 recoveryShow me the nursing care plan, does it read like the patient we just learned about?Show me the restraint documentation, order renewalShow 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, securityGo talk with anesthesia about med labeling and time outValidate privileges or refer to colleagueMed Rec on admission and discharge?Does the medical record tell the story?
68 How EP’s are Scored Category A Relate to structural and process requirements, such as policyScored 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 EPScored by the surveyors as:0 = Insufficient Compliance = 3 or > instances of non-compliance1 = Partial Compliance = 2 instances of non-compliance2 = Satisfactory Compliance = 0 – 1 instance of non-complianceFor 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 placePoor transfer of knowledge to usersPoor validation of competency of usersPoor measurement of conformance to designPoor 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 educationIneffective competency validationVariation due to work-aroundsVariation due to unit, day of week, time of day, FT/PT/agency staff, etc.John R. Rosing, MHA, FACHEPatton Healthcare ConsultingManagement Intervention (appropriate action)ManagerMeasure conformanceLINEMAGRSManagerValidate competencyStaff dev.EducatePI teamFocus/PDSA/Rapid cycle design
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