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

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Presentation on theme: "Joint Commission Readiness John R. Rosing, MHA, FACHE Vice President and Principal Patton Healthcare Consulting."— Presentation transcript:

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

2 Institute the Action Plan Everyone in Position 2


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 4

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. 5

6 TOP SCORED, STANDARD LEVEL 2012 Source: Perspectives April Complete/accurate medical record (RC – 66%) 2Maintain egress (LS – 56%) 3Fire Protection features maintained (LS – 52%) 4Fire protection features maintained to protect patients (LS – 45%) 5Maintain fire safety equipment (EC – 40%) 6

7 Top Scored TJC 2012 cont. Source: Perspectives April Medical Equip Infection Risk (IC – 36%) 7Assess and reasses per timeframes (PC – 34%) 8Medication Storage (MM – 33%) 9Verbal orders (RC %) 10Maintain system for extinguishing fire (LS – 31%) 7

8 Signing, Dating & Timing Medical Record Entries (RC – 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 8

9 MEANS OF EGRESS, USUALLY EXITS (LS ) 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 9

10 Fire Protection Features (LS %) 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 10

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 11

12 LS -Maintain Building Features (LS – 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 12

13 EC 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 13

14 Fire Protection Equipment (EC – 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 14

15 Fire Extinguisher Dating (EC 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 15

16 MEDICAL EQUIPMENT RISKS IC (IC – 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 16

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 17

18 ASSESS AND REASSESS PER POLICY (PC ) 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…. 18

19 Safe Medication Storage (MM – 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 19

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. 20

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 21

22 Provide/Maintain Fire Systems and Equip (LS ) 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. 22

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

24 Primary Source Verification (HR ) 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 24

25 Assess & Reassess Pain (PC ) 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? 25

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 26

27 Document Operative & High Risk Procedures (RC ) 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) 27

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. 28

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 29

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? 30

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?” 31





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? 36

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 37

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. 38

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 39

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 40

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. 41

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? 42

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. 43

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? 44

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 45

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 46

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?” 47

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 48

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 5/9/ Read the Book

64 READ THIS NEWSLETTER Get it Distributed

65 And Look on the Website, Print All FAQ’s

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 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 Management Intervention (appropriate action) LINEMANAGERSLINEMANAGERS Measure conformance Manager Educate Staff dev. Validate competency Manager Focus/PDSA/Rapid cycle design PI team 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

72 QUESTIONS? Please visit and bookmark

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