1. 1 Preparing Organizations: Related Joint Commission Standards Chicago, IL September 14, 2004 R. Scott Altman, MD, MPH, MBA Managing Consultant, Joint Commission Resources

2. 2 Objectives of the Presentation  Discuss the related 2004 standards and the implications for ED operations  Recognize the impact of ED overcrowding on patient safety and outcomes of care  Discuss “issues” facing ED’s and possible strategies for improvement  Understand the intent of the draft ED Overcrowding standard and the elements of performance

3. 3 What is Wrong with this Picture?

4. 4 Related Standards 1. Right to Treatment  RI.2.10 and PC.15.20 2. Settings & Services  LD.2.20, LD.3.30, LD.3.80, LD.4.40, EC.8.10, RI.2.10, RI.2.60, and RI.2.130 3. Entry to Services  PC.1.10 and PC.15.20

5. 5 Related Standards 4. Adequate Staffing  LD.3.10, LD.3.70, HR.1.10, HR.1.20, HR.1.30, and PI.2.30 5. Care, Treatment and Services  PC.2.120, PC.2.130, PC.2.150, PC.4.10, PC.5.60, PC.8.10, and IC.4.10 6. Uniformity of Care  LD.3.20

6. 6 Related Standards 7. Timely Ancillary Services  LD.2.20, LD.3.10, LD.3.30, PC.3.230, and PC.5.60 8. Discharge or Transfer  PC.15.10 and PC.15.20 9. Emergency Management  EC.4.10, HR.2.20, EC.4.20, and IC.6.10

7. 7 Related Standards 10. Continuous Improvement  PI.1.10, PI.2.20, PI.3.10, PI.3.20 and LD.4.50 11. New Standard  LD.10.11, LD.3.11, LD.3.15

8. 8 Issues: Right to Appropriate Treatment  Hospitals identify patients rights, then comply with the policy they develop  Note hallway boarding issues, such as confidentiality, privacy, security, hygiene, etc.  Hospitals plan for patients needs to be met in each step of the continuum, including the ED  To the extent that it is felt that patients use ED’s inappropriately, it is the hospitals responsibility to educate its staff, physicians, and patients on appropriate alternatives in their community.

9. 9 Right to Treatment  EMTALA  Prudent Layperson Not JCAHO

10. 10 Issues: Settings & Services  Leadership ensures that services are timely, effective, and efficient;  With adequate space, equipment, and resources;  In an environment that is safe, clean, comfortable, and well lit; and  maintain dignity, confidentiality, privacy, and security

11. 11 Issues: Entry to Services  Hospitals provide for referral, transfer, or discharge of patients to another level of care, health professional, or setting, based on the patient's assessed needs and the hospital's capability to provide the care.  Raises questions about accepting elective or direct admissions when the facility is full.

12. 12  Required admission and discharge criteria are very difficult to enforce  It is inconvenient to move patients in the middle of the night, and it can be politically difficult to require physicians to move their own patients to lower levels of care to open a bed for someone else’s patient Issues: Entry to Services

13. 13  Data should show that during periods of peak utilization, criteria based movement of patients is enforced  Hospitals are required to do discharge planning  To create flexible capacity hospitals need to be creative  Use or consideration of discharge lounges, neighboring hotels, or similar flex space should be documented  Discharge planning can be done for the ED, not just in-patients Issues: Entry to Services

14. 14 Issues: Adequate Staffing  Hospitals must demonstrate that appropriate physician, nursing, and ancillary staff are available and utilized to handle the need, recognizing that the “boarded” patients are in their most acute (highest staff demand) phase of in-patient care.  If staffing ratios are different between the ED and other units caring for patients of equivalent severity, the facility should have documentation demonstrating that the difference in staffing levels is safe and effective for both the patient and the staff.

15. 15 Issues: Care, Treatment, & Services  Initial and re-assessments are performed in the timeframe identified by the organization  The plan of care is individualized, timely, and limits the use of restraints or seclusion  Criteria based patient movement  Pain is assessed and managed  A hand hygiene program is in place  All present challenges during overflow times

16. 16 Issues: Uniformity of Care  Patients in the ED should receive an equivalent level of care to that they would receive in an inpatient bed, be it Critical Care, Psychiatric, Pediatric, or Medical-Surgical  When the ED is used for overflow capacity, it must be done in a way that maximizes the uniformity of care, and patient safety.

17. 17 Issues: Timely Ancillary Services  The environment and culture should enable timely care, treatment, and services  Timely needs to be collaboratively agreed upon and measured as part of an organization-wide performance improvement effort

18. 18 Issues: Discharge or Transfer  Communication between the origin and the destination consists of  The reason for transfer or discharge  The patient’s physical and psychosocial status  A summary of care, treatment, and services provided and progress toward goals  Community resources or referrals provided to the patient

19. 19  Emergency:  A natural or man-made event that significantly disrupts the environment of care;  Eg: severe winds, storms or earthquakes  that significantly disrupts care, treatment, and services;  Eg: loss of utilities  or that results in sudden, significantly changed or increased demands for the organization’s services.  Eg: bioterrorist attack, building collapse, or plane crash Emergency Management

20. 20  EC.4.10  The hospital addresses emergency management  A hazard vulnerability analysis is conducted  The emergency management plan comprehensively describes the hospital’s approach to internal and external emergencies  Hospital leaders including the medical staff are involved with the plan development Emergency Management

21. 21 Hazard Vulnerability Analysis

22. 22 Emergency Management  HR.2.20  Staff, LIP’s, students and volunteers can demonstrate their role relative to safety  Can describe or demonstrate: Risks within the environment Actions to eliminate, minimize, or report risks Procedures to follow in the event of an incident Reporting processes for common problems, failures, and user errors

23. 23 Emergency Management  EC.4.20  The hospital conducts drills regularly to test emergency management  Two drills annually, conducted at least four months apart and no more than eight months apart  One must include an influx of simulated patients  One must be communitywide  The communitywide drill can be tabletop

24. 24 Emergency Management  IC.6.10  As part of emergency management activities, the hospital prepares to respond to an influx, or the risk of an influx, of infections patients  Including determining how it will keep abreast of current information about the emergency of epidemics or new infections, and  how it will disseminate critical information to staff and practitioners

25. 25 Issues: Improving Organizational Performance  Hospitals collect data to monitor performance  Staff opinions, needs, perceptions of risks, and suggestions for improving patient safety  Undesirable patterns or trends in performance are analyzed  Both include management of overcrowding

26. 26 11. Managing Patient Flow  Patient Flow, not ED Overcrowding  Surveyed Beginning July 1, 2004  Scored Beginning January 1, 2005 (note: standard number change from LD.10.11 to LD.3.11, to LD.3.15) No longer includes: “These temporary locations must be outside of the Emergency Department and in an appropriate patient care area.”

27. 27 Managing Patient Flow  LD.3.15  The leaders develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital

28. 28 Rationale of LD.3.15  Managing the flow of patients through their care is essential to the prevention of patient crowding  A problem that can lead to lapses in patient safety and quality of care  Emergency Department is particularly vulnerable to experiencing negative effects of inefficiency in the management of this process

29. 29 Rationale of LD.3.15  Emergency Departments have little control over the volume and type of patient arrivals  Most hospitals have lost the “surge capacity”  Improved management of processes can ensure the wise use of limited resources and thereby reduce the risk to patients of negative outcomes  Includes delays in the delivery of treatment, care, or services

30. 30 Rationale of LD.3.15  Leadership should identify all of the processes critical to patient flow through the hospital system  From the time patient arrives to discharge  Supporting processes are included if identified by leadership as impacting patient flow  Diagnostic  Communication  Patient transportation procedures

31. 31 Elements of Performance (9) 1. Leaders assess patient flow issues within the organization, the impact on patient safety, and plan to mitigate that impact 2. Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations  Post anesthesia care units  Emergency Department areas

32. 32 Elements of Performance 3. Leaders and medical staff share accountability to develop processes that support efficient patient flow 4. Planning includes the delivery of adequate care and services to those patients who are placed in overflow locations (corridors)

33. 33 Elements of Performance 5. Specific indicators are used to measure components of the patient flow process and components  Available supply of patient bed space  Efficiency of patient care and treatment areas  Safety of patient care and treatment areas  Support service processes that impact patient flow

34. 34 Elements of Performance 6. Indicator results are available to those individuals who are accountable for processes that support patient flow 7. Indicator results are reported to leadership on a regular basis to support planning  Includes individuals who are accountable for processes that support patient flow

35. 35 Elements of Performance 8. Organization improves inefficient or unsafe processes identified by leadership as essential in the efficient movement of patients through the organization 9. Criteria are defined to guide decisions about initiating diversion

36. 36 Thank You