joint commission whats new frequently scored standards n.
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  2. CURRENT NEW DIRECTIONS AND THEMES • EC/LS heavily focused and scored • High level disinfection • OR temperature and humidity • Air handling and pressure relationships • MS.01.01.01 gaps • Contract management • Closed record review to zero in on restraint issues and ICU sedation issues • Then there are the top 10

  3. New Focus • High Reliability Organization

  4. GOOD IDEAS FOR TRACER INTERVIEW • Be enthusiastic about how good you are • Talk proudly about the excellent service and care you provide • Offer data or other follow up to support compliance if available for areas cited by surveyor • Have multiple staff (MD, pharmacist plus RN a BIG help) participate in the unit interviews, one person can forget, get intimidated • Know 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

  5. When They Are on Your Unit • Know where to find your policies & “fast facts” or other tip tool • Have two people in the patient record, a second person as back up looking for stuff • Offer policies, describe education • Use your resources, you don’t need to memorize • Call on experts around you

  6. When They Leave… • After the team leaves, find all “IOUs” • Find the order • Find the anesthesia record, the consent, etc • Copy it, highlight the part the surveyor couldn’t find • Find the surveyor, show them AND/OR • Bring a copy to the surveyor room during special issue resolution, escort should record this

  7. Role of the Escort/Note Taker • With an electronic system consider a buddy system, have someone other than the nurse search the record for requested information • Gently coach • Record offers to present support and record surveyor’s response • Record the “he said” “she said” • Record MR numbers

  8. GOOD IDEAS FOR TRACER INTERVIEW • In the PACU or PreOp holding know that your surveyor is going to want to see: • History and physical • Update to the H&P • Nursing assessment • Consults • Orders • Home medication list, reconciliation if inpatient • If surgical, pre anesthesia 1+2, time out, • Post procedure note with all elements • post anesthesia note. • Train escorts and scribes where to find these.

  9. Tracer Tips For Staff • Before answering a question: • Take a deep breath • Make sure you understand the question • Or ask “Could you please rephrase that question…” • Offer to provide the answer later in the day • Stop talking once you have answered • If your surveyor pauses after your answer, try to seek acknowledgement that you have fully answered the question don’t just restart talking.

  10. 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, or by your own management. • Do not argue with the surveyor • Take advantage of surveyor suggestions • Know what improvements in patient care came from PI (performance improvement) activities • Don’t affirm the leading question…” this isn’t a very good process, is it?”

  11. Focus on the Top 10 & NPSGs • The 2014 standards have 1700 EPs that can be scored • The Joint Commission does >90% of its scoring on about 25 standards/NPSGs • Implement the top scored and all NPSGs • Spend you dollar here!

  12. The Top 10 Most Frequently Cited TJC Standards 2013 • Medical Record Entries RC.01.01.01 EP 6, EP 11, EP 19 55% • Information needed to justify the patient’s care, treatment, and services missing • Entries are not dated, timed, signed • Illegible hand writing

  13. The Top 10 • Maintaining the Path of Egress LS.02.01.20 EP 13, 16-22 54% • Corridors are not free of clutter • Exit door, exit sign • Suites are not designated and maintained

  14. Top 10 • High Level Disinfectant IC.02.02.01 EP 1, EP 2, EP 4 47% • High level disinfection and sterilization problems • Staff competency and staff supervision are focus areas • Poor low level disinfection – Ø contact time • Poor storage of equipment, devices, and supplies • Has resulted in Immediate Threat to Life and/or Condition Level Finding

  15. Top 10 • Manage risks with Ventilation systems EC.02.05.01 46% • Will lead to a Condition Level Finding • New to the top 10 in 2012, scored in the ORs & procedure areas • Pos/Neg air pressure relationships • Air exchanges, correct # per hour • Filtration problems • Surveyors can use Tissue Test • Improper system design, or • Lack of inspection, testing, maintenance or performance problems

  16. Top 10 • Maintain building features to prevent effects of fire, smoke LS.02.01.10 45% • Penetrations in fire barriers and fire door issues are still a problem. • Usually fire doors not latching • Doors undercut, gaps, rated

  17. Top 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 equipment • Often a double hit against leadership

  18. Top 10 • Maintain building features to protect against fire and smoke LS.02.01.30 43% • Primary issue is doors to hazardous areas that are propped open • Smoke barrier penetrations, hazardous areas not protected • Gaps under doors

  19. Top 10 • Maintain fire extinguishing features LS.02.01.35 35% • Sprinkler or fire extinguishment issues • Hanging things from sprinkler pipe, • 18 inch rule, sprinkler head broken • Also, scored here: ventilation, temperature and humidity problems.

  20. Top 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 tiles • Maintain ventilation, temperature and humidity • Door held open by air pressure, hot/cold calls, humidity >60%RF • Also scored here: storage of oxygen cylinders

  21. Top 10 • Safe medication storage MM.03.01.01 EPs 2, 3, 6, 7, 8 33% • Unsafe/secure storage of medication • Refrigerator temperature not sustained/monitored • Meds unsecured – not locked or under constant surveillance • Access by non-licensed is not approved by policy • Terminated employee ADM access is not cut off • Improperly labeled including Ø beyond-use date • Expired or damaged are not removed

  22. And the Runner-Ups • EC.02.02.01 EP 3 & 5. Hazardous materials and eye wash station testing • PC.01.03.01 - care plan can be interdisciplinary and customized. • MM.04.01.01 - EP 13 Implementation of medication orders. • EC.02.05.07 - Generator testing is not done on time, or for long enough. • EC.02.05.09 - Problems with medical gas systems.

  23. And the Runner-Ups • HR.01.02.05 - This standard made it back on the top 20 list! Primary source verification. • PC.01.02.03 - EP 5 The most frequent problem is the update to the H&P. • EC.02.03.01 – This standard is a catch all for fire safety issues. • MS.01.01.01 – The biggest issue is that the requirement for completing the H&P is not specified in the medical staff bylaw.s • PC.03.01.03 - The requirement for the pre-anesthesia and pre-sedation assessments

  24. Success Strategies:Survey Checklist • Keep policies simple • Mock Tracers to check compliance • Fix it or find another way • Focus on the top 10 & NPSGs • Bullet proof weak areas • Avoid the Situational Rules

  25. STANDARDS 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

  26. EMR AND TIMING • 6:30 am, patient arrives, IV started • H+P update 7 am • Pre-anesthesia assessment 7:15 am • Pre-procedure medication orders and IV by anesthesia written at 7:30 • Pre-procedural verification by staff 7:45 • Time out 7:55 • Anesthesia record case ends 10 am • Immediate post procedure note timed 7:30 • Post procedure orders timed 7:30

  27. EMR AND TIMING • If 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

  28. WHAT REALLY ARE THE H+P REQUIREMENTS? • Done within 24 hours of inpatient admission • Done before surgery or invasive procedure • Follows your bylaws, R+R content expectations • If done in the community it can be updated if less than or equal to 30 days old • Update note must state: “I have examined the patient, I have reviewed the H+P and there are/are not changes except as noted”.


  30. Alarm Fatigue Focus Issue • A sentinel event alert was released in April ’13 • Focus of a new National Patient Safety Goal for 2014 • Alarms have led to Immediate Threat • Alarm being shut off or silenced • Not resetting alarm after silenced • Not trained on all equipment • Result in patient death

  31. Sentinel Event AlertRecommendations • 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.

  32. Sentinel Event AlertRecommendations • Establish guidelines for alarm settings. Define when alarms are not clinically necessary • Establish 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 above

  33. Sentinel Event AlertRecommendations • Adhere to manufacturer instruction for use, eg: replace single use leads, replace batteries • Assess acoustics of alarm sounds • Set as a leadership priority • Establish a team to address

  34. New NPSG on Alarm SafetyNPSG.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)

  35. HIGH 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 looping • Close the scope storage cabinet

  36. HIGH LEVEL DISINFECTION • Laryngoscopes, after HLD, must stay wrapped • ET tubes, and stylets, purchased or cleaned must stay wrapped • If 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

  37. HIGH LEVEL DISINFECTION • The endoscopy scope cleaning room should be under negative pressure to remove contaminants and Cidex or other vapors • In 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

  38. HIGH LEVEL DISINFECTION • 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 understand and follow both. Create a recipe book • Will observe proper use of PPE

  39. OR TEMP AND HUMIDITY • There 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 13-25 4/19/13, must document use of their blanket waiver on low humidity

  40. AIR HANDLING AND PRESSURE RELATIONSHIPS • OR’s, CSR, Endo, decontam, isolation rooms • Surveyors 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 test • Can’t find the test • The test failed, and no correction • The test is old and the relationship no longer works

  41. MS.01.01.01 • Required implementation April 2011 • Open book test, no performance requirement • All you had to do is place required statements in medical staff bylaws and rules and regs • Many organizations ignored the differentiation between bylaws and R+R. • Bylaws are hard to change • R+R and somewhat easier • Tab a copy of your bylaws with EP’s 16-36 identified • If gaps noticed, go back and add the content

  42. CONTRACT MANAGEMENT • LD.04.03.09 clinical contracts must be identified and a list provided to your surveyor • Each contract must have: • Performance expectations • Performance evaluation • Input from senior leadership/MS • Surveyors will pick one or more of your contracts from you list • Challenge is being able to identify them all • People who perform patient care, clinical services that would otherwise be performed by an employed healthcare professional

  43. CONTRACTS OFTEN MISSED • Off site pharmacy compounding in a licensed pharmacy (remember NECC) • Nuclear isotope compounding in a licensed pharmacy • Pacemaker interrogation by contractor • Custom orthotic fittings requested and paid for by the hospital • Physician leaders, telemedicine contractor, anesthesia group, ED group

  44. CLOSED RECORD REVIEW • When surveyors perform tracers, they see patients that your currently have • They 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 these • Must be able to find these types of records

  45. PLANS OF CARE • Review the H+P • Review the initial nursing assessment • Identify care issues to manage • Does 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.

  46. MEDICAL GASES • Staff can’t park anything in front of the gas shut off valve • Valve must be labeled correctly with room numbers • Nursing staff must know what to do in the event of a fire • Engineering staff must have an inspection report on proper functioning • Defects noted in the report must be corrected and the report annotated

  47. PAIN REASSESSMENT • We perform pain reassessment at the required intervals • We perform pain reassessment within X minutes of giving a pain med • Try to keep it simple • Document the reassessment, be careful in EMR as it may document failure if the note is late • Consider late note process if using a flow sheet to document. If end of shift note is permissible, not necessary.

  48. Patient Flow New Standards for 2013/2014 • Revisions to Standards • LD.04.03.11 – hospital manages the flow • PC.01.01.01 – Hospital meets the needs of the patient • Perspectives July, 2012 • A new R3 document was published • Another addition planned for 2014 re boarded patients

  49. Patient Flow New Standards for 2013/2014 • LD.04.03.11 – hospital manages the flow • Leaders use data • Manage throughput – Not just ED, this include PACU • Behavioral Health communication (Jan 2014) • PC.01.01.01 – focus on BHC boarded patients • Staff training • Environment safe and suited • Patient assessment, policies, community

  50. BEHAVIORAL HEALTHCARE • 37% CTS.03.01.03 Treatment planning reflect assessed needs, strengths, preferences and goals • 23% HR.02.01.03 LIP privileges or clinical responsibilities • 15% CTS.02.01.05** For non 24 hour settings: process for a requiring a medical history and physical • 15% HR.01.06.01 Competency assessment for staff • 15% NPSG.15.01.01 Suicide screen • 14% EC.02.06.01 Safe, functional environment