**The Joint Commission 2015 Update: Robust Process Improvement**

1. TJC 2015 UPDATE PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047

2. The Joint Commission 2015 • Themes • Utilization of Accreditation Process for Proactive Risk Reduction • Uniform Patient Care Process (High Reliability)-will impact PI 2015 • Robust Process Improvement

3. The Joint Commission 2015 Scoring A’s and C’s only EP’s 0, 1, 2 Timeline for Correcting • Criticality and Immediacy of Risk

4. The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC.02.05.01, EP 6 53% Ventilation, air exchanges LS.02.01.20, EP 13 52% Egress EC.02.06.01, EP1 & EP13 51% Safe environment, temp & humidity

5. The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC.02.03.05 50% Fire Safety IC.02.02.01 50% Disinfection, sterilization LS.02.01.10, EP5-7, EP9 49% Fire barrier management

6. The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 RC.01.01.01 49% Dating & Timing LS.02.01.30 46% Smoke barriers LS.02.01.35 44% Sprinklers, ceiling tiles, signage EC.02.02.01, EP 3-5 36% PPE, hazardous waste & materials

7. The Joint Commission 2015 Chapters (Alphabetized) • Accreditation Participation Requirement (APR) • Environment of Care (EC) • Emergency Management (EM)

8. The Joint Commission 2015 Chapters cont’d • Human Resources (HR) • Infection Control (IC) • Information Management (IM) • Leadership (LD) • Life Safety (LS)

9. The Joint Commission 2015 Chapters cont’d • Medication Management (MM) • Medical Staff (MS) • National Patient Safety Goals (NPSG) • Nursing (NR) • Provision of Care (PC)

10. The Joint Commission 2015 Chapters cont’d • Patient Safety System (PS) • Performance Improvement (PI) • Record of Care, Treatment and Services (RC)

11. The Joint Commission 2015 Chapters cont’d • Rights and Responsibilities (RI) • Transplant Safety (TS) • Universal Protocol (UP) • Waived Testing (WT)

12. The Joint Commission 2015 Opportunities for Improvement (OFI) • New section of TJC report • Single observations of “C” EPs • No ESC required • No opportunity for clarification

13. The Joint Commission 2015 New for 2015 Patient Safety Systems Chapter • Informs & educates on patient safety • No new requirements (not scored) • Road map for hospital leaders • Only in 2015 CAMH

14. The Joint Commission 2015 • 2nd Generation Tracers –no changes yet • Cleaning, Disinfectant and Sterilization • Contracted Services • OPPE/FPPE • Advance Diagnostic Imaging • Patient Flow and ED Overcrowding

15. The Joint Commission 2015 • 2nd Generation Tracers cont’d • Clinical Information Systems • Therapeutic Radiation • Competence Assessment Session • Credential Assessment Session • Survey Process Changes • More Staff Interviews • More Patient Interviews

16. The Joint Commission 2015National Patient Safety Goals

17. The Joint Commission 2015National Patient Safety Goals No Changes Common Challenges • Hand hygiene – no goal • Central Lines • Suicide Prevention

18. The Joint Commission 2015Universal Protocol No Changes Common Challenges • Time Out – all involved • Site Marking - radiology

19. The Joint Commission 2015Rights and Responsibilities of the Individual

20. The Joint Commission 2015Rights and Responsibilities of the Individual Changes • RI.01.01.01 – Patient/family informed of rights before care, when possible • RI.01.02.01 – want family notified of admission?

21. The Joint Commission 2015Rights and Responsibilities of the Individual Common Challenges • Advance Directives • Privacy • Pain Management • Informed Consent (per policy)

22. The Joint Commission 2015Record Care, Treatment and Services

23. The Joint Commission 2015Record Care, Treatment and Services Changes • RC.02.01.01 – include complications and Healthcare Associated Infection (HAI)

24. The Joint Commission 2015Record Care, Treatment and Services Common Challenges • Dating of entries – and timing of entries • Post procedural note • Delinquency

25. The Joint Commission 2015Record Care, Treatment and Services Common Challenges cont’d • All orders in medical record (including protocols) • Verbal Orders/telephone orders

26. The Joint Commission 2015Provision of Care

27. The Joint Commission 2015Provision of Care Changes • PC.01.02.03 – discharge planning as reason for reassessment • PC.02.01.01 – RN supervises patient care • PC.03.01.01 – Anesthesiologist supervises Anesthesia Assistant • PC.04.01.01 – Home Care agencies requested to be on list given to patients

28. The Joint Commission 2015Provision of Care Common Challenges • Pain Assessment/Reassessment • Pain management in the ED and outpatient areas • Screens • History and Physicals • Updates to H&P’s – examination • Problem list by the 3rd visit

29. The Joint Commission 2015Provision of Care Common Challenges cont’d • Restraints • Nonviolent • Violent • Patient/Family Education • Moderate Sedation ASA and Airway Assessment

30. The Joint Commission 2015 Medication Management

31. The Joint Commission 2015Medication Management Changes • MM.03.01.01 – record receipt and disposition of radiopharmaceuticals

32. The Joint Commission 2015Medication Management Common Challenges • Fanny packs and pockets • 1st Dose Review • Radiology Protocols • Security-Anesthesia • Emergency Medications

33. The Joint Commission 2015Medication Management Common Challenges cont’d • Contrast Media • Range Orders • Titrated Orders – Pitocin/Sedation for ventilator

34. The Joint Commission 2015Medication Management Common Challenges cont’d • Blanket Orders • Disposal high risk drugs - EPA • Therapeutic duplication • Zophran and Phenergan

35. The Joint Commission 2015Medication Management Common Challenges cont’d • Compounding Pharmacies • Multidose vials – safe injection practices • Auto-injector use for contrast

36. The Joint Commission 2015Medication Management Common Challenges cont’d • Refrigerator checks – weekends • Sample medications • Management of drug shortages

37. The Joint Commission 2015 Infection Control

38. The Joint Commission 2015Infection Control No Changes Common Challenges • Emergency Management • Flu Readiness • Influx of patients • Flu vaccine (staff LIPs)

39. The Joint Commission 2015Infection Control Common Challenges cont’d • Mop water (Big) • Red Bag Trash (Open) • Cleanliness – contact time/how you know it’s clean

40. The Joint Commission 2015Infection Control Common Challenges cont’d • Bar Code Device Cleaning • Sterile storage – 8”-10” off the floor • Sterile storage – solid bottoms for wire shelves

41. The Joint Commission 2015Infection Control Common Challenges cont’d • Air Quality • Exchanges • Humidity/Temps • Pressure gradients

42. The Joint Commission 2015Infection Control Common Challenges cont’d • Scope Management • Reprocess timeframes • Brushes (disposable or sterilized) • Eyewash 10 sec access • Hang freely • Scope cabinet surface – cleanable • Pressure gradient correct

43. The Joint Commission 2015Infection Control Common Challenges cont’d • Scope Management cont’d • PPEs • Impervious cover • TEE • Laryngoscopes • MacGills • Vaginal Probes

44. The Joint Commission 2015Infection Control Common Challenges cont’d • Intermediate and high level disinfection, sterilization • All staff involved have duties in Job Description

45. The Joint Commission 2015Infection Control Common Challenges cont’d • All staff involved have standard competencies • Findings in IC could be immediate threat to life

46. The Joint Commission 2015Transplant Safety

47. The Joint Commission 2015Transplant Safety • No Changes

48. The Joint Commission 2015Transplant Safety Common Challenges • Records • Procedures for tissues • Receipt of tissues • Package integrity • Daily records of temperatures

49. The Joint Commission 2015Transplant Safety Common Challenges • Bidirectional • Staff involved • Materials/Instruction to prepare • Investigation of tissue events

50. The Joint Commission 2015Transplant Safety Common Challenges • Refrigerator temperatures • Ambient temperatures • Testing of alarms • FDA verification annually • Lot numbers of supplies missing