An Update: What's New and Problematic: Joint Commission Standards and CMS Regulations

1. An Update: What's New and Problematic: Joint Commission Standards and CMS Regulations

2. Tracer Tips For Staff • Have a plan: As soon as the surveyor and escort arrive on the floor or unit, everyone knows the action plan. • Bad idea: Everyone abandons the nursing station to avoid being interviewed. • Bad idea: Who is the charge nurse? The charge nurse is Jane Doe, silence, pause, oh Jane isn’t on duty today. • Bad idea: Can I tell her what this is about? • Bad idea: Can you come back, we are so short staffed at this hospital I can’t take the time. • Bad idea: We can do the tracer review where ever you would like. I guess we can use this computer. • ID a quiet room, out of main traffic path to review the medical record for the patient tracer

3. 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

4. When They Are in 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, run policies through your command center • Use your resources, you don’t need to memorize • Call on experts around you

5. When They Leave Your Unit • After the team leaves, find all “IOUs” • Find the missing stuff, if it exists • Find the order • Find the anesthesia record, the consent, etc • Copy it, highlight the part the surveyor couldn’t find • Send to your command center • Make a copy to the surveyor room during special issue resolution, escort should record this

6. Role of the Escort/Note Taker • Record the potential problems • Warn senior leadership of anticipated RFI’s • Get ahold of senior leaders STAT if situation is significant, or surveyor mumbles anything about “immediate threat”. • Be the expert in finding OR documentation in med/surg records.

7. GOOD IDEAS FOR TRACER INTERVIEW • During tracers staff on MS units may be asked to show documents including: • 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.

8. 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.

9. 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?”

10. Focus on the Top 10 & NPSGs • The 2013 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 time and energy here! • If it’s a problem in 30% of the nations hospital make sure it is solid at yours.

11. HOT BUTTON TOPICS WITH TJC • Physical environment • Air pressures and exchanges • Fire safety documentation EC.02.03.05 • Temperature and humidity monitoring • High level disinfection and sterilization • High reliability • Risk assessment • Clinical contracting

12. THE USUAL SUSPECTS • The top 10 MFSS including: • Hallway clutter • Dating and timing medical records/legibility • Medication storage and security • Histories and physicals triple threat, PC, RC, MS • Immediate post procedure notes • Anesthesia assessments

13. THE ANNUAL PROBLEMS • Annual reports missing • Reference to pre 2009 standard numbers in annual reports • Annual evaluations missing or glowing despite known problems • Annual reports have no real performance measures • PFI deadlines missed • Failure to implement ILSM for PFI items • Failure to update ILSM policy to match standards

14. MORE ANNUAL PROBLEMS • Missing the new stuff, failure to realize that surveyors are trained on “that which is new”. • Failure to take advantage of the planning year, CAUTI, ED Flow and boarders • Missed annual education or competency requirements • CAUTI • CLBSI • SSI • Waived testing

15. MOST FREQUENT SUSTAINABILITY FAILURES • Failure to critically evaluate standards compliance • The data looks good, but the review was very superficial • There is a Med Rec form in the chart = compliance • There is a history and physical form in the chart • There is an immediate post procedure note • There is a pre-anesthesia assessment • Hand hygiene compliance was 100%

16. LEARN FROM THE MISTAKES OF OTHERS • Sentinel events have been a great teaching tool in that hospitals can learn about the common problems and root causes in other hospitals and develop prevention strategies. • The most frequently scored standards present another teaching opportunity. • If 30% or more of hospitals are getting hit, shouldn’t we prepare too?

17. The Top 10 Most Frequently Cited TJC Hospital Standards First Half 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

18. The Top 10 Most Frequently Cited • Maintaining the Path of Egress LS.02.01.20 EP 13, 16-22 54% • Corridors are not free of clutter • Rules don’t apply to crash carts and isolation carts in use • Suites are not designated where clutter rules don’t apply • Clinicians remember the 30 minute rule!

19. Top 10 • High Level Disinfection IC.02.02.01 EP 1, EP 2, EP 4 47% • High level disinfection and sterilization problems • Usually a CMS Condition Level Finding • Cidex or other test strips not dated, poor documentation of quality controls • Poor low level disinfection – Ø contact time • Poor storage of equipment, devices, and supplies

20. DISINFECTION • Has the ICP identified and evaluated every location that performs HLD? • Have the same forms and processes been standardized throughout the organization? • Is compliance consistent in every department that performs HLD? • Do we teach or label surface disinfectants to make it easy for staff to know contact time?

21. Top 10 • Manage risks with utility systems EC.02.05.01 46% • New to the top 10 in 2012, higher now in 2013, scored in the ORs & procedure areas • Pos/Neg air pressure relationships wrong • Air exchanges, correct # per hour • Filtration problems • Surveyors can use Tissue Test • Improper system design, or • Lack of inspection, testing, maintenance or performance problems • Staff don’t know what the requirement is and can’t help to support it

22. AIR PRESSURE • Do we have vendor/staff documentation at least twice a year? • If any defects in the report do we have evidence of corrective action and retest? • Do staff in the work unit understand the pressure requirements? • Do staff in the work unit do any testing like a tissue test? • Do administrative rounds demonstrate that doors that must be closed, are closed?

23. Top 10 • Maintain building features to prevent effects of fire, smoke LS.02.01.10 45% • Usually fire doors not latching • Fire barrier penetrations • Doors undercut, gaps, rated • Do you have an inventory for checking periodically like a BMP? Do you have data?

24. 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) • Often a problem with poor organization and ability to find evidence • Often a double hit against leadership

25. Top 10 • Maintain building features to protect against fire and smoke LS.02.01.30 43% • Smoke barrier penetrations, hazardous areas not protected • Gaps under doors

26. 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

27. 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

28. ADMINISRATIVE ROUNDS • Is furniture in good repair, no rips or tears? • Are ceiling tiles free of water damage and stains? • Is OR, sterile storage, central supply temperature and humidity being monitored and found compliant?

29. 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 • Medroom doors all have the same combination and have never been changed. • Improperly labeled including Ø beyond-use date • Expired or damaged are not removed

30. Lessons Learned from Recent TJC SurveysNot the top ten, but very frequently scored issues

31. Label All Medications(NPSG.03.04.01) Label all meds on and off the sterile field. All products, including sterile water/saline, disinfectants in a basin must be labeled. The safety goal includes bedside procedures as well as IR, cath lab, out patient Its an A element of performance Prelabeling??? OK if your policy permits it

32. RANGE ORDERS, THERAPEUTIC DUPLICATION AND PRNS • TJC does not prohibit range orders but it is virtually impossible to do it correctly and consistently without order specifications. • If two therapeutic agents in the same class are prescribed, there must be specifications when to give drug 1, when to give drug 2 • PRN’s must have an indication for use

33. Medication Orders • Preprocedure medications/IVs and testing nurse-initiated protocols are now permitted • Caveats: (create a policy) “Standing Orders” • Must be approved by the medical staff, nursing (to affirm the practice is within the scope of license) and pharmacy (with respect to medications) • Must be based on nationally recognized and evidence based guidelines and recommendations • Include regular PI review to look for problems or improvement opportunities • Date, time, and authenticate per state regulation

34. CPOE and the Pre-OP/Post-OP Order • CPOE signing of post-operative anesthesia or surgical orders pre-operatively now requires a risk assessment and policy to avoid a finding • Got away with it on paper; could fudge or omit the time and not be noticed • CPOE captures the time, so an easy observation • The LIP must either pend or plan the orders and log back in and sign/ release/initiate the orders post-OP, OR • Sign orders pre-OP and justify via risk assessment and policy having the RN reassess the patient and release/initiate the order based on the very nature of conditional/PRN orders

35. CPOE Pre/Post-Op Orders • Physicians and staff seek ways to expedite patient flow by writing post procedure orders before the procedure starts (sometimes hours, days, weeks). This is noble! • EHR/CPOE systems allow organizations to build standard order sets or pre-printed orders to reduce/eliminate redundant work and expedite care. Also noble!

36. CPOE Pre/Post-Op Orders • The organization must decide whether it will allowing practitioners to write post-procedure orders prior to the procedure; if yes, then… • Construct a risk assessment and policy that defends a process where conditional orders (i.e., if this, then that/PRN orders) may be entered/written ahead of time by the LIP and then allow licensed/competent PACU RN to review the order post-OP AND match the order to the assessed needs of the patient • The RN then initiates or activates the order or consults with the ordering LIP if patient condition warrants/changes

37. Sterile Processing Tour • Attire: donned at the hospital, changed daily • Red line – no one enters without proper attire • No artificial nails, nail polish, jewelry, watches • Head AND facial hair covered at all times • In Decontamination: liquid-resistant garb, heavy-duty gloves, eye protections • Follow manufacturers IFU • Temp and humidity monitor and actions • Competency assessment

38. Reduce Risk of Infection • 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 or OneSource • Will observe proper use of PPE

39. SPD Facility • Easily cleaned walls, floors and ceiling • Daily housekeeping • No exposed pipes, etc. that collect dust • Maintain neg/pos pressure by keeping doors and windows closed; test pressures monthly • Sinks available for hand washing • Eye wash within 10 second travel time; single action lever, tepid water temperature to allow 15 minute flush time

40. HVAC Temperature, Humidity, Storage • Monitor and record daily • Temp 68-73 in clean area of department • Temp 60-65 in decontamination • Humidity 20-60% in work areas • Proper # of Air Exchanges (>10, 2 fresh) • Pos/Neg pressure relationships • Humidity not > than 70% in sterile storage • 18 inch, 6 inch, 2 inch, solid lower shelf

41. Relative Humidity to 20% • CMS finally agreed to lower the minimum acceptable humidity level from 30% to 20% • Requires an “internal” waiver • You need not submit a waiver request to CMS or TJC, but simply discuss at a committee of record (e.g., EOC, IC, OR Operations, etc.) and conclude and memorialize in minutes that you have adopted the 20% minimum acceptable

42. EYE WASH STATIONS • Bottles are red flags • Bottles are only good for blood, body fluid, minor irritant splashes • Corrosives must have plumbed eyewash or equivalent • Staff must be able to find MSDS • Staff must be able to correctly operate eyewash • ANSI recommends weekly testing • Water must be tepid

43. H&P and Update • An H&P is done no more than 30 days prior to admission or within 24 hours of admission. • If the H&P is done anytime in the 30 days prior to admission you must update it within 24 hours of admission, or prior to an invasive procedure on the day of the procedure, whichever comes first. • Must document: the patient was examined, and the H&P was reviewed, changes___ or no changes. • In EMR – use a SmartText: e.g., .no changes or .changes

44. HISTORY AND PHYSICAL • MS.03.01.01, EP 6, A,D – “The organized medical staff specifies the minimal content of medical histories and physicals, which may vary by setting, level of care, tx and services”. • Problem: a long form, short form or “ad hoc” form is spotted which doesn’t meet your requirements • CMS now prohibits anything but a “comprehensive H&P” for ASC; Hospitals?

45. HISTORY AND PHYSICAL • EP 7, A – “The medical staff monitors the quality of H+P’s”. • Surveyors score failure to obtain within 24 hours of admission or prior to surgery, then look for actions taken by MEC to improve. • If quality data indicates that indeed sometimes there are performance gaps, what do the minutes show for actions?

46. Sample H&P Bylaw Language A medical history and physical examination be completed and documented for each patient by a hospital practitioner with appropriate privileges no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.  An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration.

47. Document Operative & High Risk Procedures (RC.02.01.03) • H&P in record before procedure (EP 3) • Post op/post procedure report is written or dictated before transfer to next level (EP 5) • (Unless a post op/post procedure note is entered immediately [see EP 7], if so, report may be written or dictated per policy) • The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

48. Document Operative & High Risk Procedures (RC.02.01.03) • No premature Post-OP notes!!! • Medical record includes the LIP release order or approved DC criteria (EP 9) • Medical record includes the use of DC criteria/pt readiness (EP10)

49. Informed Consent • Physician responsibility • Risk of not receiving treatment • Paper form needs date and time for all signatures • CMS requires patient to sign, date, time • May need to have them re-initial, date, time on day of surgery • Form may include potential use of blood • Process includes discussion of likelihood of desired outcome • Anesthesia consent is usually in anesthesia record • Sedation consent is on presedation assessment • RN confirms patient understanding, advocate

50. PREANESTHESIA ASSESSMENT • PC.03.01.03 • EP 1: Presedation/anesthesia assessment required for any type of anesthesia including moderate • EP 8: Immediate reassessment just prior to induction • Not optional, always a 2 step process • Know where these 2 assessments are documented