Unannounced Visitors – You and The Joint Commission (TJC)

1. Unannounced Visitors –You and The Joint Commission (TJC) David Gourley, RRT, MHA, FAARC Executive Director of Regulatory Affairs Chilton Hospital Pompton Plains, New Jersey

2. Unannounced Visitors -You and The Joint Commission (TJC) • Shared Visions – New Pathways • Periodic Performance Review • Unannounced Surveys • Priority Focus Process • Tracer Methodology • Patient Safety • Emergency Preparedness • Performance Measurement • Hot Topics for RT’s Focus Conference - Fall 2013

3. Accreditation • Why are we accredited? • Quality of patient • Patient safety • External validation • CMS requirement • Third party payors • Accreditation options • TJCAOA • DNV • Home care (10 accrediting bodies) Focus Conference - Fall 2013

4. CEO’s Perspective on Environment • Affordable Care Act (ACA) requirements • Clinically integrated services • Team based models • Accelerated changes to provide evidence-based care • Pressures from physicians to affiliate with hospital • Increased costs (drugs, supplies, technology, staff) • Increased competition • Consumer interest in public scorecards • Decreased reimbursement Focus Conference - Fall 2013

5. Intracycle Monitoring (ICM) • Goals of ICM • Improve/add value to PPR/FSA • Significant improvements in process and assessment tool • Valued, relevant, and efficient for customers and TJC • Identify and proactively manage risk • Focus on risk points throughout accreditation cycle • Proximity to patient • Probability of harm • Severity of harm • Number of patients at risk • Provide tools/resources/solutions Focus Conference - Fall 2013

6. Intracycle Monitoring (ICM) (cont.) • Periodic Performance Review (PPR) changed to Focused Standards Assessment (FSA) • Completed annually • Required to complete “Risk” standards • Four options for completion of FSA • Full FSA (self evaluation) • Option I • Option II • Option III Focus Conference - Fall 2013

7. Challenging Standards • RC.01.01.01 • Hospital maintains complete and accurate medical record for each individual patient • All entries are timed • All entries are dated (10/05/13) • Information needed to justify the patient’s care, treatment, and services • LS.02.01.20 • Hospital maintains the integrity of the means of egress • Hallway clutter Focus Conference - Fall 2013

8. Challenging Standards (cont.) • Hallway clutter • “If the hallway looks cluttered…. it probably is!” • Carts allowed: • Code Carts • Isolation Carts • Chemo Carts • Anything in egress corridor for more than 30 minutes is storage • Dead end corridors may be used for storage Focus Conference - Fall 2013

9. Challenging Standards (cont.) • LS.02.01.10 • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. • Fire barrier penetrations • Fire door issues • EC.02.03.05 • The hospital maintains fire safety equipment and features. Focus Conference - Fall 2013

10. Challenging Standards (cont.) • IC.02.02.01 • Hospital reduces risk of infections associated with medical equipment, devices, and supplies • Intermediate and high-level disinfection and sterilization • Storage of medical equipment, devices, and supplies • Contact time for disinfectants • MM.03.01.01 • Hospital safely stores medications • Medications stored according to manufacturer’s specifications • Medications are stored in secure area to prevent diversion • Expired meds are removed from stock Focus Conference - Fall 2013

11. Challenging Standards (cont.) • LS.03.01.30 • Hospital provides and maintains features to protect from hazards of fire and smoke • Smoke barriers and doors • Door “chocks” • LS.02.01.35 • There is 18” or more clearance maintained below sprinkler head to the top of storage Focus Conference - Fall 2013

12. Challenging Standards (cont.) • EC.02.06.01 • Interior spaces meet the needs of patient population and are safe for care, treatment, and services • Unsecured oxygen cylinders • Adequate ventilation, temperature, and humidity • EC.02.02.01 • Personal protective equipment (PPE) and process to manage hazardous materials and waste Focus Conference - Fall 2013

13. Challenging Standards (cont.) • PC.01.02.03 • Hospital assesses and reassesses the patient according to defined time frames. • Initial assessment performed within defined time frame • H&P no more than 30 days prior to surgery or procedure • Updated H&P documenting any changes within 24 hours of admission • RC.02.03.07 • Qualified staff receive and record verbal orders • Verbal orders are authenticated within defined time frame Focus Conference - Fall 2013

14. Challenging Standards (cont.) • MM.04.01.01 • Medication orders are clear and accurate • Hospital policy for medication orders are implemented • Hospital reviews and updates preprinted order sheets within identified time frame, based on current evidence and practice • PC.01.03.01 • Hospital plans for patient’s care • Based on assessment, reassessment, and results • Written care plan based on patient goals and time frames • Revises plan and goals, based on patient needs Focus Conference - Fall 2013

15. Challenging Standards (cont.) • EC.02.05.09 • Medical gas systems • Inspection, testing, and maintenance • Labeling of medical gas shut-off valves • Contents of piping • Areas served • PC.03.01.03 • Hospital provides patient with care before initiating operative or other high-risk procedures • Pre-sedation/pre-anesthesia assessment • Immediate reassessment Focus Conference - Fall 2013

16. Challenging Standards (cont.) • EC.02.03.01 • Fire safety • More than 300 cubic feet of non-flammable medical gas open to egress corridor • Lack of fire safety training as per fire plan • PC.01.02.07 • Hospital assesses and manages the patient’s pain • Conduct comprehensive pain assessment • Reassesses patient and responds to patient’s pain • Consider overmedicating as much of a problem as undermedicating Focus Conference - Fall 2013

17. New for 2014 • Clinical alarms • Originally one of the National Patient Safety Goals (NPSG) • Sentinel Event Alert # 50 (April 8, 2013) • NPSG for 2014 • Incidents of alarms being silenced or shut off • Default settings • Incidents of inadequate staffing to support • No mechanisms for monitoring/responding • Incidents of “alarm fatigue” • Overuse, excessive number of alarms • Patient deaths have occurred Focus Conference - Fall 2013

18. New for 2014 (cont.) • Clinical alarms (cont.) • Effective 7/1/14, leaders establish alarm system safety as a hospital priority. • During 2014, identify the most important alarm signals to manage based on the following: • Input from medical staff and clinical departments • Risk to patients if alarm is not attended to or malfunctions • Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue • Potential for patient harm based on internal incident history • Published best practices and guidelines Focus Conference - Fall 2013

19. New for 2014 (cont.) • Clinical alarms (cont.) • Effective 1/1/16, establish policies and procedures for managing alarms, at a minimum, address the following: • Clinically appropriate settings for alarm signals • When alarm signals can be disabled • When alarm parameters can be changed • Who has authority to set alarm parameters • Who has authority to change alarm parameters • Who has authority to turn alarm off • Monitoring and responding to alarms • Checking alarm signals for accurate settings, operation, and detectability Focus Conference - Fall 2013

20. New for 2014 (cont.) • Clinical alarms (cont.) • Effective 1/1/16, healthcare organizations must educate staff about purpose and proper operation of alarm systems for which they are responsible Focus Conference - Fall 2013

21. Unannounced Surveys • Survey may occur anytime from 18 to 36 months from last survey date • Promote a positive culture regarding accreditation • Create perpetual state of readiness • Eliminate need for ramp-up • Integrate prep activities with management activities • Develop internal accreditation experts Focus Conference - Fall 2013

22. Arrival of surveyors on-site Prepare information desk Meet and greet surveyors Notification of all key personnel Notification of all staff Secure conference rooms Email notifications to appropriate staff Unannounced Surveys (cont.) Focus Conference - Fall 2013

23. Preparing your department Educate back-up personnel Needed documents: Policy and procedure manual PI data Infection control data Competency assessment data Communicate with staff Unannounced Surveys (cont.) Focus Conference - Fall 2013

24. Tracer Methodology • “A Systems Approach to Evaluation” • Traces a number of patients through Healthcare organization’s entire process • Surveyor may identify performance issues in one or more steps of the process – or in interfaces between processes • Initially uses priority focus areas and clinical service groups Focus Conference - Fall 2013

25. Tracer Methodology (cont.) • Follows course of care/service provided to patient • Assesses relationship among disciplines and important functions • Evaluates performance relevant to the individual • Comprises 50 – 60% of on-site survey • Approximately 90 minutes in length Focus Conference - Fall 2013

26. Tracer Methodology (cont.) • Patient tracer selection criteria • Clinical service groups • Patients receiving complex services • Patients crossing different programs/ services • Patients related to systems tracers • Infection Control • Medication Management Focus Conference - Fall 2013

27. Tracer Methodology (cont.) • Starts in setting where patient is located • May include sequential following of course of care • Includes evaluation of top 4 – 5 priority focus areas • Observation of care areas and environment of care issues Focus Conference - Fall 2013

28. Tracer Methodology (cont.) • Patient tracer visits may include: • Observation of direct care • Observation of medication mgmt. process • Observation of care planning process • Patient or family interview • Review of medical record with staff • Staff level interaction • Review of policies and procedures Focus Conference - Fall 2013

29. Tracer Methodology (cont.) • Systems tracers • Medication Management • Data Use • Infection Control • Emergency Management • Environment of Care • Suicide Prevention • Patient Flow • Set of components working toward common goal • Evaluation of how well systems function • Addresses interrelationship of elements • Translates standards compliance into potential vulnerabilities Focus Conference - Fall 2013

30. Patient safety • Integrated patient safety program • National patient safety goals (NPSG) • Sentinel events • Failure mode and effects analysis (FMEA) Focus Conference - Fall 2013

31. Patient safety (cont.) • Integrated patient safety program • Managed by qualified individual or interdisciplinary team • Definition of scope of program oversight • Integrated throughout organization • Procedures for response • Systems for internal and external reporting • Defined responses to unanticipated events • Support systems for staff members • Annual reports on system/process failures and actions taken to improve safety Focus Conference - Fall 2013

32. Patient safety (cont.) Focus Conference - Fall 2013

33. Patient safety (cont.) • National patient safety goals for hospitals (2014) • Improve accuracy of patient identification • Eliminate transfusion errors related to patient misidentification • Report critical results of tests and diagnostic procedures on a timely basis • Label all medications, med containers, and other solutions • Reduce patient harm from anticoagulant therapy • Accurately and completely reconcile medications across the continuum of care • Comply with CDC or WHO hand hygiene guidelines Focus Conference - Fall 2013

34. Patient safety (cont.) • National patient safety goals for hospitals (2014) (cont.) • Implement evidence-based practices to prevent healthcare-associated infections from multidrug-resistant organisms • Implement evidence-based practices to prevent CLABSI • Implement evidence-based practices to prevent SSI • Implement evidence-based practices to prevent CAUTI • Identify patients at risk of suicide • Universal protocol Focus Conference - Fall 2013

35. Patient safety (cont.) Focus Conference - Fall 2013

36. Patient safety (cont.) • Surveying and scoring NPSG • All accreditation programs • Must implement all relevant goals, or acceptable alternative • Surveyors evaluate actual performance, not just intent Focus Conference - Fall 2013

37. Patient safety (cont.) • Sentinel events • Defining sentinel events • Reporting of sentinel events • Conducting root cause analysis • Creating risk reduction strategy Focus Conference - Fall 2013

38. Failure mode and effects analysis (FMEA) Pro-active program for identifying and reducing unanticipated adverse events Select high risk process to be analyzed One process to be analyzed annually Based in part on Sentinel Event Alerts Patient safety (cont.) Focus Conference - Fall 2013

39. Patient safety (cont.) • Failure mode and effects analysis (FMEA) (cont.) • Identify high-risk process and assemble a team • Diagram the process • Brainstorm potential failure modes and their effects • Prioritize failure modes • Identify root causes of failure modes • Redesign the process • Analyze and test the new process • Implement and monitor the redesigned process Focus Conference - Fall 2013

40. Hot Topics for RT’s • Orientation and Competency • How were you oriented to vent care? • How often is your competency evaluated? • What is your newest ventilator? • Did you get an in-service? • Was there a competency? • Do you intubate? • How is your competency assessed? • Are you ACLS or PALS certified? Focus Conference - Fall 2013

41. Hot Topics for RT’s (cont.) • Clinical Practice • If two or three vent alarms are going off at once, how do you differentiate? • What is your role on the Code Team? • What is the criteria for restraints and vent patients? • How often are vents checked? • How often do you check alarms? • How often is tubing changed? • How often is PM done on vents? Focus Conference - Fall 2013

42. Hot Topics for RT’s (cont.) • Clinical Practice • Where do you document treatments? • Are you evaluating missed treatments? • Are missed treatments considered med errors? • What is the most common reason for missed treatments? • What can be done about it? • Are you drilling down “refusals” • Do you track by shift, time of day, RT? Focus Conference - Fall 2013

43. Hot Topics for RT’s (cont.) • Clinical Practice • Do you draw blood gases? • How do you label specimens? • How do you identify the patient? • What is your turnaround time? • How do you communicate critical values? • Have you had any needlesticks? • Do you have safety devices on your needles? Focus Conference - Fall 2013

44. Hot Topics for RT’s (cont.) • Clinical Practice • Do you have weaning protocols? • Who weans patients? • Do you attend critical care rounds? • What measures are being taken to prevent VAP? • How are vents cleaned between patients? • How would you evacuate vent patients? • Can RTs transcribe verbal orders? • What are the “don not use” abbreviations? Focus Conference - Fall 2013

45. Hot Topics for RT’s (cont.) • Assessment • What is included in your assessment? • What do you reassess after treatments? • Do you assess smoking status? • Staffing • How many RTs are here during the day? • How many RTs are here at night? • What is the RT staffing plan? Focus Conference - Fall 2013

46. Hot Topics for RT’s (cont.) • Performance Improvement • What PI projects are you working on? • Do you track re-intubations? • What is your vent LOS? • How do you track VAP? Focus Conference - Fall 2013

47. Hot Topics for RT’s (cont.) • Medication Management • How do you get meds for treatments? • Are RT meds on med profile? • Are RT meds reviewed by pharmacy? • Who pulls RT meds from Pyxis? • Are RT meds documented on MAR? • Do you have a “window of time” before or after a treatment is due to be considered late? Focus Conference - Fall 2013

48. Questions???