Joint Commission Mock Survey

1. Joint Commission Mock Survey December 2007

2. Documentation Standards • 1. Is H&P in chart within 24 hours of admission • 2. If H&P performed >24 hrs prior to admission, has it been updated by attending physician • 3.When H&P performed by NP or PA, is it co-signed by attending physician • 4. When performed by a Resident, is the H&P verified and co-signed by attending physician (verification is a linking statement such as “I have reviewed the H&P by Dr. X and I agree with the history and physical findings”) • 5.Do physician’s progress notes refer to the problem and goals list (Blue Form at beginning of progress notes)

3. Documentation Standards • 6. Is the admitting diagnosis on the Problem and Goal list (admitting dx must always be problem #1 on P&G list) • 7.Is there evidence of prohibited abbreviations anywhere in the medical record. (prohibited abbreviations may not be used in progress notes nor in orders) • 8.Are medication orders complete (all med orders must include date, dose, route, frequency and an indication for PRN orders. Range orders may not be for time, only dose) • 9. Are all orders appropriate and complete (all orders must include date, complete and legible signature, degree, pager # and PGY level for housestaff) name stamps encouraged

4. Documentation Standards • 10. If informed consent is required, is it present and complete (indicating procedure to be performed, explanation of risks, benefits and alternatives, dated and signed by provider and patient) • 11. If applicable, is there evidence of the use of the universal protocol/safety pause? (identification of patient using 2 forms of ID, agreement on procedure, position, correct side marked and required equipment present)

5. NPSGEvery care giver must comply • Accurately identify patients with two forms of identification prior to drawing blood or other invasive procedures. • Compare info on pre-printed labels with pt’s id band or stated data. • Label all blood and other specimens in the presence of the patient. • Improve communication among caregivers • eliminate unapproved abbreviations, • verify read back & sign verbal orders, • receive and act upon critical test results, • give & receive required information during patient handoffs. • Reduce the risk of health care acquired infections • foam and hand wash, • clean stethoscopes between patients, • follow precautions posted outside patient rooms.

6. Methodology and Approach BESLER consultant(s) met with various groups throughout the organization, visited patient care units and performed individual tracers and individual-based systems tracer methodology based on the unique populations of the Medical Center. A telephone call to discuss findings and recommendations has been scheduled for January 4, 2008. The engagement was conducted over five days and followed the 2007, five days, Joint Commission accreditation program survey agenda. Five BESLER consultants were provided in accordance with the survey agenda. During the course of the engagement consultants conducted individual tracer activities in the areas listed in Attachment I. In addition, program specific tracers were conducted to evaluate several processes identified as high-risk. These tracers focused on blood transfusions, restraints, suicide risk assessment and lab integration tracer. Also, an audit of nine Human Resource files, seven Medical Staff files and two Affiliate Practitioner files was conducted based upon files requested by the BESLER consultants.

7. The findings are presented by CAMH chapter. Standards found non-compliant have been given a priority ranking of high, medium or low in order to assist the Medical Center in developing its corrective action plan. The criteria used to determine the rankings: HIGH: National Patient Safety Goals; 2007 Top Requirements for Improvement (RFIs) as listed in the 2007 Hospital Executive Briefings; Organization-wide tracer findings; Therefore, corrective action requires significant effort to achieve compliance. MEDIUM: Findings that do not appear to be organization-wide; Therefore, correctiveaction requires moderate effort to achieve compliance. LOW: Single findings during tracers; Therefore, corrective action required at unit/department level.

8. Goal 1: Improve the accuracy of patient identification; labeling of specimens High Priority In the settings which provide inpatient and outpatient services, staff are utilizing three patient identifiers including patient name, date of birth and medical record number. In one clinic setting, it was stated that the outpatient identifiers of name and date of birth are not applicable to their setting since the patient identification band has the medical record number and not the date of birth. Recommend review of FAQs for NPSG#1. Requirement is to utilize only two identifiers within a setting. To promote consistency, consider constructing a simple outline for each applicable NPSG for each setting that includes the name of the responsible discipline(s) and the exact steps of practice. Recommend staff review of labeling specimens in presence of patient rather than labeling outside the patient room and/or transporting to a laboratory area.

9. Goal 2: Improve the effectiveness of communication among caregivers Requirement 2A High Priority For verbal orders or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result. Staff in two areas required coaching to articulate the process. In addition, in one tracer, the staff member indicated that critical results are not always read back to the individual giving the result. Recommend re-education at the department level. May consider further monitoring to determine if issue affects more areas than identified in Attachment I.

10. Requirement 2B Medium Priority Use of prohibited abbreviations was limited during this review. The Medical Center has made significant improvement in decreasing the use of the prohibited abbreviations. Recommend continued monitoring efforts and focused staff reminders.

11. Requirement 2E High Priority Implement a standardized approach to “hand-off’’ communications, including an opportunity to ask and respond to questions. A consistent approach to hand-off communication was not demonstrated in multiple settings. The inhouse transfer form, unit acceptance note was found to be consistently blank. Staff in multiple units were unable to articulate required information to be communicated in a hand-off. In addition, an intra-campus transfer process did not demonstrate compliance with a hand-off communication. Recommend establishing core elements essential to the hand-off and include as standard in every report. Recommend review of the transfer form, location of the transfer form at the actual time of the patient transfer and assess need for documenting an acceptance note.

12. Goal 7: Reduce the risk of health-care associated infections Requirement 7A High Priority Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. In the perioperative areas, observed numerous staff members not cleaning hands between patients. Recommend re-education regarding the hand washing process. Consider implementation of best practice to monitoring compliance utilizing “secret observers” to collect staff compliance data. Follow-up with staff by providing compliance data at individual unit/department/clinician level.

13. Goal 8: Accurately and completely reconcile medications across the continuum of care Requirement 8A High Priority There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. A consistent approach to medication reconciliation was not demonstrated in multiple settings as well as inconsistent and incomplete documentation. The lack of a consistent process was observed in the Emergency Department, inpatient units, procedural areas, outpatient areas and clinic setting. Requirement 8B High Priority A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside of the organization. The complete list of medications is also provided to the patient on discharge from the facility. In the Endoscopy Units, a complete list of medications is not provided to patients on discharge. Recommend staff and physician education regarding the collection of medications upon admission to the inpatient and outpatient settings. Follow-up with all outpatient areas to ensure staff education and understanding of the forms and processes. Determine reason why patient information may not be available from electronic clinic record for subsequent visits. Identify medical staff champions for process improvements. Clarify specific steps of expected practice and re-educate staff. Monitor practice and knowledge on an ongoing basis.

14. Requirement 1C High Priority Conduct a “time out” immediately before starting the procedure. Observed a number of “time outs” at University, Memorial and Hahnemann campuses. There was lack of the full attention of the entire team as the time out was being conducted. There appears to be confusion between “final verification”, safety pauses and the final time out. Processes were not active; staff were all involved in other activities. Staff are using the patient’s medical record number during the final time out. The timing of the time out does not correspond to what is documented on the medical record e.g., it was not observed being performed immediately before the start of the procedure, yet the documentation is entered as such. Two bedside procedures did not include documentation of a time out. Recommend staff re-enforcement (including bedside procedures) relating to the inclusion of entire surgical team’s full attention in the safety process indicating: Correct patient identity Correct side and site Agreement of the procedure to be done Correct patient position Availability of correct implants or special equipment

15. APR 10: Misrepresentation of Information High Priority Information provided by the organization must be accurate and truthful. Two potential APR 10 situations were identified during the assessment. A medical record was reviewed intraoperatively. The immediate post operative note was completed including estimated blood loss and condition yet surgery was in process. The second event was a history and physical which was completed during a Preadmission testing visit by the nurse practitioner. On the day of surgery the date of the history and physical was crossed out and the date of surgery was entered in. Recommend immediate review with the Medical staff and all staff in the Medical Center. The Joint Commission requires each organization to engage in the process of accreditation in good faith. Any hospital that fails to participate in good faith by falsifying information or by failing to exercise due care and diligence to ensure the accuracy of such information may have its accreditation denied or removed.

16. ETHICS, RIGHTS AND RESPONSIBILITIES (RI) High Priority Standards RI.2.40 Informed consent is obtained Multiple consent issues identified including obtaining consents from a family member yet patient was competent; consents signed but unclear if the patient signed the consent; staff knowledge regarding time frames for a valid consent was weak; incomplete consent forms; consistent practice of following the consent policy was not evident. Recommend staff education that competent patients should sign their own consents. Review of processes for obtaining an informed consent. Explanation of procedure and risks and benefits should be provided and documented per policy before staff witness of signatures. RI.2.80 End of life Decisions In multiple areas, staff unable to address the follow up requirements related to the presence or absence of a health care proxy. If the Meditech system reflected that a health care proxy was completed, staff did not know whether they needed to obtain a copy from medical records for the current inpatient chart. Recommend staff re-education relating to requirements for end of life decisions. Determine whether it is necessary to have a hard copy of the health care proxy in the chart if the information is in Meditech. Communicate consistent process to staff.

17. PROVISION OF CARE, TREATMENT AND SERVICES (PC) High Priority Standards PC.2.120 and MS.2.10 History and Physical completed within 24 hours of admission Identified incomplete H&Ps, lack of updates to H&Ps if completed prior to admission and lack of staff knowledge related to requirements for completing the H&P. Staff unable to locate H&P during one tracer and then located the H&P in the thinned record. Recommend staff education highlighting when an update is required and incorporation into pre operative checklist to facilitate monitoring. Recommend implementation of concurrent monitoring for compliance.

18. PC.11.40 Restraint Orders In one medical record, one restraint order was not dated and one 24 hour period was missing a restraint order. This is a high focus, patient safety process that will continue to be under scrutiny by all external agencies. Recommend a review of the process and procedure to ensure that physician orders are obtained and completed for each 24 hour period of restraint usage. Recommend implementation of a concurrent monitoring process to ensure compliance

19. IM.6.10 Complete and Accurate Medical Record Multiple issues identified related to this standard and the elements of performance. Noncompliance issues consisted of: all pages of the medical record are not consistently identified with patient identification labels; lack of authentication as required by the standard; lack of availability of complete electronic clinic notes; lack of timely authentication of electronic entries by physicians and staff; legibility issues. Recommend review of organizational documentation forms to ensure ease of readability or revise form electronically. Evaluate the legibility situation, monitor legibility via medical record reviews and other methods and determine appropriate action as indicated. Recommend continued staff education on documentation requirements and importance of timely documentation.

20. Medication Management: Prohibited Abbreviations • DO NOT USE prohibited abbreviations: U TIWIU ADQD AU trailing zero (.50 mg) OSlack of leading zero (.5 mg) ODMS AS MSO4 OUMgSO4 mg(for mcg) Every order with a prohibited abbreviation will be delayed (hard stop!) until clarified by the person writing the order.