Joint Commission Update 2017Quorum Health Pharmacy Education Series
ProCE, Inc.www.ProCE.com 1
2017 Pharmacy Education Series
April 27, 2017Joint Commission Update 2017
Featured Speaker:
Kurt A. Patton, MS, RPhPresident EmeritusPatton Healthcare Consulting, LLC
Providing Continuing Education For Healthcare Professionals
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Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar
Go to www.ProCE.com/QuorumRx
Webinar attendees will also receive an email with a direct link to the web page
Print your CE statement of completion online
– Credit for live or enduring (not both)
Deadline: May 26, 2017
CPE Monitor (applicable to pharmacists)
– CE credit automatically uploaded to NABP/CPE Monitor upon completion of post‐test and evaluation (user must complete the “claim credit” step)
Online Evaluation, Self-Assessmentand CE Credit
Attendance Code
Code will be provided at the end of today’s activity
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Robert Fink, Pharm.D., MBA, FACHE, FASHP, BCNSP, BCPS
VP – Ancillary Services & Chief Pharmacy Executive
QUORUM Health
Update on Current Pharmacy Initiatives and Strategies
April 27, 2017Joint Commission Update 2017
Featured Speaker:
Kurt A. Patton, MS, RPhPresident EmeritusPatton Healthcare Consulting, LLC
Providing Continuing Education For Healthcare Professionals
It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Mr. Patton has served as a consultant for Patton Healthcare Consulting.
Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature. 6
Joint Commission Update 2017Quorum Health Pharmacy Education Series
ProCE, Inc.www.ProCE.com 4
CE Activity Information & Accreditation
ProCE, Inc. (Pharmacist)
– 2.0 contact hours
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Funding:This activity is self‐funded through Quorum Health.
Joint Commission Update 2017
Kurt A Patton
Patton Healthcare Consulting, Inc.
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Joint Commission Update 2017Quorum Health Pharmacy Education Series
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New TJC Scoring System
All surveys beginning 1/1/17 now use a new risk assessment methodology to score standards. No A or C elements, no direct or indirect
Two variables will be considered. How wide spread is the defect? How critical, how important is the defect?
Examples: 1 paper medical record entry missing a time. All endoscopes improperly processed
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Project RefreshOnsite SAFER Matrix
Survey Analysis for Evaluating Risk (SAFER)Matrix
Help you prioritize
Visual – on report
Can sort & filter
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How Will Surveyors Assign Risk
Surveyor experience and expertise based on “scope” and “likelihood to harm”
Talking amongst the team
Impact of risk assignment: Guldens mustard color and red will require coaching session with TJC leadership and additional content on leadership involvement and sustainability in ESC.
As of 3/20/17 26% of findings are red or dark mustard color.
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What Might Be Red in Medication Management? The most difficult and complex medication issue on
surveys today - improper medication titration in the ICU setting.
Nurses practicing outside the scope of licensure
Protocols not in the chart or not referenced
Incremental dose missing from the order
Assessment criteria missing from the order
Failure to assess
How and where this gets scored is very diverse so this does not show in stats published by TJC.
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Why Do Surveyors Like to Score the MM Chapter?
It’s objective: you did it or you did not.
TJC shares lots of medication safety information with surveyors including the ISMP newsletter.
Compare with the more subjective PC standards regarding the quality of a history and physical or the accuracy of a pre-sedation assessment.
TJC does not perform peer review.
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The Most Problematic MM Standard Today
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MM.04.01.01 – Seems Easy, But it is Not and it may be Red
The most problematic standard today.
The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use.
This includes, PRN, standing orders, titration orders, taper orders, range orders, etc.
Hospitals did not specify enough order details so TJC has posted an FAQ with the minimum requirements.
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Titration Order Minimum Elements
Medication name
Medication route
Initial or starting rate of infusion
Incremental rate the infusion can be increased or decreased
Frequency of rate adjustments
Maximum rate of infusion
Objective clinical endpoint, RASS, BP, etc.
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Sedation Titration Example
Propofol 5-50 mcg/kg/min, start at 5 mcg and increase by 5 mcg every 5 minutes to a maximum dose of 50 mcg/kg/min to achieve a RASS of -3.
If this is in a structured order set in an EMR or a paper order form, practitioners don’t need to remember all the required order details.
If you allow ad hoc EMR or paper orders you are likely to have many gaps requiring clarification.
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Sedation Titration Pitfalls
The order is written well, but the hospital policy is to document a RASS every 2 or 4 hours.
You will not have documentation that an adjustment was needed.
You will not have documentation that the adjustment reached the therapeutic endpoint.
You need an assessment of RASS to adjust the dose, and you need a reassessment of RASS after that adjustment.
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More Sedation Titration Pitfalls
If the order is written well, and the nurses are diligent about documenting RASS But the patient has a head injury creating a level of
sedation greater than the RASS goal… The patient has pain and nursing staff want to
adjust propofol. The patient is on a paralytic The patient has a second drip, e.g., fentanyl or
Versed The staff are having difficulty maintaining a systolic
BP The patient is having ventilator asynchrony
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Sedation Titration Solutions
Use a structured order set, not a secondary document as a reference with the order details.
Modify the RASS target or therapeutic endpoint for head injury patients.
Discuss patient management with the ICU nurses and physicians to document how to manage SBP, ventilator asynchrony, pain, use of paralytics.
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Sedation Titration Survey Follow up
Simple RFI, document in ESC how you fixed it and sound convincing, easy.
If survey outcome is AFS, PDA or MM Medicare condition out, document in ESC how you fixed it and sound convincing, but TJC surveyors are coming back to validate and you must be 100% compliant, all titrations all charts - and this is hugely different.
MM Condition out less than 45 days
PDA you have about 60 days
AFS you have about 4 months to make it perfect.
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Sedation Titration, Real Example of Survey Disaster Full survey, hospital cited for improperly written
and documented sedation titrations.
Survey outcome AFS
ESC submitted said a titration protocol was prepared for nursing staff with instructions on how to titrate sedating agents.
AFS follow up survey conducted, nursing staff interviewed and replied: “we just use our clinical judgment.”
Accreditation status changed to PDA, hospital now decides to develop detailed order sets in EMR.
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Other Frequently Scored MM Standards
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MM.01.01.03 High Alert
EP 1: The hospital identifies in writing its high alert and hazardous medications.
The hazardous list is often missing. TJC does not mean dangerous, they mean hazardous just like NIOSH.
This was moved from EC to MM a decade ago and still often missing.
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MM.01.02.01 LASA
EP 3: The hospital annually reviews its list of LASA medications. Date the list? You incentivize the surveyor to drill
down if your list is undated. Need to find reauthorization in minutes. You get no credit if its 2 years old.
Staff on the units need to be able to find the list. Write your enhanced safety strategies describing
what you do and where you do it. If hospital practices vary, mention it, e.g. these strategies occur in the pharmacy itself, while these are required for nursing, etc.
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Frequently Scored, but Much Easier to Manage MM.03.01.01 – Medication storage temperatures Paper logs – gaps and failure to act on out of range
conditions is the problem Automated data loggers – failure to document
actions taken is the problem Failure to document what happened over the
weekend in a 5 day/week clinic Failure to document vaccine storage per CDC Data loggers required, no dorm refrigerators.
Failure to track or document fluid and contrast warmer storage conditions and shortened expiration dating.
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MM.03.01.01 Medication Security
Non controlled drugs can be secured by supervision or locking Your hospital sets the standard for non-
controlled drug security. You identify those authorized. If you say licensed professionals only, TJC
holds you to that. No materials management or central
sterile supply delivery of IV fluids No unlocked storage in a clean utility
room on the floor
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MM.03.01.01 Medication Security
If you say the area is secure, but the surveyor walks in and there are no staff around…
If you say the OR is secure, but the surveyor walks in and only the housekeeper is present cleaning up after a case and there are medications present….
Crash carts in areas not open 24/7 and supervised must be placed in locked storage when closed.
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MM.03.01.01 Medication Security –New Spin 2017
Pharmaceutical waste and sharps bins in non-secure locations like a dirty utility room, or in a pick up cart in the hallway, or on the back loading dock, and even in the OR with the housekeeper.
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MM.03.01.01 Medication Expiration
EP 7: All meds are labeled with contents and an expiration date. MDV – not a date opened, an expiration date Short stability meds like propofol need a time of
expiration even from anesthesia Warmers – not a date placed, an expiration
date Remember the One and Only campaign: If a
MDV has been brought into a procedure room is becomes an SDV and any residual is discarded after the procedure.
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MM.03.01.03 Emergency Medications
EP 3: Whenever possible, emergency medications are available in unit-dose, age specific, and ready to administer form. Magnesium sulfate is often stocked 1G/2 ml Broselow tape for 3-4 Kg infants calls for doses
150mg, 225 mg Can staff in a crisis situation easily calculate
the volume of magnesium sulfate to administer? Test your own ED staff, but consider a volume
table as an aide.
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MM.04.01.01 Medication Orders
EP 13: The hospital implements its policies for medication orders.
A PRN without indication
An unclear order not clarified
A range order not adherent to your policy
TJC does not prohibit range orders, but it would be easier if they did. Consistency in application is the problem.
Go and interview 10 nurses and check the documentation in the record
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MM.04.01.01 Minutiae and Gotcha’s EP 7: The hospital reviews and updates preprinted
order sheets… EP 15: Processes for the use of preprinted and
electronic standing orders, order sets and protocols include: 4 bullet points that only reference standing orders and protocols. Regular review by medical, nursing, pharmacy
leadership. CMS tag A-0457 is clearer that basic order sets do
not require this 3 department approval. However EP 7 above does call for the hospital to be
involved in approval.
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Ambiguous Definitions
Suggestion:
Order sets – basic preprinted or electronic orders that a physician will make selections from individually or in its entirety.
Standing order – an order that authorizes a nurse to administer a medication prior to a physician actually writing that order.
Protocol – details about medication dosing or administration not included in the body of the order.
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MM.05.01.01 Pharmacist Review of Orders EP 1: Pharmacist reviews the new order prior to
administration, unless LIP control. Exemptions: ED, radiology if radiologist is present
to intervene and urgent situations anywhere in the hospital. What do you do in PACU and outpatient clinics?
EP 8: Pharmacist reviews for therapeutic duplication. *** Duplicative PRN analgesics, antiemetic's Advice: stratify your order sets Analyze your interventions; ID root cause and fix
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MM.05.01.01 EP 8 Complication The order is written well with all the details such as
Tylenol for mild pain, Percocet for moderate pain and Dilaudid for severe pain.
The patient with a pain of 9 requests Percocet instead of Dilaudid because they don’t want….
New FAQ, you can do it if approved in policy
The patient with a pain of 3 requests Dilaudidbecause they just saw the physical therapist walk down the hallway and they know their pain will spike during therapy.
You can’t do it
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MM.05.01.07 IV Preparation
TJC hospital surveyors are not expert in all things relative to USP 797.
Over time they may gain knowledge from their colleagues performing the new Medication Compounding certification or these standards.
They are very familiar with specialized air pressures and may carry a vaneometer.
If you have wall meters, be ready and able to discuss what those meters are measuring.
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MM.05.01.07 IV Preparation EP 2: Staff use clean or sterile techniques and
maintain clean, uncluttered, and functionally separate areas for product preparation to avoid contamination.
Surveyors readily ID filth, clutter and too close a proximity to sinks in medication rooms.
Sometimes pill crushers and tablet splitters are the problem.
Make these patient specific with patient labels
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MM.06.01.03 Self Administration
Seldom scored, except in the sleep lab. Policies are often well written for the inpatient
units describing pharmacist verification of the patients own medication and a specific physician order to self administer or use own medication. Sleep labs routinely advise patients to bring
their medications and to self administer before going to bed.
Suggestion: Define your policy for inpatients only.
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MM.07.01.03 Errors and ADR’s
Often a topic of discussion at the MM System Tracer.
Bring your data
Describe your actions in response
Describe your actions to increase ADR reporting
Only scored if there is failure to act, failure to analyze, failure to try and enhance ADR reporting.
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MM.08.01.01 PI FOR MM
7 Elements of performance stating you collect information, you analyze it, you compare over time, you review best practices in the literature and you take action.
Consider an annual report addressing each of these elements.
You may be able to scramble and piece it together, but prepared is always better.
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MM.09.01.01 Antibiotic Stewardship
Nicely written new set of requirements, 1 standard, 8 elements of performance.
Consistent with CDC and NQF guidance
Survey process design is about the best seen for any new requirements.
ASP designed to be explored in 6 different survey sessions. Patient tracers, competence assessment session, medical staff, data management system tracer, MM system tracer, leadership
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ASP EP 1
Leadership has identified ASP as an organizational priority.
Accountability documents
Budget plans
IC plans
PI plans
Strategic plans
EMR used to collect ASP data
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ASP EP 2
The hospital educates staff, and LIP’s involved in ordering, dispensing, administration and monitoring about antimicrobial resistance and ASP practices. Upon hire and “periodically”.
You are going to want some evidence this was done, even though this is not a D element.
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ASP EP 3 The hospital educates patients and their families as
needed, regarding appropriate use of antimicrobials.
TJC suggests CDC document: http:www.cdc.gov/getsmart/healthcare/index.html
Suggest using EMR patient teaching logs even though there is no D.
Surveyors may interview patients or families of patients being discharged on antibiotics.
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ASP EP 4
The hospital has an ASP team that includes:
ID physician
ICP
Pharmacist
Practitioner
Part time, consultants and telehealth are all acceptable.
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ASP EP 5 The ASP includes core elements:(same as CDC) Leadership commitment Accountability (single leader) Drug expertise Action Tracking Reporting Education
What are you going to show to TJC to convince them you have all these elements? D for documentation This document is requirement #49 in Day one
document list.
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ASP EP 6 The hospitals ASP uses organization approved
multidisciplinary protocols. Examples: Formulary restrictions Community acquired pneumonia Skin and soft tissue infections UTI infections C. diff care Appropriate use in pediatrics Parenteral to oral conversion Preauthorization Use of prophylaxis
D for documentation – be ready to discuss and show at MM system tracer session
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ASP EP 7
The hospital collects, analyzes and reports data on its ASP.
D for documentation
Be prepared to discuss and show at the data use system tracer and potentially MM system tracer.
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ASP EP 8
The hospital takes action on improvement opportunities identified in its ASP.
Be careful how you word minutes of meetings, don’t point fingers.
Get it done, don’t whine
Be ready to discuss accomplishments in MM system tracer.
Provide leadership some bullet points in the event this is asked at the leadership session.
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ASP Conclusion Meticulously written requirements, consistent with
other expert groups.
Superb survey process written for surveyors for these new standards.
So far in 2017, not seeing scoring on this issue.
May be due to surveyor training, may be due to newness
Be prepared to pro-actively discuss if you have accomplishments at MM, Data.
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NPSG.03
Label medications in procedural settings. The OR usually does this well Surveyors look in outpatient procedural settings, bedside
procedures and ED procedures. No one can be compliant if you don’t give them the
tools to be compliant – sterile labels in procedure kits.
Try to convince anesthesia that even propofol needs a label. Try to convince radiology that contrast and saline in a
power injector needs a label. PS – the saline is single dose, the contrast if manufactured,
labeled and used appropriately may be MDV. This safety goals is scored way too often and it will be red.
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NPSG.03
Anticoagulation safety goal, seldom scored today. Sometimes EP 2: Use approved protocols for the
initiation and maintenance of anticoagulants. You want to be able to say: “yes we have
protocols and here they are” If the protocol is used by an LIP to aide in
decision making the protocol does not need to be in the chart.
PC.02.01.03 – Top 10, 46% of hospitals getting hit for failure to include the protocol used by a dependent practitioner in the EMR. If the protocol is used by a dependent practitioner, a copy
of the protocol must be in the chart. Not easy to do with most EMR’s
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NPSG.03 Medication reconciliation: Seldom scored today.
Sometimes EP 3: Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies.
Many times staff during a tracer are unable to display the end result of med rec drug by drug.
“I reconciled” button is a problem
Errors of omission are a problem
User security and viewing is a problem
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D for Documentation
The MM chapter has 24 elements of performance identified as D.
Do you really have 24 policy statements addressing all these EP’s?
Remember a written policy is different from “our practice, or usually we..”
If you think you do, congratulations, you will be the first I have encountered.
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Obscure D MM.03.01.01: The hospital has a written policy addressing the
control of medication between receipt by the individual healthcare provider and administration of the medication, including safe storage, handling, security, disposition and return to storage. Can a nurse or respiratory therapist take multiple patient doses out
of an ADC at one time? If they do, where may it be stored until administered? If it is not administered, how can they return it to stock and cancel
the transaction? Can an anesthesiologist carry sedating agents from the OR, down
to MRI to help sedate a patient? How do they carry it? If they inadvertently carry it out of the hospital, can it be returned to
stock? What if it was in their car trunk? What if it is a controlled drug?
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D with an Invisible Component
MM.04.01.01, EP 2: The hospital has a written policy that defines the required elements of a complete medication order.
You probably have this one, but…
Day one document list #46 says you must make this policy available and include your definition of therapeutic duplication.
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Preparing for the MM System Tracer
Plan for a conference room, but the surveyor may surprise you and want to go trace a patient with you. Come prepared and bring that which is good
about your practices and be prepared to discuss. Take the initiative. Come prepared to discuss, defend, prevent
potential findings you have heard about from the morning briefings. Everyone invited should come prepared,
knowing what they are invited to talk about.
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Examples for the MM System Tracer If ASP is significant, do show and tell
If you did an annual report for MM.08…
Bring your medication error data and be sure to include good catches that never reach the patient.
Bring your ADR data
Bring your interventions data
Coach and rehearse what to say with your planned attendees
TJC looks to you for MM leadership throughout the hospital, not just within the 4 walls of the pharmacy.
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Questions?
To review past monthly newsletters, or to subscribe go to:
www.Pattonhc.com
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