Transcript Success Strategies for the Survey

The Surveyors are Here, Now
What?
Success Strategies for the Survey
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Success is an Ongoing Activity
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Managing the non-survey years
Managing the onsite survey process
Several roads to onsite survey trouble
After the survey – when to clarify
Top scored problem areas
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Benefits of Accreditation
• Why do we put ourselves through this?
– Yes, you really are better than non accredited
hospitals
• The process involves state of the art, peer
developed standards and safety goals
• Participation helps create a better, safer
environment
• The on site survey validates your hard work.
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Managing the Non-Survey Years
• Keep policies simple
• Mock Tracers to check compliance
• If you are in a whole stop digging (fix it or find
another way)
• Focus on the top 10 and new things
• Avoid the Situational Rules (quick trip to PDA)
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What You Can Be Scored On
• The Elements of Performance/Standards
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Situational rules in manual
The Frequently Asked Questions
Information found in Perspectives
Your own policies
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FIX IT OR FIND ANOTHER WAY
• Einstein on insanity – “Doing the same
thing over and over again and expecting
different results.”
• If your self evaluation finds failure with
this expectation month after month, it
isn’t going to get better before survey
• TJC’s specific requirements can become
steps in your processes
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MANAGING THE NON SURVEY YEARS
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3/26/2016
Maintain the momentum
Stay in contact with your account rep
Access the extranet regularly
Read and distribute Perspectives monthly
Remember, your next survey may not be in the
year due
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MANAGING THE NON SURVEY YEARS
• Track the PFI progress and request an extension
if needed
• Make sure ancillary departments have their
licenses and fulfill accreditation requirements.
• Implement the new stuff as soon as published
• Assume nothing, rely on data to self assess
• Consider smart phone or tablet applications for tracer
teams to capture, photo, fix and track compliance.
(iAuditor, AuditBee, Comply Flow Audit)
3/26/2016
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Focus on the Top 10 & NPSGs
• The 2012 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 dollar here!
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DESIGN FORMS FOR ENHANCED COMPLIANCE
 Consent Obtained
... Other text …
Signed: ____________ MD
 H and P Updated
... Other text …
Signed: ____________ MD
 Pre-induction assessment
conducted.
... Other text … Consent obtained.
Signed: ____________ MD
... I have examined the patient,
reviewed the findings of the history
and physical and any changes are
specified as follows:
______________________________.
Signed: ____________ MD
Identify natural components of the
pre-anesthesia evaluation.
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Preparing for Successful
Surprise-Free Survey
• Get all the day 1 and LSC documents
together, print draft agenda *1
• Read the SAG
• Look for problems in the unlikely spots,
UP in procedure areas not main OR,
unlabeled syringes in procedure rooms.
• Train and practice with staff and escorts
on successful survey interview tips
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Success During the Survey
Managing the Onsite Survey
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GOOD MORNING, WE ARE HERE FROM THE JOINT
COMMISSION
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Have an action plan *2
Institute the action plan
Have identified back up staff
Verify ID via extranet
Rolling carts with required information
Optional information shows great things
only
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They’re Here!
A Well Planned Calling Tree
• Have a call list with back-ups and double
back-ups for key roles
• Staff invited to system tracers should get
notice as to the time and location of these
with reminder as to which documents to
bring
• Have back-up for the 7:30 am TJC web
check
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Have Your Binders Ready
• One for the surveyor team
• A different/more detailed one for staff
• Recommend individual surveyor folders
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Meet & Greet,
They are at the Door
• First impressions are important
• Have ground crew act as scouts for team arrival,
not joking!
• Front line staff greet and seat.
• Get their IDs, compare to your photo from TJC
• Issue IDs
• Walk them to their room,
• Present them with day one binders
• Get leaders ready for opening conference
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Other Day One Action Items
• Reserve conference rooms
• One for surveyors, one for staff and all
meetings
• Get catering
• Print and distribute agenda (found on
extranet under pre-survey documents)
• Invite system tracer attendees
• Identify any necessary agenda changes
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Opening Conference
• Slide set or no slide set???
– Have a prepared short slide set
– Print and place in each surveyor folder
– Be prepared to do the opening with and
without the projector, may just want casual
talking
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Opening Presentation
• Basics of who you are, size, services
• Mission, vision, goals
• Bragging Rights - Special awards,
certifications
• Sob stories - how do you address a
potential big risk area?
• Community you serve
• Some PI or patient satisfaction data
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Day One Binders
• There are two TJC day one lists
– The list from the Survey Activity Guide (SAG)
– The surveyor list, PRN items
• Have the Day One SAG list ready – give to
surveyor
• Have the PRN list in your hands, give only
what is requested specifically
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Tips
• Avoid showcasing dirty laundry
– Have fresh eyes look through every thing in
the day one material and other material given
to surveyors
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Send “Checklist” to All Unit
Managers
• Each manager to print or pull punch list
from their TJC folder, give location specific
list to staff to review:
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Medication room
Hallways and nurses station
Clean utility
Dirty utility
• Each list is specific to their area, check
everything, initial, call in work orders
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Escorts, the Power Player!
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Assign escort and note taker *4
Never leave the surveyor alone
Eyes and ears for your leadership
You are the early warning system; text the
next unit when the surveyor is on the way
• Be adept at the computer
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Role of the Escort/Note Taker
• With an electronic system consider a buddy
system, have someone other than the nurse
search the record for requested information
• Gently coach
• Record offers to present support and record
surveyor’s response
• Record the “he said” “she said”
• Record MR numbers
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On the Unit, all Hands on Deck
• When surveyor is on the way, assemble
your team
• Meet the surveyor at the entrance to unit,
escort them
• Find a clean room for them to review
charts
• Get your team, include pharmacy, nurse
educator, Respiratory Therapy, case
workers, (have them up and “working” on
unit
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Institute the Action Plan, Everyone
in Position
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When They Are on the Unit
• Know where to find your policies & “fast
facts” or other tip tool *5
• Have two people in the patient record, a
second person as back up looking for stuff
• Offer policies, describe education
• Use your resources, you don’t need to
memorize
• Call on experts around you
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When They Leave Your Unit
• After the team leaves, find all “IOUs”
• Find the order
• Find the anesthesia record, the consent, etc
• Copy it, highlight the part the surveyor couldn’t
find
• Find the surveyor, show them AND/OR
• Bring a copy to the surveyor room during special
issue resolution, escort should record this
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Help Staff by Conducting Internal
Tracers:
• Train staff on what to expect during the
survey
• Ask yourself, ask your staff:
– Do we do this?
– Where is it written we do this?
– How well, or how often do we do this?
– Show me the evidence that we do this
– Validate the “doing” with high risk and high
priority standards
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Tracer Tips For Staff
• Be enthusiastic about how good we are
• Focus on the excellent service and care we provide
• Find a quiet room, out of main traffic path to review the
medical record for the patient tracer
• Before answering a question:
– Take a deep breath
– Make sure you understand the question
– Or ask “Could you please rephrase that question…”
– Stop talking once you have answered
– Know where policies are kept & how to access them
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Tracer Tips For Staff
• Training – practice tracers
• Never, never “fix” a chart to avoid an RFI
• Don’t allow yourself to be intimidated by
surveyors, or by your own management. Stay
calm if possible.
• If you do not know the answer to a question,
describe how you would find the answer, who
has the answer, and/or offer to provide the
answer later in the day
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Tracer Tips For Staff
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Take advantage of surveyor suggestions
Never “make up” answers to please the surveyor
Do not argue with the surveyor
Know what improvements in patient care came
from PI (performance improvement) activities
• Describe your continuous compliance in an
environment of improvement
• Don’t affirm the leading question…” this isn’t a very
good process, is it?”
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Trouble Onsite
Immediate Threat to Life
Immediate
Threat
•It is the Joint Commission equivalent of
the “go directly to jail” card!
“Situational”
Decision Rules
Direct Impact
Indirect Impact
•Joint Commission believes there is
substantial noncompliance issues that have
caused or could cause harm/death to
patients or staff.
•ITL called, your accreditation status
changes to Preliminary Denial of
Accreditation (PDA) overnight!
How Bad Can It Be?
Immediate Threat to Life
• The surveyors survey protocol guide for immediate
threat states: "Failure to follow pertinent
guidelines from APIC, CDC, WHO, etc."
• Requires the surveyor to consult with the Joint
Commission field director, who consult with VP’s
and EVP’s
• Can only be approved by President of Joint
Commission
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Immediate Threat to Life
Immediat
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Threat
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“Situational”
Decision
Rules
Direct
Impact
Indirect
Impact
•EC & LS examples from Perspectives,
conferences, other communications:
– One single issue or a
combination of observations:
– Inoperable fire alarm system
– Inoperable or unreliable fire
pump
– Inoperable Medical Gas System
or alarms
– Negative pressure rooms not
working
– Generator tests failed, not fixed
Immediate Threat to Life
Immediat
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Threat
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“Situational”
Decision
Rules
Direct
Impact
Indirect
Impact
•EC & LS examples cont:
– Utility system: main circuit
breaker not tested or
maintained
– Raw sewage leaking from pipes
in basement
– No way to transmit fire alarm
signal to local fire department
– No emergency exit and no ILSM
to compensate
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Leadership action plan:
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All hands on deck quickly!
Get the facts, copies
Involve your leadership
Clarify with the surveyor
The phone call from Joint Commission leadership
is your best time to prevent ITL… be prepared to
coherently explain why patients were not in
jeopardy if you get “the call”
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After the Survey
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Post Survey
• Clarify everything even if you are not
adverse
– Random Unannounced Validation (RUV)
surveys - 5%
– RUVs will review ESC and MOS onsite
– RFIs add to S3 point total, may be used to
shorten time until next full survey
• Keep records of ESC & MOS (RUV)
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Clarification
• Evidence that the organization was
compliant with the element of
performance at the time of survey
– We found it, here it is
– We audited and are compliant 90% of the
time
• Corrective actions do not count in your
favor
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MANAGING THE POST SURVEY PROCESS
• Understand you’re A,+ C’s
• Use audits for C’s and look for the
documentation about missed A’s.
• The performance observation may be
totally correct, but you still have audit
opportunities.
• Remember 2 observations is very sensitive
compared to 90%.
3/26/2016
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Lessons Learned from
Recent TJC Surveys
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Strategies for Success
Preparing Clinical Areas
• Rollout the Clinical Area Checklists
– Email them out, assign, implement, collect
them back, analyze compliance
• Involve/educate clinical & frontline staff
• Everyone knows who to call to get fixed
• Identify areas to improve, fix it, then
reassess
• Make LS an every day expectation!
Environment of Care
10 easy fixes
• No equipment blocking
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fire alarm pull boxes,
fire extinguishers,
electric breaker panels,
medical gas shut-off valve boxes.
• No blocking fire doors,
• No storage in stair wells
Environment of Care
10 easy fixes
• Keep hallways clear of clutter
• Fix broken locks and hardware
• Fix large gaps under doors or at door
closures
• Fire rating label on doors should be
visible
• Doors that don’t self close properly,
door wedges!
Environment of Care
10 easy fixes
• Unclear, or missing or unmarked fire exits, exit
lights that are burnt out
• Fire extinguisher checks, safely stored
• Label and secure hazardous areas
• 18 inch rule for sprinklers
• Sprinkler pipes can not support other items like
cables or wires
• Sprinkler head clean and free of obstruction, collar
flush
• Remove or repair nasty things: Ripped mattresses,
cracked ceiling tile, mold, broken wheel chair
Environment of Care
10 easy fixes
• Medical Gas shut off valves must be
labeled with rooms they shut off. Staff
must know who can shut these off and
when. Alarms working
• No unsecured O2 tanks, no storing too
many
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 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 - CMS mandate
– In EMR – use a SmartText: e.g., .no changes or .changes
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Document Operative & High Risk Procedures
(RC.02.01.03)
 H&P in record before procedure (EP 3)
 Post op/post procedure report is dictated
before transfer to next level (EP 5)
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(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)
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Document Operative & High Risk Procedures
(RC.02.01.03)
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If report is delayed, an immediate post
procedure note is entered and includes LIP,
assistants, procedure(s) performed and
finding(s), ANY EBL, ANY specimens, Post op
diagnosis (EP 7 top scorer). Check your policy.
Medical record includes the LIP release order or
approved DC criteria (EP 9)
Medical record includes the use of DC
criteria/pt readiness (EP10)
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Medication Orders
• Preprocedure meds and testing by protocol
is now permitted with qualifications
• Cannot sign post-operative anesthesia or
surgical orders pre-operatively
• Got away with it on paper; could fudge or
omit the time and not be noticed
• CPOE captures the time automatically
• Must pend and go back in and sign
Medication Orders
• Intraprocedure verbal orders need to be
countersigned by LIP
• On paper – sign the OR flow sheet/ MAR
• eFlow Sheet or eMAR and goes to LIP inbox
for electronic signature
Medication/Fluid Integrity
• IV bag fluids and Irrigation bottle fluids
• Cannot exceed 104 degrees F, check
manufacturer
• Wise to record a daily temp reading
• IV bag in outer pouch: 14 days,
– label with new, “do not use beyond” date
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
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Time Out
(UP.01.03.01)
The final verification process must be
conducted in the location where the
procedure will be done, just before starting
the procedure
Cath, Endo, ASC, AMB, IR, bedside, etc.
Compare two identifiers on the arm band (if
visible) against the medical record, OR
select one of the following three options…
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Time Out and 2 identifiers
Three Options
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Two team members confirm patient ID upon arrival in the procedure suite
using two identifiers.
One of the two team members remains with the patient during the entire preprocedure process.
During the final time out, this team member confirms patient ID.
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• Two team members ID patient upon arrival in procedure suite as previously
described.
• Two patient identifiers are written on white board in procedure room and
confirmed by the two team members.
• During final time out, the team confirms patient ID against information on
white board.
OR
• Place a patient ID on an exposed extremity – alternate wrist or either ankle.
• Reference the two identifiers on this ID band during the final time out.
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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
• Will observe proper use of PPE
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Laryngoscope Blades
• Clean and (at least) high level disinfect them per
manufacturer instructions for use
• Store in manner that prevents recontamination
• One blade per Zip-Lock bag if HLD, or
• Peal pouch if steam
• Consistent practice throughout the hospital
• Testing light source?
– Hand hygiene and/or use gloves
– Place back into Zip-lock bag or peal pouch
– Battery expiration dates!
High Level Disinfection - Scopes
• Follow manufacture recommendations
• E.g., glutaraldehyde or OPA test strips
– Date when opened
– QC run on a positive and negative solution
– Requires 6 strips right from the start
– Document the strip QC
– Testing prior to each load, document QC
Separation of Clean/Dirty
• Scrutiny of scope cleaning room to
determine if flow/practice prevents crosscontamination
• Key: remove HLD scopes from sterilizer only
when no other dirty scopes are in the room
• Flawless QC and load record documentation
• Proper PPE
Scope Storage
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Hang in a positive pressure vented cabinet
Avoid tip dragging on base (avoid rack sag)
Avoid cross-contamination (adjacent sink??)
30 day shelf life? (August 2011 OR Manager)
Never store in foam mold in hard case
Consistent Practice
• How many TEE probes exist in the hospital?
• How many nasogastric scopes? Where???
• In each area – are decontamination, testing,
QC, HLD processing, load record-keeping
steps performed consistently???
• Exact concentrations, soak times, handling
• Inventoried by Biomed/Clinical Engineering
Sterile Processing Tour
• Attire: donned at the hospital, changed daily
• Red line – no one enters without proper
attire
• No artificial nails, nail polish, jewelry, watch
• Head AND facial hair covered at all times
• In Decontamination: liquid-resistant garb,
heavy-duty gloves, eye protections
• WASH HANDS WHEN FINISHED
Immediate Use Sterilization
• Important that staff can speak to the process without
using the term “flash”
• Follow manufacturer recommendations for sterilizer,
pack, instruments, CI, BI
• Covered containers even in sub-sterile
• “A sterilized item intended for immediate use is not stored for
future use, nor held from one case to another.”
• “Instrument inventories should be sufficient to meet anticipated
surgical volume and permit the time to complete all critical
elements of reprocessing.”
• Submit data to PI Committee /leadership to justify purchase
SPD Facility
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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
Temperature, Humidity, Storage
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Monitor and record daily
Temp 68-73 in clean area of department
Temp 60-65 in decontamination
Humidity 30-60% in work areas
Humidity not > than 70% in sterile storage
18 inch, 6 inch, 2 inch, solid lower shelf
Loaner Equipment
• Clear policy and procedure, penalties for
noncompliance; ripe for short-cuts
• Mandate 48 hour lead-time???
• Follow manufacture recommendations
• Staff should blow whistle if uncertain
Tissue Management TS.03.01.01
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EP 1 Assign responsibility for tissue
EP 2 Policy for acquisition, receipt, storage, issuance
EP 3 Confirm FDA registration, have current paperwork
EP 4 Spread process throughout hospital
EP 5 Use manufacturer instructions for transporting,
handling, storing and using tissue (verify that vendor
keeps records per lot # in event of RCA)
– EP 6 document receipt of tissue(TS.03.02.01 EPs 3 &6)
– EP 7 at receipt, package integrity and temp control is
verified (TS.03.02.01 EP 6)
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TS.03.02.01
– EP 1 Bi-directional tracing including discarded (FAQ ‘10)
– EP 2 Written materials/instructions to prepare or
process (FAQ TJC)
– EP 3 date/time/name of staff involved at receipt/
acceptance, preparation, and issuance.
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Questions???
• Kurt Patton
– [email protected]
• Jennifer Cowel
– [email protected]
• John Rosing
– [email protected]
• Mary Cesare Murphy
– [email protected]