Transcript patient - Healthcare Accreditation Consultants

TRACER TRAINING
Patton Healthcare Consulting
Success Strategies Checklist
Mock Tracers to check compliance
Patient tracers
The environment
The care provided
System Tracers
Scoring yourself AKA TJC 101
Avoid Immediate Threat/Situational rules
Focus on the top scored & NPSGs
Bullet proof weak areas
Tips for Staff
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IMPROVING OPERATIONAL SYSTEMS
• When you identify standards non compliance you really
are identifying systems that have not worked as designed.
– We didn’t train employee Smith
– Employee Smith forgot the training
– Employee Smith chose not to use the system they
were trained on.
– Employee Smith had a falsified license
– Why didn’t we know Smith was not following our
policy?
• You are not identifying employees that don’t know the
standards.
Swiss Cheese Model of
Adverse Event Causation
Inadequate
Mixed
Training
Messages
Attention
Production
Distractions
Pressures
Regulatory
Responsibility
Narrowness
Shifting
Incomplete
Procedures
Deferred
Maintenance
Clumsy
Technology LATENT
FAILURES
Triggers
The World
Adverse
Event
Adopted from J. Reason
DEFENSES
TRACERS FOLLOW THE PATH OF THE PATIENT
• Patient evaluated in the ED, and a decision made to
admit the patient
• Patient transferred to the inpatient medical surgical
unit.
• Patient sent to radiology the next morning for CT with
contrast
• Patient scheduled for surgical procedure
• Patient sent post surgery to ICU
• Patient transferred to med surg unit
• Patient discharged to home.
TRACERS EVALUATE THE INTERFACES OF CARE
• Each transfer of responsibility involves
the transfer of critical information
necessary to provide safe and effective
services.
• Communication breakdowns during
these transfers are common root
causes as identified by hospitals.
TRACER – EVALUATE EXECUTION OF YOUR POLICIES
AND PROCEDURES
• At the start of our patients episode of care in the ED, what can
we evaluate?
– Timeliness of triage, evaluation, treatment, transfer after
decision to admit.
– Depth, completeness and appropriateness of assessments
– Staff knowledge of hospital assigned responsibilities
– TAT of critical tests, results or treatments
– Handoff to the unit
– Issues about flow
– Privacy and patient rights
– Medication security and storage
– Hand hygiene and IC in general
TRACER TECHNIQUE
• Staff should be programmed to pick a room, get the chart, get the
nurse, get surveyor out of the hallway.
• At the start, try to put staff at ease, consider their case load and
timing of your visit
• Chart review, followed by oral interview, or vice versa, or tour first.
Pick your most comfortable technique.
• Concurrent oral interview and staff guided tour with presentation of
key documents pertinent to the responses.
• Listen to the responses and allow those responses to shape the next
question.
• Remember Peter Falk, Inspector Columbo?
• Ask questions pertinent to the patient being traced.
• Keep your checklist or form in the background
TRACER TECHNIQUE
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How do you do…..?
What did you do……?
What would you do if…?
Can you show me where/how that is documented?
Are the responses consistent from staff person to staff person?
Are the responses consistent with hospital policies?
Can staff find policies?
Validate staff responses prn with patient directly.
Listen to and observe pertinent practices that may be taking place
in the background.
• Never ask about standards or safety goals, ask only about what
was done for the patient.
WHAT WILL WE FIND?
• Knowledge deficits
• Process variation unit to unit, person to person
and acceptance of the practice.
– Listen carefully to response: “I do”
• Short cuts, work arounds and personal belief
systems
• Policy deficits or non compliance
• Documentation defects
• Fumbles
• You relate the findings in your notes to standards
when finished.
Goal of Internal Tracers
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Get staff ready for the survey
Find it before the survey team does
Measure internal compliance –
Allows you to fix it or find another way
Focus on
– Actual performance
– Execution not potential
Benefits and Challenges
• Benefit of internal tracers
– Staff will grow comfortable with the technique
– Staff will know how to respond/react upon arrival
– Assess sustained compliance
– You know what correct responses should be according
to your hospital policy
• Challenges of internal tracers
– Being the bad-guy with peers, risk “you don’t score
me, I don’t score you”
– Keeping the attention of staff
– You may feel less knowledgeable about standards.
Practice All Types of Tracers
• Patient Tracers
• System Tracers
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Medication Management
Data Use
Environment of Care
Emergency Management
Competency Assessment - HR
Infection Control
• Survey readiness – drill the day 1 books,
room, check in process, etc (Stop, See List)
Patient Tracers
– Focus is on actual care practices.
• The patient’s care drives assessment of compliance to
standards not vice versa
• Focus is on linkages, continuum of care, and
communication among the healthcare team
• Quality, timeliness, and completeness of the medical
record drives compliance
• Focused tracers will go into depth on the issue.
System Tracers
– Interview Sessions, do mocks for these sessions also, practice!
– Come ready to talk proudly and showcase
– Hospital system tracers:
• Medication Management
• Data Use
• Environment of Care – must have documents at your finger
tips.
• Emergency Management – make sure your plan addressed
every EP
• Competency Assessment - HR
• Infection Control – make sure your plan addressed every EP
PATIENT TRACER MODEL
Tracer
PATIENT
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Medication Mgt
EMERGENCY
DEPARTMENT
MEDICAL
EQUIPMENT
SURGERY
HR Process
ICU
INFECTION
CONTROL
MED/SURG
Picking Your Patient
• Where will the surveyor visit:
– All anesthesia and sedation areas
– At least 50%-100% inpatient locations
– Sample of outpatient sites
• Picking an internal tracer patient:
– Multiple units, enter through the ED, transfer from
another facility, had surgery
– Watch procedures everywhere all the time!
– Can’t decide? Pick the fattest chart or at least a 2 day
chart, procedure patients, restrained patients
– Use CSG’s, typical patients, allow PFA’s to help guide
areas of inquiry.
Starting the Tracer
• Look up and down the hallway upon exiting elevator
• Go up to the unit, introduce yourself
• STOP! – LOOK! – LISTEN!
– Challenge is to conduct tracer while observing everything!
– Tracer staff, envision the following:
• You are the mother in law with a white glove
• You are creating a new house “punch list”
• You are determining if you would find the care acceptable if it
was your loved one in there.
• Unit staff – As you learn tracer techniques, when your unit is
being “traced” try to limit the surveyors snooping, control the
situation if you can.
Starting the Tracer
• You choose the start technique that works best for
you. Tour, chart, interview.
• The tour gives the opportunity to do the EOC/LSC
things
• Observe care being delivered, ask “I am doing a mock
tracer, may I follow you as you administer that
medication?”
• Pick your patient, review the care with the staff
caring for that patient
• Follow your instinct, if something doesn’t look right,
trace it
• STOP, see Departmental Walkthrough Checklist
Why Do I want to See a Med Pass?
• Standards you can observe during a pain med
pass
– If med is drawn up prior to administration was the
medication properly labeled
– Two patient identifiers
– EMAR, bar code compliance
– Hand hygiene x2
– Nursing 5 rights
– Pain assessment and reassessment
– Patient education on the medication
Remember...
• You must be compliant with:
– The standards
– The FAQs published by the Joint Commission
– Anything in Perspectives
– Your own internal policies
• The surveyor will hold you to the most
stringent where differences exist!
Tracer Strategy
• Establish Internal Tracer Teams
– “validate” compliance with standards,
– Incorporate findings into appropriate performance
improvement programs
– Incorporate findings into existing HR and MS
evaluation mechanisms
– Provide real time feedback
– Provide real time education
– Report findings back to the unit
– Track findings over time, make sure corrections do
occur
WHAT SHOULD WE ASK?
• Tell me about the initial nursing
assessment. What do you look for?
– Fall risk screening and actions taken
– Nutritional screening and timeliness
– Abuse screening
– Patient education
– Decubiti screening
– Pain assessment and reassessment process,
right technique and adherence to policy.
WHAT SHOULD WE ASK?
• Show me the H+P, is it done <24 hours, updated,
legible, complete?
– Does this H+P read like the same patient in the care plan?
• Show me the pre-anesthesia assessment and
immediate reassessment.
• Show me the time out documentation
– Unit staff, if not familiar with surgical area documentation
should acquire familiarity.
• Show me the consent, translators, process.
• Keep track of names, who was interviewed, who was
the person that performed some task in the record.
WHAT SHOULD WE ASK?
• Show me the immediate post procedure note, 7
elements? Time performed?
• Show me the post anesthesia assessment < 48 hours after
recovery
• Show me the nursing care plan, does it read like the
patient we just learned about?
• Show me the restraint documentation, renewal
• Show me the lab work, any critical results? What is that
process?
• Lets look at medication orders, range, prn,
anticoagulation?
FOLLOW UP QUESTIONS
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Do staff know how to navigate the chart?
Can staff find policies?
Were staff trained and competent?
Go to PACU, med orders, security
Go talk with anesthesia about med labeling and time out
Validate privileges or refer to colleague
Medrec on admission and discharge?
Does the medical record tell the story?
STOP, See Procedure Area Survey Checklist and 1 page
tracer tool for ideas
Keeping Tracer Staff Sharp
• Learning is a group event
• Schedule tracer time optimally, not at lunch, not at
change of shift, not in OR at 7 am
• Schedule debriefings for tracer staff
– Discuss observations
– Ask questions you are unsure of
– You learn from one another
• When possible trace in pairs, learn each others
techniques
• Provide feedback to unit staff
Scoring Basics:
What You Score Yourself On
• You must be compliant with:
– The standards including the situational
decision rules
– The FAQs published by the Joint
Commission
– Anything in Perspectives
– Your own internal policies
• The surveyor will hold you to the most
stringent where differences exist!
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Read the Book
3/28/2016
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READ THIS NEWSLETTER
Get it Distributed
And Look on the Website, Print All FAQ’s
http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards
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Standards
• Consist of Three Parts:
– Standard Statement
– Rationale and/or Notes (not in the
excel file)
– Elements of Performance (EP)
• These are the score-able elements
Scoring Sample
The CAMH
Scoring Sample
Your Excel Scoring Tool
STOP See Mock Finding Form
Scoring of Standards
• Standards are NOT scored by you
• You score only the Elements of
Performance (EP) under the standard
• If one EP is non compliant or partial, the
standard is considered non compliant by
The Joint Commission.
How EP’s are Scored
• Category A
– Relate to structural and process
requirements, such as policy
– Scored as either exist or not. Either
compliant or not. All or nothing.
How EP’s are Scored
• Category C
– Based on the number of times you do NOT meet a EP
– Scored by the surveyors as:
• 0 = Insufficient Compliance = 3 or > instances of noncompliance
• 1 = Partial Compliance = 2 instances of non-compliance
• 2 = Satisfactory Compliance = 0 – 1 instance of noncompliance
– For you…. Two observations is NON-COMPLIANT
Immediate Threat to Life
•It is the Joint Commission equivalent of
the “go directly to jail” card!
PDA
Contingent
Accreditation
Accreditation with Followup Survey (AFS)
Accredited
•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!
Immediate Threat to Life
•Examples from Perspectives, conferences,
other communications:
PDA
Contingent
Accreditation
Accreditation with Followup Survey (AFS)
Accredited
– Inoperable fire alarm system
– Inoperable Medical Gas System or
alarms
– Negative pressure rooms not working
– Generator tests failed, not fixed
– Inappropriate, excessive flashing
– Pediatric crash cart, only adult strength
meds on cart
– Intimidating or threatening behavior
– Patient care issues: excessive rates of
ulcers, infections, psychotropic meds,
weight loss, etc
– LIP procedures without
credentials/privileges
– Inappropriate restraint use resulting in
injury
Situational Decision Rules cont.
New Decision Rules
Immediate
Threat
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“Situational”
Decision Rules
3
Direct Impact
Indirect Impact
• CON01 – Survey findings
demonstrate systemic patterns,
trends or repeat findings from
previous surveys.
• CON08 – Credible evidence indicates
possible fraud has occurred.
New Survey Type:
• FOLL-U – an onsite follow up will be
conducted in Medicare certified
hospitals for condition level
deficiency
Direct Impact EPs
Severity “3”
Immediate
Threat
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3
“Situational”
Decision Rules
Direct Impact
Indirect Impact
•EPs with a direct impact on quality of care
and patient safety
•“Implementation” based requirements
– Must submit ESC if scored by TJC within
45 days
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Thresholds established, if exceed
threshold, your report is reviewed by
TJC for possible adverse decision
•Failure to resolve can results in adverse
decision
•Examples:
– Site marking
– Time out
– Patient Assessment prior to anesthesia
Indirect Impact Requirements
Severity “4” or blank
Immediate
Threat
2
“Situational”
Decision Rules
3
Direct Impact
•Less risk of immediate care impact
•“Planning” and “Evaluation” based
requirements
•Must submit ESC for non-compliant
requirements
– Longer time-frame (60 days)
•These are not part threshold count when
reviewing reports after a survey
•Failure to resolve = progressively more
adverse certification decision
•Examples:
– Policy development
– Hospital provides storage space to meet
patient needs
Indirect Impact
Scoring – How To:
For Each Standard
• 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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Focus on the Priority Issues
• The standards have ~1800 EPs that can be
scored
• The Joint Commission does >90% of its
scoring on about 25 standards/NPSGs
– Focus on the top scored
– Focus on all NPSGs
– Focus on any NEW standards
– Focus on previously scored issues
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WHATS NEW I SHOULD WORRY
ABOUT?
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MISC UPDATES
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The One and Only campaign
OR fire prevention
Scope cleaning and high level disinfection
Pressure relationships, OR’s, decontamination areas
Central supply adherence to manufacturers
sterilization guidance.
• Look at CMS tracer checklists for ideas.
• Know that multi-dose vials are vulnerable
• Closed Record Review is BACK! Stop, see Medical
Record Review Tool
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AND THEN THERE ARE THE MOST
FREQUENTLY SCORED STANDARDS
• Low hanging fruit, almost fall on surveyor
• Learn from the mistakes of others
• If the surveyors see it everywhere and score it
everywhere, there is no chance they are going
to look the other way at your hospital.
• Focus on these issues and fix them long before
survey.
• STOP See Top 10 Scored List
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TOP SCORED, STANDARD LEVEL 2011
Source: Perspectives April 2012
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2
3
4
5
Complete/accurate medical record (RC.01.01.01 –
66%)
Maintain egress (LS.02.01.20 – 56%)
Fire Protection features maintained (LS.02.01.10 –
52%)
Fire protection features maintained to protect
patients (LS.02.01.30 – 45%)
Maintain fire safety equipment (EC.02.03.05 – 40%)
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Top Scored TJC 2011 cont.
Source: Perspectives April 2012
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Medical Equip Infection Risk (IC.02.02.01 – 36%)
Assess and reasses per timeframes (PC.01.02.03 –
34%)
8 Medication Storage (MM.03.01.01 – 33%)
9 Verbal orders (RC.02.03.07 32%)
10 Maintain system for extinguishing fire (LS.03.01.35 –
31%)
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Signing, Dating & Timing Medical Record Entries
(RC.01.01.01 – 66%)
Hospital maintains a complete and accurate medical record
• The author identified and authenticated. (EP 11)
• Timing - Biggest Problem (EP 19)
– Have you designed paper forms to enable success?
• Every form has a time box
• Multipurpose forms have time/date, signature for every section
• Information needed to justify patient care (EP 6)
**Legibility is scored here!
• Consider using data for OPPE or HR evaluation process
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MEANS OF EGRESS, USUALLY EXITS
(LS.02.01.20) 56%
Hospital maintains means of egress
• Easy to find issues, educate on:
– Blocked or locked egress doors
– Corridor clutter, storage in hallways
• Linen carts and latex carts will be scored
• Cart on Wheels can be plugged in but not parked for
>30 minutes
• OK stuff:
– Crash carts are considered “in use”
– Isolation carts outside occupied room also considered “in
use”
– Dietary cart while delivering
– Med cart in use
• Consider CMS waiver to 2012 code
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Fire Protection Features
(LS.02.01.10 - 52%)
Building & fire protection features minimize the effects
of fire, smoke and heat.
32 elements of performance!
– Fire and smoke doors labeled, correct type, close,
label visible, under cut, door gaps, adhesive tape
over latch
– Penetrations are sealed with correct material – IT
cables a large offender. Consider a work permit
and inspection
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Fire Doors, cont
• Inspect and maintain fire doors
– Appropriate fire rating on doors and
frame
– Door positively latches
– Door had a closure
– No gaps > 1/8 inch, or undercut
>3/4 inch
– Resulted in ITL if multiple problems
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LS -Maintain Building Features
(LS.02.01.30 – 45%)
25 elements of performance, 1 with its own
25 bulleted requirements.
Building features are provided and
maintained to protect individuals from
smoke
– Label all Hazardous Areas (such as boiler rooms, laboratories, O2
tank supply rooms, flammable liquid storage rooms)
– Limit access to hazardous areas
– Self closing doors work as expected and designed
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EC.02.03.05 FIRE PROTECTION
EQUIPMENT 40%
• 21 elements of performance
• More focused on testing, inspection and
maintenance of fire protective features.
• Testing alarms and strobes
• Testing pumps and sprinklers
• Testing dampers
• And don’t forget the documentation
requirement for the new EP 25 to include NFPA
reference
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Fire Protection Equipment
(EC.02.03.05 – 40%)
Hospital inspects, tests & maintains
fire safety equipment.
 Includes testing of: fire alarms boxes, smoke detectors,
sprinklers, portable extinguishers, magnetic release
devices, tamper switches & water flow devices.
 If outsourced to a vendor keep the report, read the
report and act on problems!
 Make sure reports are tied to an inventory of devices and
make sure the inventory doesn’t change every quarter
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Fire Extinguisher Dating
(EC.02.03.05 EP 15)
 Month, day, year and initials of
inspector required per NFPA 10-1998
 They will review the tag
 If bar coded, they will review
documentation
 Required monthly
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MEDICAL EQUIPMENT RISKS IC
(IC.02.02.01 – 36%)
Cleaning, sterilizing, storing and disposing
of medical equipment & supplies. C & 3
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Problems or gaps with dating controls & biologicals
Store clean and dirty separately
Air handling
Flexible Scope Cleaning
Laryngoscope storage FAQ
Surveyors trained on AAMI standards for sterilization
and disinfection
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Reduce Risk of Infection, cont
• 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 understanding, and
precision
• Will observe proper use of PPE
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ASSESS AND REASSESS PER POLICY
(PC.01.02.03) 34%
• Initial nursing assessment done on time.
• If initial nursing assessment screened for dietary
consult or other, it is done on time.
• Reassessments are done per plan of care. If I+O is in
POC, it is done.
• H+P done or updated in 24 hours or updated prior
to surgery
– H+P isn’t more than 30 days old
– H+P update language includes: I have reviewed
the H+P, I have examined the patient and….
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Safe Medication Storage
(MM.03.01.01 – 33%)
• Been a top 10 for years. First booster pack
• Largest problem was medication storage
temps, this is now a C element!
• Tackle both refrigerators and warmers
– Warmers max and duration an issue
– 1 months log only if using paper
– Always Document actions taken
– Describe how you monitor on weekends in 5
day areas
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Medication Storage, cont.
• Clarified - Expired medications including multidose
vials
– Use BUD label, not date open label
– Expire in 28 days or less, vaccines are exception
• Policy addressing med storage by a provider after
access and before administration (There are 19 MM
chapter D’s)
• Unauthorized access to medications – “do what you
say” If housekeepers are permitted or prohibited.
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Verbal Orders
RC.02.03.07 32%
When required by law or regulation, verbal or telephone
orders are authenticated within the specified
timeframe. (48 hours)
– And the authentication is timed
• It’s a C element of performance, no MOS
• It’s a criticality 4 so you have 60 days to fix it if scored
• Consider data use for OPPE, consider hard-stops in
your EHR
– EHR is not foolproof on this issue
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Provide/Maintain Fire Systems and Equip
(LS.02.01.35)
Sprinklers
• 18 inch rule
• Sprinkler pipes can not support other items like
cables or wires
• Sprinkler head clean and free of obstruction,
collar flush
• Ansul system shuts off gas, activates alarm,
controls exhaust system.
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NOT TOP 10, BUT FREQUENT FLYERS
• Additional, problematic standards that are
frequently scored on surveys.
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Primary Source Verification
(HR.01.02.05)
Photocopies of licenses have no validity in the Joint
Commission process.
Primary source verification of licensure on time, prior to
expiration
– If the individual really was unlicensed for a period of
time, risk of PDA/CON
• Problem areas: Decentralized responsibility with lack of
oversight
• Special competencies or certifications required by the
hospital are obtained according to hospital policy. ACLS,
BLS
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Unapproved Abbreviations
(IM.02.02.01)
• Hospitals are forgetting clarification opportunity
• If you exceed the minimum list, you are held to your
additions also.
• QD still biggest problem
• Always clarify, almost never fail
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Assess & Reassess Pain
(PC.01.02.07)
• Sev. 3- Conduct a comprehensive pain
assessment consistent with scope of care, Tx,
services and patients condition.
• Your policy spells out the depth of the
assessment, the form, the timing.
• Follow your policies or TJC RFI
• Keep your policies simple, 90% minimum
compliance?
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Medical Gas
(EC.02.05.09)
• Hospital inspects, tests & maintains
medical gas and vacuum systems.
• No parking zone!
• Get vendor reports, fix problems noted
• Gas shut off valves must be labeled with
rooms they shut off. Staff must know who
can shut these off and when.
• Alarms must be working. Has led to ITL
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Document Operative & High Risk Procedures
(RC.02.01.03)
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H&P in MR before procedure (EP 3)
Post op, post procedure report is
dictated is before transfer to next level
(EP 5)
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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NATIONAL PATIENT SAFETY GOALS
• Must be evaluated by your surveyors
• They are almost all criticality 3, so they
count
• Always a focus of surveyor training
• They are complex because you have to
know the requirements and the FAQ
explanation of details.
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GOAL 1, USE OF 2 PATIENT
IDENTIFIERS
• Nothing new here, just get staff to
correctly verbalize what your two
identifiers are.
• Make sure staff really use those 2
identifiers on each patient interaction,
even when they know the patient.
– Be careful in amb care, hyperbaric, dialysis
still need to use 2 ID
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GOAL 2, CRITICAL TEST RESULTS
• Do you have a goal or timeframe in which
your staff are expected to reach the LIP?
• Are you meeting that expectation?
• Remember, the lab reaching a nurse is only
step 1 in the process and timeline.
• Do you expect something to be in the
chart?
• How do you monitor performance?
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GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
• Part 1 – label every medication or solution on a
sterile field. This includes water, saline,
chlorhexidine, propofol or one syringe.
• Do staff have the tools they need to perform this
function? Look at bedside procedures in ICU, OR
and minor procedures in AHC settings.
– “show me where you store your sterile labels”
– “what is your process to make sure that
proper labeling is performed?”
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THE ONE ON THE LEFT IS FENTANYL, THE ONE
ON THE RIGHT IS….
ITS WHITE, THEREFORE IT DOESN’T…..
TWO ARE LABELED, THEREFORE THE
THIRD IS….
ITS ONLY WATER, ITS ONLY REFUSE, IT
DOESN’T NEED A LABEL
GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
Part 2: Reduce harm from anticoagulation
therapy.
Do you have and do you use protocols for
anticoagulants?
Surveyors will trace anticoagulation
patients so is it clear that protocols are
being used?
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GOAL 3, IMPROVING THE SAFETY OF
USING MEDICATIONS
• Part 3 Medication reconciliation
– Is a list created for each inpatient or outpatient?
– Does someone analyze the list to “identify and
resolve discrepancies?”
– Procedural settings can be simplified and made
easy
– Inpatient admission reconciliation is not easy.
Discrepancies include omissions and changes.
– Inpatient discharge reconciliation is not easy.
Requires one complete list
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GOAL 7 INFECTION PREVENTION
• Part 1 – your hand hygiene program
– You have a program, you have goals, you are
improving.
– Be prepared to discuss at IC system tracer and
Data use tracer.
– Will surveyors see your program implemented
and working or significantly missed?
– Reduce your vulnerability in ICU, ED, PACU,
dialysis, infusion center by conducting tracer
interview where less observation is possible.
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GOAL 7 INFECTION PREVENTION
• Part 2 – prevention of MDRO infections
– Show me your risk assessment, and most recent
update, EP 1
– Lets ask staff, patients and LIP’s about your education
or optionally lets look at some documentation. EP 2
and 3
– Show me your measurement data from surveillance
and how this was presented to leadership. EP 5,6
– Show me which CPG’s you used. EP 7
– Show me how you alert ICP to new cases. EP 8
– Show me how you alert your ICP and staff to a
readmission of an MDRO patient. EP 9
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GOAL 7 INFECTION PREVENTION
• Part 3 – central line infection prevention
– Lets talk with patients, families, staff and LIP’s about
your education, or optionally show me documentation.
EP 1,2
– Show me your CPG’s. EP 3
– Show me your most recent risk assessment. EP 4
– Show me the report you sent to leadership with the
data analysis. EP 5
– Show me you catheter insertion checklist. EP 6
– Show me your standardized supply cart. EP 9
– During tracers what will the surveyor see during and
insertion relative to femoral vein, barrier precautions
used, hand hygiene and antiseptic used? EP 7,10,11
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GOAL 7 INFECTION PREVENTION
• Part 4 – prevention of surgical site infection
– Lets talk with staff, LIP’s and patients about the
education you provided or optionally lets look
at documentation.
– Same CPG, risk assessment, measurement,
report to leaders.
– Hair removal technique and antibiotic
prophylaxis in accordance with CPG’s.
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GOAL 7 INFECTION PREVENTION
• Part 5 – CAUTI
– How are you planning implementation, who is
doing what in 2012?
– What CPG are you planning to use?
– What data are you going to collect and who is
going to do it?
– Are you ready to implement house wide
1/1/13?
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GOAL 15 IDENTIFY PATIENT SAFETY RISKS
INHERENT IN THE POPULATION
• Part 1: Conduct a risk assessment for the patient and the
environment for features that may increase or decrease
risk for suicide.
– Each patient is clinically screened and a decision
reached about their risk.
– Environmental risks are identified and evaluated to
determine if we can mitigate the risk or must
eliminate the risk.
• Part 2: do something about it
• Part 3: upon discharge give each patient a list of
resources such as crisis lines.
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UNIVERSAL PROTOCOL
• Part 1: pre-procedure verification process
– We have the right patient, procedure, plan and
equipment present
•
•
•
•
•
Part 2: site marking by the surgeon
Part 3: Time out just prior to the procedure
Take a look at ambulatory and bedside procedures.
Make sure no one leaves the room after timeout.
Does your paperwork trail and timing make sense?
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The mock is Complete, Now What?
Bullet Proof Weak Areas
• Internal tracers/data will highlight these
• Formalize decisions in writing, do risk
analysis, communicate decisions
• Communicate top hot spots
– In pocket guides, in games, in annual
education, screen savers, table tent cards
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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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DESIGN FORMS FOR ENHANCED COMPLIANCE
 Consent Obtained
... Other text …
Signed: ____________ MD
 H and P Updated
... Other text …
Signed: ____________ MD
... Other text … Consent obtained.
Signed: ____________ MD
..I reviewed the H&P and examined the
patient… There are no changes unless
noted below:
______________________________.
Signed: ____________ MD
 Pre-induction assessment
conducted.
Identify natural components of the
pre-anesthesia evaluation.
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Managing the Onsite Survey …
GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION
• Validate ID on the extranet
• Institute your calling tree
• Everyone or their back up initiates the preplanned action.
• Rooms are freed up,
• Documents are rolled in, opening
conference starts. Optional information
shows great things only
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Institute the Action Plan
Everyone in Position
93
Tracer Tips For Staff
•
•
•
•
Its not a police interrogation, its not root canal
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…”
– Offer to provide the answer later in the day
– Stop talking once you have answered
– Know where policies are kept & how to access them.
• Make sure you have the right policy, screen
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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
• 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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Role of the Escort/Note Taker
• Upon arrival handle introductions and get the
ball rolling ASAP
• Gently coach struggling staff
• Record offers to present support and record
surveyor’s response
• Record the “he said” “she said”
• Record MR numbers
• ID potential pitfalls, RFI’s, or potential disasters
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Questions?
• [email protected]