Transcript TJC Update 2016 - McKenna Consulting

2016 JOINT COMMISSION
UPDATE
PO Box 3187
Charleston, WV 25332
www.mckennaconsulting.com
304-988-1047
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The Joint Commission 2016
Major Influences continue for 2016
 CMS Deeming Status
 Competition
 DNV ties to ISO
 Now The Joint Commission
moving to tie to ISO – not much
action (high amount of turnover in
TJC)
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The Joint Commission 2016
Scoring for 2016
A’s and C’s only (C’s may go)
EP’s 0, 1, 2
Timeline for Correcting
Criticality and Immediacy of
Risk
45 – 60 days
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The Joint Commission 2016
Standard Based Leadership
Conditions Failures
 Don’t just fail one (Governing
Body)
 Infection Control, Physical Plant
and Surgical Services
 About 95% fail two conditions
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The Joint Commission 2016
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Sessions
 Remain same right now
Opening Conference
Leadership (High Reliability)
Medication Management
Infection Prevention Control
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The Joint Commission 2016
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Sessions cont'd
 Data Management
 Environment of Care (Big trouble)
 Emergency Management
 Competency
 Credentials
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The Joint Commission 2016
 Tracers – most significant
 Cleaning, disinfectant and
sterilization (1 ½-2 hrs in OR,
Endo) from procuring, to
storage, to distribution, to use
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The Joint Commission 2016
 Evaluation of Physical Plant
 Starts upon arrival
 Specified OR time (1 ½-2 hrs)
 Single document list
http://www.jointcommission.org/life_safet
y_code_information_resources/
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Diagnostic Imaging (July 2015)
 Ask for policies to show
compliance with new standards
 Minimum qualifications for CT
techs – still on hold
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The Joint Commission 2016
Chapters (Alphabetized)
 Accreditation Participation
Requirement (APR)
 Environment of Care (EC)
 Emergency Management (EM)
 Human Resources (HR)
 Infection Prevention & Control (IC)
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Chapters cont'd
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Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSG)
Nursing (NR)
Patient Safety Systems (PS)
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Chapters cont'd
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Provision of Care (PC)
Performance Improvement (PI)
Record of Care, Treatment and Services
(RC)
Rights and Responsibilities (RI)
Transplant Safety (TS)
Universal Protocol (UP)
Waived Testing (WT)
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The Joint Commission 2016
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Most Significant Findings that will
follow us into 2016
 NPSG – Labeling of meds
Anesthesia
Dating large volumes
Syringes including autoinjections
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The Joint Commission 2016
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Most Significant Findings that will
follow us into 2016 cont’d
 Alarm Management – fully
implemented
 Rights/Responsibilities
Informed Consent
Advanced Directives
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The Joint Commission 2016
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Most Significant Findings that will
follow us into 2016 cont’d
 Record of Care, Treatment and
Services
Dating/timing
Post procedural Note
Immediate
Legibility
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The Joint Commission 2016
Provision of Care
 Pain Assessment/Reassessment
 ED triage
 OP areas
 Histories and Physicals
 Ambulatory Problem List
 Restraints
 Moderate Sedation
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The Joint Commission 2016
Provision of Care
 Anesthesia
 Immediate Reassessment
 Post anesthesia visit
 Plan of Care
 Individualized
 Updated to current discharge plan
 New diagnosis
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The Joint Commission 2016
Medication Management
 Security
 Anesthesia
 Labor and Delivery
 Emergency medications
 Reason for medication
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The Joint Commission 2016
Medication Management
 Titrated orders
 Pitocin
 Diprivan
 High risk drug disposal
 Compounding – Doctor’s office
practices
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The Joint Commission 2016
Medication Management
 Multidose vials
 Fluids
 Expired medications
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The Joint Commission 2016
Infection Control
 Sterilization, High Level Disinfectant
 Job descriptions
 Competencies
 Observe employees following
manufacturer’s instructions
 Brushes
 Storage of sterile items
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The Joint Commission 2016
Infection Control
 Sterilization, High Level
Disinfectant cont’d
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Contact time for cleaning
Temperature of chemicals
Standardized i.e. enzymatic soaks
Scopes hang freely
Semi-critical items – stored with
impervious covers
 Air quality
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The Joint Commission 2016
Transplant Safety
 Bidirectional
 Lot number of anything used with
 Staff involved
 FDA
 Alarms
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The Joint Commission 2016
Performance Improvement
 Leadership findings
 Complex organization
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The Joint Commission 2016
Leadership
 Contracts
 Policies and Procedures
 Failure to hold accountable
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The Joint Commission 2016
Environment of Care
 Eyewashes
 Ventilation systems
 Oxygen storage
 Egress
 Relative humidity
 Behavioral – ligature risk
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The Joint Commission 2016
Life Safety
 Fire Doors
 Smoke barriers
 Penetrations
 Fire proofing beams
 Non-coded storage
 Things hanging from sprinklers
 Trash receptacles
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The Joint Commission 2016
Emergency Management
 96 hours sustainability
 Drills/events
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The Joint Commission 2016
Human Resources
 Doctor’s offices
 Primary Source
 Overstepping scope
(compounding)
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The Joint Commission 2016
Information Management
 Accurate Computer Information
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The Joint Commission 2016
Nursing
 Over stepping scope
 Oversight
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The Joint Commission 2016
Medical Staff Standards
 OPPE
 FPPE
 Bylaw requirements
 Radiology/Nuclear Qualifications
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Waived Testing
 Quality Controls
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References
 Joint Commission (2016). Comprehensive
Accreditation Manual, Department of
Publications and Education Joint
Commission Resources, Oakbrook
Terrace, Illinois, 2016
 AIA Academy Of Architecture for Health,
United States. Dept of Health and Human
Services. Guidelines for design and
construction of hospital and healthcare
facilities. American Institute of Architects
Press, 2010 (Facility Guidelines Institute –
FGI)
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References
Centers for Disease Control
http://www.cdc.gov/hicpac/pdf/guidelines/Disinf
ection_Nov_2008.pdf
Accessed: 10-27-2015
 http://www.jointcommission.org/sea_issue_52/
Accessed: 10-27-2015
 http://www.jointcommission.org/sea_issue_55/
Accessed: 10-27-2015
 http://www.jointcommission.org/life_safety_cod
e_information_resources/ Accessed: 10-272015
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Thank you
[email protected]
McKenna Consulting
Post Office Box 3187
Charleston, WV 25332
304-988-1047
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