Transcript TJC Survey Feedback 2016

TJC Survey Feedback 2016
PO Box 3187
Charleston, WV 25332
www.mckennaconsulting.com
304-988-1047
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Survey Process
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Opening Conference
Leadership (High Reliability)
Medication Management
Infection Prevention Control
Data Management
Environment of Care
Emergency Management
Competency
Credentials
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Historical Approach Continuing
 90 + % Receive Condition Level
Findings
 Results in Revisits
 45 days for Medicare
Condition
 3-6 months regular resurvey
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Most Common Conditions
 Physical Environment
 Surgical Services
 Nursing
 Governing Body
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Life Safety and
Environment of Care
 Over 50% findings
 Majority from observation
 Significant findings from
document
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Units/Depts Receiving
the Most Deficiencies
 Operative/Invasive Areas
 OR, Cath Lab, Radiology, Sterile
Processing, Endo, Rehab,
Anesthesia, Doctors Offices, ICU
 Behavioral
 Emergency Department
 Provide Based Clinics
 Cancer Centers
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Document Findings
 Inventory of Utilities
 Autopsy Findings
 Tissue Records
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Medical Records
 Pain
 ED
 Units
 Learning needs assessment
 Operative Report
 Diagnostic Results ED and Clinics
 Falls Risk
 H&Ps
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Accreditation Participation
Requirements
APR.01.02.01
The hospital provides accurate
information throughout the
accreditation process
(Falsification of records-Crash
Carts-OR records)
 None for 2016
 Some for 2015
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Environment of Care
Safety & Security
 Eyewash stations
 X-ray aprons
 Oxygen storage
 Access to nurse call
 Behavioral health safety issues
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Environment of Care
Safety & Security
 MRI safety
 Smoking Policy
 Staff badges
 Infant/pediatric abduction
 Control of security sensitive areas
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Environment of Care
Hazardous Material & Waste
 Identify soiled utility as containing
hazardous waste
 Unattended/unlocked
housekeeping carts
 Hot lab
 Staff can access SDS
 Spill kits
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Environment of Care
Fire Safety
 Fire drills
 Medical gas panels/electrical
panels blocked by equipment
 Equipment checks/documentation
 Fire doors propped open
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Environment of Care
Medical Equipment
 Patient owned
 Loaner equipment
 Use of manufacturer
recommendations
 Management of radiology
equipment
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Environment of Care
Utility Systems
 Air quality
 Air exchange rates
 Ventilation systems
 Emergency power testing
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Environment of Care
Know your own documentation
even if completed by vendor
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Emergency Management
 Exercises not implemented
 Exercise critique with no follow
through
 Complete inventory list
 96 hour sustainability
 Leadership accountability
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Life Safety
 PFIs on final JC report
 E-SOC changed
 Categorical waivers
 Equivalency Process Modification
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Life Safety
 Egress path blocked
 Fire doors
 Exit signs
 Penetrations
 Interim Life Safety Measures
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Human Resources
 Organized files
 Primary Source Verification
 Contractors/Vendors
 Non-employees
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Human Resources
 Provider-based practice
employees
 Competency
 Annual report includes staffing
effect on quality
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Medical Staff
 Compliance with MS.01.01.01
 Non-inpatient H&P requirements
 Accurate privilege list
 Setting specific privileges
 FPPE
 OPPE
 Complete credentials file
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Nursing
 Nurse executive qualifications
 Nurse executive oversight to all
areas providing nursing care
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Leadership
 Emphasis on leadership
responsibility and accountability
 Contract management
 Policies and procedures
consistently implemented
 Space
 Disruptive behavior
 Patient flow
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Performance Improvement
 Use PI data to improve patient
care processes
 During tracers, evaluate staff
knowledge related to PI
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Performance Improvement
 During tracers, look for evidence
of ongoing PI activities
 Performance Improvement project
for each area
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Provision of Care
 History & Physical is current and
updated with evidence of
examination
 Pain assessment/reassessment
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Provision of Care
 Moderate sedation – ASA and
airway assessment
 Problem list by 3rd outpatient visit
 Care Planning
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Provision of Care
 Patient/family education
 Patient communication – preferred
language
 Restraints
 Discharge planning
 Crash cart checks
 Nutrition management
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Transplant Safety
 Record keeping:
 Verification of package integrity
upon receipt
 Staff involved
 Allows for bidirectional tracking
 Lot numbers and expiration dates
of supplies used
 Annual verification of FDA approval
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Waived Testing
 Dating of BGM reagents when
opened
 Quality controls
 Staff competency
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Medication Management
 Medication storage
 Security
 Temperature
 Expiration
 Contrast
 Multi dose vials
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Medication Management
 Medication orders
 Blanket orders
 Range orders
 Titration orders
 Therapeutic duplication
 Sample medications
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Infection Control
 Complete IC plan and risk
assessment – annual evaluation
 Separation of clean and dirty
equipment
 TEE scopes, laryngoscope blades,
Magill forceps, vaginal probes
 Contact time for disinfectant
solutions
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Infection Control
 High level
disinfection/sterilization
 Storage of sterile supplies
 Scope storage
 Isolation practices
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Rights & Responsibilities
 Confidentiality/Privacy
 Informed Consent
 Advance Directives
 Pain management
 Communication –
interpreter/translator
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Record of Care
 Dating/timing/authentication
 Post procedure note
 All orders in medical record –
including protocols
 Verbal orders/telephone orders
 Complete and accurate medical
record
 Medical record audit
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National Patient Safety Goals
NPSG.01.01.01: Use at least 2
patient identifiers when providing
care, treatment, and services
 Use of 2 patient identifiers in office
setting
 Forms in Medical record
 Food tray delivery
 Pre-labeling of containers for
blood or specimens
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National Patient Safety Goals
NPSG.01.03.01: Eliminate
transfusion errors related
to patient
misidentification
 Qualified individuals
 Good process to observe
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National Patient Safety Goals
NPSG.02.03.01: Report critical
results of test and diagnostic
procedures on a timely basis.
 Written procedure
 Staff knowledge of
organizational requirement
 Use of data to evaluate
timeliness of reporting
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National Patient Safety Goals
NPSG.03.04.01: Label all
medications, medication containers,
and other solutions on and off the
sterile field in perioperative and
other procedure settings
 Bowls on sterile field
 Anesthesia meds especially
Diprovan
 Pre-labeled syringes
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National Patient Safety Goals
NPSG.03.05.01: Reduce the likelihood
of patient harm associated with the
use of anticoagulation therapy.
 Written policy addressing
required lab test
 Staff knowledge of policy and
approved protocols
 Patient education
 Education for prescribers/staff
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National Patient Safety Goals
NPSG.03.06.01: Maintain and
communicate accurate patient
medication information.
 List of a patient medication
upon admission
 Comparison of home meds to
those ordered in hospital
 Written information upon
discharge
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National Patient Safety Goals
NPSG.06.01.01: Improve the safety of
clinical alarm systems
By now:
 Established alarm safety as priority
 Identified most important alarm
signals
By January 1, 2016
 Policies & procedures in place
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 Educated staff & LIPs
National Patient Safety Goals
NPSG.07.01.01: Comply with
CDC or WHO hand hygiene
guidelines
 Failure to set goals for
improving hand hygiene
compliance
 Lack of confidence in hand
hygiene data
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National Patient Safety Goals
NPSG.07.03.01: Implement EBP to
prevent healthcare associated
infections due to MDRO
 Periodic risk assessments
 Educate staff & LIPs at hire and
annually
 Patient/family education
 Monitor MDROs in organization
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National Patient Safety Goals
NPSG.07.04.01: Implement EBP to
prevent central line associated
bloodstream, infections
 Catheter checklist &
standardized protocol for CL
insertion
 Standardize all processes related
to CL management
 Periodic risk assessment
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National Patient Safety Goals
NPSG.07.04.01: cont’d
 Educate staff & LIPs at hire
and annually
 Patient/family education
 Monitor CL infectionssurveillance on all central
lines
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National Patient Safety Goals
NPSG.07.05.01: Implement EBP for
preventing surgical site infections
 Periodic risk assessment
 Educate staff & LIPs at hire and
annually
 Patient/family education
 Implement EBP
 Monitor compliance with policies
 Measure infection rates
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National Patient Safety Goals
NPSG.07.06.01: Implement EBP to
prevent indwelling catheter
associated urinary tract infections
 Insert catheters based on EB
guidelines
 Manage catheters based on EB
guidelines
 Monitor compliance with
organization policy-measure
effectiveness of program
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National Patient Safety Goals
NPSG.15.01.01: Identify patients at
risk for suicide
 Applies to any patient in general
hospital with a primary diagnosis
or primary complaint of an
emotional or behavioral disorder
 Appropriate follow-up required in
response to assessment-address
patient’s immediate safety needs
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National Patient Safety Goals
UP.01.01.01: Conduct a
preprocedure verification
process
 Verify correct procedure,
patient, site
 Verify all items required for
procedure available
 Match items to patient
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National Patient Safety Goals
UP.01.02.01: Mark the procedure
site.
 Site marked by procedurealist
 Method of marking
standardized
 Written process for patients
who refuse or marking is
impossible
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National Patient Safety Goals
UP.01.03.01: Timeout is
performed before the procedure
Challenges:
 Failure to complete or document
timeout
 Failure of entire team to pause
and participate in timeout
 Timeout conducted too earlynot immediately before
procedure
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References
 Joint Commission (2016). Comprehensive
Accreditation Manual, Department of
Publications and Education Joint Commission
Resources, Oakbrook Terrace, Illinois, 2016
 Centers for Medicare and Medicaid Services,
Department of Health and Human Services.
(Rev. 151, 11-20-15) State Operations Manual,
Appendix A, Survey protocol, regulations and
interpretive guidelines for hospitals, retrieved
from http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som1
07ap_a_hospitals.pdf accessed 2/18/16
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Thank you
[email protected]
McKenna Consulting
Post Office Box 3187
Charleston, WV 25332
304-988-1047
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