Transcript Situation Decision Rules - KHA Accreditation > Getting Started

Essentials of Joint
Commission Readiness
Stephen M. Dorman, MD
Dale Brown, RN, MSN
Day 1
Web Sites
Dr. Dorman
www.redandgold.com
Dale Brown
www.kentandassociates.biz
2
Accreditation Decisions
Preliminary Accreditation
Accredited
Accredited with follow-up survey (30 days
to 6 months) (Non-CMS issues)
Contingent Accreditation: follow up survey
within 30 days
Preliminary Denial
Denial
3
Flow of Decision
Accreditation with follow-up survey (1st
failed condition level deficiency)
Contingent accreditation (2nd failed CLD)
PDA: Immediate threat to life
4
Flow of Decision
Single or multiple instances
Nature and significance of findings
Failed On-site ESC
Decision rules triggered
Repeat findings
5
Condition Level Deficiencies
Determination based on manner and
degree:
– Manner: prevalence, how pervasive, number
frequency
– Degree: magnitude, how severe, how bad
– Collaboration among team members AND
Central office staff
6
Condition Level Deficiencies
Noncompliance within the condition stem
statement
Single requirement out of compliance
which is of such magnitude to result in
noncompliance with entire condition
Many requirements and standards
noncompliant
7
Condition Level Deficiencies
Follow up survey MUST occur within 45
calendar days of last day of accreditation
survey
If the problem remains a second follow up
survey MUST occur within 30 days of first
follow up survey
8
Condition Level Deficiencies
The follow up survey will focus on the RFIs
that were determined to be the condition
level deficiencies
The surveyors can score other issues that
are identified during an onsite visit
Failure to clear a condition level deficiency
after the second survey results in
notification to CMS
9
Condition Level Deficiencies
Governing Body CoP:
– When any condition level deficiencies are
identified during the survey, TJC is required to
include a condition level deficiency in the
leadership standards.
10
Situation Decision Rules
11
Situation Decision Rules
The Accreditation with Follow-up Survey
could occur within 30 days or up to six
months after the decision is rendered.
(AFS01) The hospital demonstrates
systemic patterns, trends, and repeat
findings primarily with direct impact
standards.
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Situation Decision Rules
(AFS02) The hospital demonstrates
systemic patterns, trends, and repeat
findings primarily with indirect impact
standards.
(AFS03) The hospital fails to successfully
address all RFIs in an ESC or MOS.
(AFS04) At least two on-site ESC
demonstrate the need for continued
monitoring to assess whether the hospital
sustains improvements.
13
Situation Decision Rules
(AFS05) The hospital, which has failed to
resolve one or more of its original RFIs,
may be scheduled for a second
Accreditation with Follow-up Survey
(AFS06) The hospital fails to submit a
PPR and corrective action plan as
appropriate.
(AFS08) The hospital has one or more
Condition of Participation scored as a
Condition-level deficiency.
14
Immediate Threat to Life
15
Scoring/Decision
The Immediate Threat to Life process has
been modified. Upon resolution of the
threat, the accreditation status will change
from Preliminary Denial of Accreditation
(PDA) to Contingent Accreditation and
include a follow-up survey.
16
Immediate Threat to Life
Situations, identified at the time of survey,
which have or may potentially have a
serious adverse effect on patient health
and safety.
The Joint Commission President can issue
an expedited Preliminary Denial of
Accreditation (PDA) decision.
17
Immediate Threat to Life
PDA remains until corrective action is
demonstrated, via an on-site validation
survey.
PDA changes to Contingent Accreditation
which includes a follow-up survey to
assess sustained implementation
18
Situational Decision Rules
Examples:
– Unlicensed facility
– Unlicensed individual who requires a license
– Failure to implement LSC deficiencies
Some standards will trigger Situational
Decision rule directly and immediately
19
Standards Notation
20
Immediate Jeopardy
CMS Examples
Actual injury NOT required to
occur for a citation
CMS: Abuse
Failure to protect from abuse
1. Serious injuries such as head trauma
or fractures;
2. Non-consensual sexual interactions;
e.g., sexual harassment, sexual coercion
or sexual assault;
3. Unexplained serious injuries that have
not been investigated;
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CMS: Abuse
4. Staff striking or roughly handling an
individual;
5. Staff yelling, swearing, gesturing or
calling an individual derogatory names;
6. Bruises around the breast or genital
area; or Suspicious injuries; e.g., black
eyes, rope marks, cigarette burns,
unexplained bruising.
23
CMS: Neglect
1: Lack of timely assessment of individuals
after injury;
2. Lack of supervision for individual with
known special needs;
3. Failure to carry out doctor’s orders;
4. Repeated occurrences such as falls
which place the individual at risk of harm
without intervention;
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CMS: Neglect
5. Access to chemical and physical
hazards by individuals who are at risk;
6. Access to hot water of sufficient
temperature to cause tissue injury;
7. Non-functioning call system without
compensatory measures;
8. Unsupervised smoking by an individual
with a known safety risk;
25
CMS: Neglect
9. Lack of supervision of cognitively
impaired individuals with known elopement
risk;
10. Failure to adequately monitor
individuals with known severe selfinjurious behavior;
26
CMS: Neglect
11. Failure to adequately monitor and
intervene for serious medical/surgical
conditions;
12. Use of chemical/physical restraints
without adequate monitoring;
13. Lack of security to prevent abduction
of infants;
14. Improper feeding/positioning of
individual with known aspiration risk
27
CMS: Neglect
15. Inadequate supervision to prevent
physical altercations.
28
CMS: Psychological Harm
1. Application of chemical/physical
restraints without clinical indications;
2. Presence of behaviors by staff such as
threatening or demeaning, resulting in
displays of fear, unwillingness to
communicate, and recent or sudden
changes in behavior by individuals; or
29
CMS: Psychological Harm
3. Lack of intervention to prevent
individuals from creating an environment
of fear.
30
CMS: Medication Errors
1. Administration of medication to an
individual with a known history of allergic
reaction to that medication;
2. Lack of monitoring and identification of
potential serious drug interaction, side
effects, and adverse reactions;
3. Administration of contraindicated
medications;
31
CMS: Medication Errors
4. Pattern of repeated medication errors
without intervention;
5. Lack of diabetic monitoring resulting or
likely to result in serious hypoglycemic or
hyperglycemic reaction; or
6. Lack of timely and appropriate
monitoring required for drug titration.
32
CMS: Nutrition/Hydration
1. Food supply inadequate to meet the
nutritional needs of the individual;
2. Failure to provide adequate nutrition
and hydration resulting in malnutrition;
e.g., severe weight loss, abnormal
laboratory values;
33
CMS: Nutrition/Hydration
3. Withholding nutrition and hydration
without advance directive; or
4. Lack of potable water supply.
34
CMS: Infections/Sterility
1. Pervasive improper handling of body
fluids or substances from an individual
with an infectious disease;
2. High number of infections or
contagious diseases without appropriate
reporting, intervention and care;
35
CMS: Infection/Sterility
3. Pattern of ineffective infection control
precautions; or
4. High number of nosocomial infections
caused by cross contamination from staff
and/or equipment/supplies.
36
CMS: Identification
1. Blood products given to wrong
individual;
2. Surgical procedure/treatment
performed on wrong individual or wrong
body part;
3. Administration of medication or
treatments to wrong individual; or
37
CMS: Identification
4. Discharge of an infant to the wrong
individual.
38
CMS: Blood/Transplant
1. Wrong blood type transfused;
2. Improper storage of blood products;
3. High number of serious blood
reactions;
4. Incorrect cross match and utilization of
blood products or transplantation organs;
5. Lack of monitoring for reactions during
transfusions.
39
CMS: Fire/Hazards
1. Nonfunctioning or lack of emergency
equipment and/or power source;
2. Smoking in high risk areas;
3. Incidents such as electrical shock, fires;
4. Ungrounded/unsafe electrical
equipment;
40
CMS: Fire/Hazards
5. Widespread lack of knowledge of
emergency procedures by staff;
6. Widespread infestation by
insects/rodents;
7. Lack of functioning ventilation, heating
or cooling system placing individuals at
risk;
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CMS: Fire/Hazards
8. Use of non-approved space heaters,
such as kerosene, electrical, in resident or
patient areas;
9. Improper handling/disposal of
hazardous materials, chemicals and
waste;
10. Locking exit doors in a manner that
does not comply with NFPA 101;
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CMS: Fire/Hazards
11. Obstructed hallways and exits
preventing egress;
12. Lack of maintenance of fire or life
safety systems; or
13. Unsafe dietary practices resulting in
high potential for food borne illnesses.
43
CMS: Emergency Care
1. Individuals turned away from ER
without medical screening exam;
2. Women with contractions not medically
screened for status of labor;
3. Absence of ER and OB medical
screening records;
4. Failure to stabilize emergency medical
condition; or
44
CMS: Emergency Care
5. Failure to appropriately transfer an
individual with an unstabilized emergency
medical condition.
45
CMS: Hospital Acquired
Conditions
Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure ulcers stages III/IV
Falls and trauma
CLABSI
Catheter Associated infections
Poor glycemic control
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Survey Preparation
Document Review
Receiving Surveyors
47
Survey Preparation
Expanded Document Request First
Morning of Survey
The Infection control plan, risk
assessment and annual evaluation
The ILSM policy and most recent or in
progress implementation documentation.
Disaster critiques for the past 12 months.
Performance Improvement Committee
minutes for past 12 months.
Expanded Document Review
List
A list of all sites, including off sites that
clean/disinfect/sterilize equipment or
devices.
EOC meeting minutes for the past 12
months.
IC Committee meeting minutes for the
past 12 months.
MEC meeting minutes including the one
where the medical staff approved the
qualifications of the radiology and nuclear
medicine staff.
Expanded Document Review
List
Pharmacy and Therapeutics committee
minutes for the past 12 months.
OR Temperature and Humidity readings
for the past 6 months.
EOC testing reports for air exchanges
and positive, negative pressure areas.
Critical test result data for the past 12
months to include Radiology.
Expanded Document Review
List
Patient Flow data for 12 months and analysis.
Written inventory of all medical equipment
categorized by risk.
The hospital fire response plan.
The infant abduction plan and code exercises.
Written plans for actions taken in the event of
utility disruptions.
Inspections conducted by Federal, State or
Local authorities in the past 2 years.
Expanded Document Review
List
Generator testing logs for the past 2 years.
Fire alarm and suppression testing reports
for the past two years.
Piped medical gas testing and inspection
policy and the most recent inspection
report.
Fire drill data for the past 12 months
including a matrix or grid showing dates
and locations of drills.
Expanded Document Review
List
Hospital policies that define frequencies for
inspections, testing and maintaining medical
equipment based on manufacturer’s
recommendations.
A written inventory of all operating components
of utility systems based on risks of infection,
occupant needs and systems critical to patient
care.
Policies Required for Deemed
Status
Autopsy policy/process
Blood supplier agreement
Blood transfusion policies including HCV and
HIV
CLIA Certificates for Lab
Complaint/Grievance policy/log for past 12
months
Discharge Planning policies
Policies Required for Deemed
Status
Food Service Director job description
Hospital License
Lead dietitian job description
Organ, eye and tissue procurement
policies and agreements
Policies for food handling, menu
planning, frequency of meals, ordering
and delivering food
Utilization Review plan
Polices That MAY Be Requested
(Bring Only If Requested)
Advance directive policy
Critical results policy
Falls policy
Informed consent policy
Medication orders required elements
policy
OPPE/FPPE policies
Pain assessment & reassessment policies
Patient identification policies
Polices That MAY Be Requested
(Bring Only If Requested)
Patient rights policy and how the patient
becomes aware
Patient visitation policy
Restraint & Seclusion policy
Sign language and foreign language
policy
Suicide screening policy
Tissue procurement and storage policy
Universal protocol, time out policy.
Closed Medial Record Request
List
2 restraint charts for non-violent behavior
1 pediatric moderate sedation chart from
ED
1 adult moderate sedation chart from ED
1 infant circumcision
1 C-Section
1 transfer out of ED
2 discharge records from the past 7 days
flagging the discharge summary
Closed Medial Record Request
List
2 ventilator charts
1 restraint chart for violent or selfdestructive behavior
2 transfusion charts, with special
attention to the transfusion record
1 tissue implant
1 chest pain
1 heart failure
Closed Medical Record Request
List
1 patient who expired during the
hospital stay
1 patient who received an autopsy
First Morning Of
Survey
First Morning of the Survey
Actions to be taken on unit when
surveyors arrive at hospital:
– Close doors to patient rooms
– Make sure medications are secure
– Computers are not unattended with
patient information
– Hallways are clear of clutter except for
Crash Cart and Isolation cart
– One month of crash cart check sheets
and defib tested for the day
62
Tracer Activity
Medication room is clean,
Refrigerator temps documented
Signage on isolation rooms is
correct
Oxygen cylinders are segregated
and secured
Review assignments and determine
who will cover for who if surveyor
visits unit.
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Tracers
Remember the surveyor will want all
documentation related to the patient
available.
The Command Center will be
communicating with the scribe to
advise the unit of Surveyor
movement.
Receiving Surveyors
Receiving Surveyors
When the unit is notified of the surveyors
impending arrival be ready to receive the
surveyor as soon as possible. Surveyors
understand care is being delivered but try to
expedite attending to the surveyor. Sooner you
arrive the sooner they leave hopefully! 
The last thing you want is for the surveyor to
arrive and no one pays any attention to them.
This is a control point for the survey. If we don’t
engage them they will wander and potentially
find issues to score.
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Receiving Surveyors
Plan ahead as to where to take the
surveyor for review of the medical
record. Try to avoid conducting this
activity at the Nurse’s Station if at all
possible.
Survey Behaviors
Survey Behaviors
Look interested!
Listen carefully to the surveyor’s
question-think about the answer
prior to speaking.
Don’t answer the question prior to
the surveyor finishing their sentence.
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Survey Behaviors
If you do not understand the question try
using “help me to understand the question”.
Please remember they know you have a
level of anxiety but you want to be sure to
keep emotions in check.
If you do not know the answer to the
question, pause to think then if you are
SURE you do not know the answer, tell the
surveyor that you are not sure but you will
be glad to find out.
Survey Behaviors
Navigation of the medical record is VERY
IMPORTANT (handout). Navigation is
another control point.
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Emergency Management
Oversight
Leadership
04.01.01
Leaders establish priorities for
performance improvement
EP # 25 (A)
– Senior hospital leadership directs
implementation of selected hospital-wide
improvements in emergency management
based on the following:
Review of the annual emergency management
planning reviews
Review of the evaluations of all the emergency
response exercises and all responses to actual
emergencies.
Leadership
04.01.01
Senior hospital leadership directs
implementation of selected hospital-wide
improvements in emergency management
based on the following:
Determination of which emergency
management improvements will be prioritized
for implementation, recognizing that some
emergency management improvements
might be lower priority and not taken up in the
near term.
Leadership
LD 04.01.05
The hospital effectively manages its
programs, services, sites, or departments.
(A) EP # 12
Leaders identify an individual to be
accountable for the following:
– Staff implementation of the four phases of
emergency management(mitigation,
preparedness, response and recovery)
Leadership
LD.04.01.05
The leaders identify an individual to be
accountable for the following:
– Staff implementation of emergency
management
Across six critical areas(communications,
resources, and assets, safety and security,
staff responsibilities, utilities, and patient
clinical and support activities.
– Collaboration across clinical and operational
areas to implement emergency management
(hospital-wide)
Leadership
04.01.05
Leaders identify an individual to be
accountable for the following:
– Identification of an collaboration with
community response partners.
Note: This role addresses matters of
emergency management that are not within
the responsibilities of the incident commander
role.
Emergency Management
EM 03.01.01
The hospital evaluates the effectiveness of
its emergency management planning
activities.
EP # 4 (A) The annual emergency
management planning reviews are
forwarded to senior hospital leadership for
review.
Emergency Management
EM. 03.01.01
Senior leadership refers to those leaders
with responsibility for organization-wide
strategic planning and budgets ( VP’s and
officers
The hospital may determine that all senior
hospital leaders participate in reviewing
emergency management reviews, or it
may, designate specific senior hospital
leaders to review this information.
Emergency Management
EM. 03.01.03
The hospital evaluates the effectiveness of its
Emergency Operations Plan
EP 13 (A) Based on all monitoring activities
and observations, including relevant input
form all levels of staff affected the hospital
evaluates all emergency response exercises
to actual emergencies using a
multidisciplinary process which includes
licensed independent practitioners.
Emergency Management
EM .03.01.03
The hospital evaluates the effectiveness of its
Emergency Operations Plan
EP # 15 (A) The deficiencies and
opportunities for improvement identified in the
evaluation of all emergency response
exercises and all responses to actual
emergencies, are communicated to the
improvement team responsible for the
monitoring environment of care issues and to
senior hospital leadership.
NPSGs 2013
Goal 1
Improve the accuracy of patient
identification.
83
NPSG.01.01.01
Use at least two patient identifiers when providing
care, treatment, and services.
1: Use two patient identifiers when
administering medications, blood, or blood
components, when collecting blood
samples and other specimens for clinical
testing, and when providing treatments or
procedures. The patient’s room number
or physical location is not used as an
identifier. (C-3)
84
NPSG.01.01.01
2: Label containers used for blood
and other specimens in the presence
of the patients. (A-3)
85
NPSG.01.03.01
Eliminate transfusion errors related to patient
misidentification.
1: Before initiating a blood or blood component
transfusion:
– Match the blood or blood component to the order.
– Match the patient to the blood or blood component.
– Use a two person verification process or a one person
verification process accompanied by automated
identification technology, such as bar coding.
86
NPSG.01.03.01
2: When using a two-person
verification process, one individual
conducting the identification
verification is a qualified transfusionist
who will administer the blood or blood
component to the patient. (A-3)
87
NPSG.01.03.01
3: When using a two-person
verification process, the second
participant conducting the
identification verification is qualified to
participate in the process as
determined by the hospital. (A-3)
88
Goal 2
Improve the effectiveness of
communication among caregivers.
89
NPSG.02.03.01
Report critical results of tests and
diagnostic procedures on a timely
basis.
90
NPSG.02.03.01
1: Develop procedures for managing
critical results of tests and diagnostic
procedures that address the following:
– The definition of critical results of tests and
diagnostic procedures.
– By whom and to whom critical results of tests
and diagnostic procedures are reported.
– The acceptable length of time between the
availability and reporting of critical results of
tests and diagnostic procedures. (A-D)
91
NPSG.02.03.01
2: Implement the procedures for
managing the critical results of tests
and diagnostic procedures. (A)
3: Evaluate the timeliness of reporting
the critical results of tests and
diagnostic procedures. (A)
92
Goal 3
Improve the safety of using
medications.
93
NPSG.03.04.01
The organization labels all medications,
medication containers and other solutions
on and off the sterile field in perioperative
and other procedural settings. Note:
Medication containers include syringes,
medicine cups, and basins.
94
NPSG.03.04.01
1: In perioperative and other procedural settings
both on and off the sterile field, label
medications and solutions that are not
immediately administered. This applies even if
there is only one medication being used.
Note: An immediately administered medication is one that an
authorized staff member prepares or obtains, takes directly to a
patient, and administers to that patient without any break in the
process. Refer to NPSG.03.04.01, EP 5, for information on timing of
labeling.
(A-3)
95
NPSG.03.04.01
2: In perioperative and other
procedural settings both on and off
the sterile field, labeling occurs when
any medication or solution is
transferred from the original
packaging to another container. (A-3)
96
NPSG.03.04.01
3: In perioperative and other procedural settings both on
and off the sterile field, medication or solution labels
include the following:
–
–
–
–
–
–
–
–
Medication Name
Strength
Quantity
Diluent and volume if not apparent from container
Preparation date (DELETED MARCH)
Expiration date when not used within 24 hours
Expiration time when expiration occurs in less than 24 hours
Note: the date and time are not necessary for short procedures
as defined by the hospital. (A-3)
97
NPSG.03.04.01
4: Verify all medication or solution labels
both verbally and visually. Verification is
done by two individuals qualified to
participate in the procedure whenever the
person preparing the medication or
solution is not the person who will be
administering it. (C-3)
98
NPSG.03.04.01
5: Label each medication or solution as
soon as it is prepared, unless it is
immediately administered. (A-3)
Note: An immediately administered
medication is one that an authorized staff
member prepares or obtains, takes directly
to a patient, and administers to that patient
without any break in the process.
99
NPSG.03.04.01
6: Immediately discard any medication or
solution found unlabeled. (A-3)
7: Remove all labeled containers on the
sterile field and discard their contents at
the conclusion of the procedure. (A-3)
Note: This does not apply to multi-use
vials that are handled according to
infection control practices.
100
NPSG.03.04.01
8: All medications and solutions both
on and off the sterile field and their
labels are reviewed by entering and
exiting staff responsible for the
management of medications. (C-3)
101
NPSG.03.05.01
Reduce the likelihood of patient harm associated with
the use of anticoagulation therapy.
Note: This requirement applies only to organizations that
provide anticoagulant therapy and/or long-term
anticoagulation prophylaxis (for example, atrial
fibrillation) where the clinical expectation is that the
patient’s laboratory values for coagulation will remain
outside normal values. This requirement does not apply
to routine situations in which short-term prophylactic
anticoagulation is used for venous thromboembolism
prevention (for example, related to procedures or
hospitalization) and the clinical expectation is that the
patient’s laboratory values for coagulation will remain
within, or close to, normal values.
102
NPSG.03.05.01
1-A: Use only oral unit dose products, prefilled syringes, or pre-mixed infusion bags
when these types of products are
available. (A-3)
Note: For pediatric patients, pre-loaded
syringe products should only be used if
specifically designed for children.
103
NPSG.03.05.01
2: Use approved protocols for the initiation and
maintenance of anticoagulant therapy.
(C-3)
3: Before starting patients on warfarin, assess
the patient’s baseline coagulation status; for all
patients receiving warfarin therapy, use a
current International Normalized Ratio (INR) to
adjust this therapy. The baseline status and
current INR are documented in the clinical
record. (A-3)
104
NPSG.03.05.01
Note: The patient’s baseline coagulation
status can be assessed in a number of
ways, including through a laboratory test or
by identifying risk factors such as age,
weight, bleeding tendency, and genetic
factors.
105
NPSG.03.05.01
4: Use authoritative resources to manage
potential food and drug interactions for patients
receiving warfarin. (A-3)
5: When heparin is administered intravenously
and continuously, use programmable pumps in
order to provide consistent and accurate dosing.
(A-3)
106
NPSG.03.05.01
6: A written policy addresses baseline and
ongoing laboratory tests that are required
for anticoagulants. (A-3-D)
(revised 6/23/2010).
107
NPSG.03.05.01
7: Provide education regarding
anticoagulant therapy to staff, patients,
and families. Patient/family education
includes the following: (C-3)
- The importance of follow-up monitoring
- Compliance
- Drug-food interactions
- The potential for adverse drug reactions and
interactions
108
NPSG.03.05.01
8: Evaluate anticoagulation safety
practices, take action to improve practices,
and measure the effectiveness of those
actions in a timeframe determined by the
organization. (A)
109
NPSG.03.06.01
Maintain and communicate
accurate patient medication
information.
110
NPSG.03.06.01
1: Obtain information on the
medications the patient is currently
taking when he or she is admitted to
the hospital or is seen in an outpatient
setting. This information is
documented in a list or other format
that is useful to those who manage
medications.
111
NPSG.03.06.01
Note 1: Current medications include those taken
at scheduled times and those taken on an asneeded basis. See the Glossary for a definition
of medications.
Note 2: It is often difficult to obtain complete
information on current medications from a
patient. A good faith effort to obtain this
information from the patient and/or other
sources will be considered as meeting the intent
of the EP.
112
NPSG.03.06.01
2. Define the types of medication
information to be collected in non–24hour settings and different patient
circumstances.
Note 1: Examples of non–24-hour settings
include the emergency department,
primary care, outpatient radiology,
ambulatory surgery, and diagnostic
settings.
113
NPSG.03.06.01
Note 2: Examples of medication
information that may be collected include
name, dose, route, frequency, and
purpose.
114
NPSG.03.06.01
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.
115
NPSG.03.06.01
Note: Discrepancies include omissions,
duplications, contraindications, unclear
information, and changes. A qualified
individual, identified by the hospital, does
the comparison. (See also HR.01.06.01,
EP 1)
116
NPSG.03.06.01
4. Provide the patient (or family as
needed) with written information on
the medications the patient should be
taking when he or she is discharged
from the hospital or at the end of an
outpatient encounter (for example,
name, dose, route, frequency,
purpose).
117
NPSG.03.06.01
Note: When the only additional
medications prescribed are for a short
duration, the medication information the
hospital provides may include only those
medications. For more information about
communications to other providers of care
when the patient is discharged or
transferred, refer to Standard
PC.04.02.01.
118
NPSG.03.06.01
5. Explain the importance of
managing medication information to
the patient when he or she is
discharged from the hospital or at the
end of an outpatient encounter.
119
NPSG.03.06.01
Note: Examples include instructing the
patient to give a list to his or her primary
care physician; to update the information
when medications are discontinued, doses
are changed, or new medications
(including over-the-counter products) are
added; and to carry medication information
at all times in the event of emergency
situations.
120
Goal 15
Identify patients at risk for suicide.
Note: This requirement applies only to
psychiatric hospitals and patients
being treated for emotional or
behavioral disorders in general
hospital.
121
NPSG.15.01.01
1: Conduct a risk assessment that identifies
specific patient characteristics and
environmental features that may increase or
decrease the risk for suicide. (C-3)
2: Address the patient’s immediate safety needs
and most appropriate setting for treatment. (C-3)
3: Provide suicide prevention information to
individuals at risk for suicide and their families
when they leave the care of the organization.
(C-3)
122
Universal Protocol
123
UP.01.01.01
Conduct a preprocedure process
The preprocedure verification is an
ongoing process of information
gathering and confirmation.
124
UP.01.01.01
1: Implement a preprocedure process
to verify the correct procedure, for the
correct patient, at the correct site.
(A-3)
Note: The patient is involved in the
verification process when possible
125
UP.01.01.01
2: Identify the items that must be available for the
procedure and use a standardized list to verify their
availability. At a minimum, these items include the
following: (A-3-D)
- Relevant documentation (for example, history and physical, signed
procedure consent form, nursing assessment, and preanesthesia
assessment)
- Labeled diagnostic and radiology test results (for example, radiology
images and scans, or pathology and biopsy reports) that are properly
displayed
- Any required blood products, implants, devices, and/or special equipment
for the procedure
Note: The expectation of this element of performance is that the standardized list is
available and is used consistently during the pre-procedure verification. It is not
necessary to document that the standardized list was used for each patient.
126
UP.01.01.01
3: Match the items that are to be
available in the procedure area to the
patient. (A)
127
UP.01.02.01
Mark the procedure site.
128
UP.01.02.01
1: Identify those procedures that require marking
of the incision or insertion site. At a minimum,
sites are marked when there is more than one
possible location for the procedure and when
performing the procedure in a different location
would negatively affect quality or safety. (C-3)
Note: For spinal procedures, in addition to
preoperative skin marking of the general spinal
region, special intraoperative imaging
techniques may be used for locating and
marking the exact vertebral level.
129
UP.01.02.01
2: Mark the procedure site before the
procedure is performed and, if
possible, with the patient involved.
(C-3)
130
UP.01.02.01
3: The procedure site is marked by a
licensed independent practitioner who is
ultimately accountable for the procedure
and will be present when the procedure is
performed. In limited circumstances, the
licensed independent practitioner may
delegate site marking to an individual who
is permitted by the organization to
participate in the procedure and has the
following qualifications: (C-3)
131
UP.01.02.01
An individual in a medical residency program who is
being supervised by the licensed independent
practitioner performing the procedure; who is familiar
with the patient; and who will be present when the
procedure is performed
- A licensed individual who performs duties requiring a
collaborative agreement or supervisory agreement with
the licensed independent practitioner performing the
procedure (that is, an advanced practice registered
nurse (APRN) or physician assistant (PA)); who is
familiar with the patient; and who will be present when
the procedure is performed.
132
UP.01.02.01
4: The method of marking the site and the
type of mark is unambiguous and is used
consistently throughout the hospital. (A-3)
Note: The mark is made at or near the
procedure site, and is sufficiently
permanent to be visible after skin
preparation and draping. Adhesive
markers are not the sole means of
marking the site.
133
UP.01.02.01
5: A defined, alternative process is in
place for patients who refuse site
marking or when it is technically or
anatomically impossible or impractical
to mark the site (for example,
mucosal surfaces or perineum).
(A-3-D)
134
UP.01.02.01
Note: Examples of other situations which involve
alternative processes include:
- Minimal access procedures treating a
lateralized internal organ, whether percutaneous
or through a natural orifice
- Interventional procedure cases for which the
catheter/instrument insertion site is not
predetermined (for example, cardiac
catheterization, pacemaker insertion)
- Teeth
- Premature infants, for whom the mark may
cause a permanent tattoo
135
UP.01.03.01
A time-out is performed before the
procedure.
136
UP.01.03.01
1-A: The time-out is conducted
immediately before starting the
invasive procedure or making the
incision. (A-3)
137
UP.01.03.01
2-A : The time-out has the following
characteristics: (A)
- It is standardized (as defined by the
hospital).
- It is initiated by a designated member of
the team.
- It involves the immediate members of the
procedure team including the individual
performing the procedure, the anesthesia
providers, the circulating nurse, the operating
room technician, and other active participants
who will be participating in the procedure
from the beginning.
138
UP.01.03.01
3: When two or more procedures are
being performed on the same patient, and
the person performing the procedure
changes, a time-out is performed to
confirm each subsequent procedure
before it is initiated. (A-3)
139
UP.01.03.01
4: During the time-out, the team
members agree, at a minimum, on
the following:
(A-3)
- Correct patient identity
- The correct site
- The procedure to be done
140
UP.01.03.01
5: Document the completion of the
time out. (C-3-D)
Note: The organization determines
the amount and type of
documentation.
141
NPSG 06.01.01
Clinical Alarms
NPSG 06.01.01
Clinical Alarms
Improve the safety of clinical alarm
systems
EP # 1 (A) As of July 1, 2014 leaders
establish alarm system safety as a
hospital priority.
EP # 2 (A) During 2014, identify the most
important alarm signals to manage based
on the following:
– Input from the medical staff and clinical
departments
NPSG 06.01.01
Clinical Alarms
EP # 2 (A) During 2014, identify the most
important alarm signals to manage based
on the following: (Continued)
– Risk to patients if the alarm signal is not
attended to or if it malfunctions.
– Whether specific alarm signals are needed or
unnecessarily contribute to alarm noise and
alarm fatigue.
– Potential for patient harm based on internal
incident history.
NPSG 06.01.01
Clinical Alarms
EP # 2 (A) During 2014, identify the most
important alarm signals to manage based on
the following: (Continued)
– Published best practices and guidelines
EP # 3 (A) As of January 1, 2016 establish
policies and procedures for managing the
alarms identified in EP 2, at a minimum that
address the following:
– Clinically appropriate settings for alarm signals
NPSG 06.01.01
Clinical Alarms
EP # 3 (A) As of January 1, 2016
establish policies and procedures for
managing the alarms identified in EP 2, at
a minimum that address the following:
– When alarm signals can be disabled
– When alarm parameters can be changed
– Who in the organization has the authority to
set alarm parameters
– Who in the organization has the authority to
change alarm parameters.
NPSG 06.01.01
Clinical Alarms
EP # 3 (A) As of January 1, 2016 establish
policies and procedures for managing the
alarms identified in EP 2, at a minimum
that address the following:
– Who in the organization has the authority to
set alarm parameters to “off”.
– Monitoring and responding to alarm signals
– Checking individual alarm signals for accurate
settings for which they are responsible.
NPSG 06.01.01
Clinical Alarms
EP # 4 (C)
As of January 1, 2016, educate staff and
licensed independent practitioners about
the purpose and proper operation of alarm
systems for which they are responsible.
Infection Control
National Patient Safety Goals
149
NPSG # 7
• Reduce the risk of health
care associated infections.
150
NPSG 07.01.01
Comply with current World Health
Organization (WHO) hand hygiene
guidelines or
Centers for Disease Control and
Prevention (CDC) hand hygiene
guidelines.
151
NPSG 07.01.01
Elements of Performance
• EP # 1 (M, DI, C)
The hospital complies with current
World Health Organization (WHO) or
Centers for Disease Control and
Prevention (CDC) hand hygiene
guidelines.
152
Hand Hygiene
Measurement Methods
• Direct Observations
• Product Use Measurement
• Surveys
• Wi-Fi
153
Hand Hygiene
Pro’s to Direct Observation
• Direct observation considered the “gold
standard”.
• Training of observers
• Link to Johns Hopkins Hand Hygiene
Observer Training
http://www.hopkinsmedicine.org/innovation_quality_pati
ent_care/areas_expertise/infections_complications/hand
_hygiene/hand_hygiene_training_video/player.html
154
Hand Hygiene
Pro’s to Direct Observation
• Easily understandable data collection
forms utilized.
• Placement of hand hygiene products.
• Reporting by observers.
• Adequate sample size of observations.
155
Hand Hygiene
Product Measurement
• Indirect way of measuring staff adherence
to hand hygiene practices
• Less labor intensive than observations
• Less likely than the direct observation
method to improve the health care
worker’s HH practice.
• Does not discriminate as to who does and
who does not perform good hand hygiene
practices
156
Hand Hygiene
Surveys
• Yields information related to perceptions,
attitudes, and behavior related to hand
hygiene
• Staff surveys will provide information
about what staff members think about
hand hygiene, and why they adhere and
do not adhere to good practices
157
Hand Hygiene Measurement
• Often good to use more than one
approach for measuring hand hygiene.
• Multiple sources give a better
representation of the practice within the
organization.
158
Components of Hand
Hygiene Measurement
• Type of product used
• Type of healthcare worker being
•
•
•
•
observed
Thoroughness of cleansing
Appropriate use of gloves
Was HH product available, accessible
and did the dispenser/sink work?
Adherence to nail length
policy/presence of jewelry.
159
Pro’s & Cons of Various Hand
Hygiene Measurement Processes
Strength of observation method:
• Individual hand hygiene practices can be
determined.
• Technique can be determined.
• Very reliable method for assessing
adherence rates.
160
Pros & Cons of Various Hand
Hygiene Measurement Processes
Direct Observation Weaknesses
• Hawthorne Effect
• Labor intensive & costly
• Requires observer training
• Captures only a sample of HH
opportunities
161
Pros & Cons of Various Hand
Hygiene Measurement Processes
Strengths of Product Measurement
• Allows efficient monitoring of hand
hygiene per patient day over time in a
given unit.
• Is not subject to recall bias.
• Less time consuming and less costly.
162
Pros & Cons of Various Hand
Hygiene Measurement Processes
Product Measurement Weaknesses
• Does not reveal who is performing hand hygiene
• Does not asses technique
• Opportunities for HH not captured
• Cannot account for spillage or borrowing
between units
• Amount can be effected by patient’s and
families use
163
Pros & Cons of Various Hand
Hygiene Measurement Processes
Strength of Surveys
• Inexpensive
• Not resource intensive
• Can provide information about compliance
• Helps staff to focus attention on hand
hygiene
164
Pros & Cons of Various Hand
Hygiene Measurement Processes
Survey Method Weaknesses
• Staff tend to overestimate compliance.
• Survey tool’s validity and depends on the
development and testing of the tool.
165
Improvement Strategies
• Several strategies have been shown to be
effective in enhancing hand hygiene
practices, including education, feedback,
reminders, and structured performance
improvement approaches.
166
NPSG. 07.03.01
Implement evidence-based practices
to prevent health care–associated
infections due to multi-drug resistant
organisms in hospitals.
167
Multi-drug Resistant Organisms
• Primary Application of this NPSG
– Methicillin-resistant Staphylococcus
aureus (MRSA)
– Clostridium Difficile (CDI)
– Vancomycin-resistant Enterococcus
(VRE)
168
MRSA
• Routine screening for MRSA upon
hospital admission is controversial.
Although the CDC does not recommend
preadmission screening, a few states
have called for universal patient
screening, and some hospital systems
have adopted it.
169
NPSG. 07.03.01
Elements of Performance
• EP# 1 (A)
• Conduct periodic risk assessments
(in time frames determined by HCO)
for multi-drug resistant organism
acquisition and transmission.
170
NPSG. 07.03.01
Elements of Performance
• EP # 2(M, C)
Based on the results of the risk
assessment, the hospital educates staff
and LIP’s about health care–associated
infections, MDRO’s, and prevention
strategies at hire and annually thereafter.
171
NPSG 07.03.01
Elements of Performance
• EP # 3 (M, C)
The hospital educates patients, and their
families as needed, who are infected or
colonized with a multi-drug resistant
organism about health care–associated
infection strategies.
• EP # 4 (A)
The hospital implements a surveillance
program for multi-drug resistant organisms
based on the risk assessment.
172
NPSG 07.03.01
Elements of Performance
• EP # 5 (A)
The hospital measures and monitors multi-drug
resistant organism prevention processes and
outcomes including the following:
- Multi-drug resistant organism infection rates
using evidence-based metrics
- Compliance with evidence-based guidelines or
best practices
-Evaluation of the education program provided
to staff and licensed independent practitioners
173
NPSG 07.03.01
Elements of Performance
• EP # 6 (A)
The hospital provides multi-drug
resistant organism surveillance data
to key stakeholders, including
leaders, licensed independent
practitioners, nursing staff, and other
clinicians.
174
NPSG 07.03.01
Elements of Performance
• EP # 7 (DI, C)
The hospital implements policies and
practices aimed at reducing the risk of
transmitting multi-drug resistant organisms
that meet regulatory requirements and are
aligned with evidence-based standards
(for example, the Centers for Disease
Control and Prevention (CDC) and/or
professional organization guidelines).
175
NPSG 07.03.01
Elements of Performance
• EP # 8 (DI, A)
when indicated by the risk assessment, the
hospital implements a laboratory-based alert
system that identifies new patients with multidrug resistant organisms. The alert system
may be either manual or electronic or a
combination of both of these methods.
• Note: The alert system may use telephones,
faxes, pagers, automated and secure
electronic alerts, or a combination of these
methods.
176
NPSG 07.03.01
Elements of Performance
• EP # 9 (DI, A)
When indicated by the risk
assessment, implement an alert
system that identifies readmitted or
transferred patients who are known to
be positive for multi-drug resistant
organisms.
177
NPSG 07.03.01
Elements of Performance
• Each hospital may define its own
parameters in terms of time and
clinical manifestation to determine
which re-admitted patients require
isolation.
178
NPSG 07.04.01
Implement best practices or evidencebased guidelines to prevent central
line–associated bloodstream infections.
• Note 1: This requirement covers short- and
long-term central venous catheters and
peripherally inserted central catheter (PICC)
lines.
• Surveillance of this NPSG is expected to be
whole-house rather than targeted in the ICU.
179
NPSG 07.04.01
Elements of Performance
• EP # 1 (M, C)
• The hospital educates health care workers
who are involved in these procedures
about healthcare–associated infections,
central line–associated bloodstream
infections, and the importance of
prevention. Education occurs upon hire,
annually thereafter, and when involvement
in these procedures is added to an
individual’s job responsibilities.
180
NPSG 07.04.01
Elements of Performance
• EP # 2 ( M, C)
Prior to insertion of a central venous
catheter, the hospital educates
patients and, as needed, their
families about central line–associated
bloodstream infection prevention.
181
NPSG 07.04.01
Elements of Performance
• EP # 3 (M, DI, C)
The hospital implements policies and
practices aimed at reducing the risk of
central line–associated bloodstream
infections that meet regulatory
requirements and are aligned with
evidence-based standards.
182
NPSG 07.04.01
Elements of Performance
• EP # 4 (A)
• The hospital conducts periodic risk
assessments for central line–associated
bloodstream infection rates, monitors
compliance with best practices or
evidence-based guidelines, and
evaluates the effectiveness of
prevention efforts. The risk
assessments are conducted in time
frames determined by the HCO and this
infection surveillance activity is hospital
wide not targeted.
183
NPSG 07.04.01
Elements of Performance
• EP # 5 (A)
The hospital provides central line–
associated bloodstream infections
rate data and prevention outcome
measures to key stakeholders
including leaders, licensed
independent practitioners, nursing
staff, and other clinicians.
184
NPSG 07.04.01
Elements of Performance
• EP # 6 (M, D, DI, C)
• Use a catheter checklist and a
standardized protocol for central
venous catheter insertion.
• EP # 7(C)
Perform hand hygiene prior to
catheter insertion or manipulation.
185
NPSG 07.04.01
Elements of Performance
• EP # 8 (M, DI, C)
• For adult patients, do not insert
catheters into the femoral vein unless
other sites are unavailable.
(Justification)
• EP # 9 (M, DI, C)
• Use a standardized supply cart or kit
that is all inclusive for the insertion of
central venous catheters. (Kit used
broadly)
186
NPSG 07.04.01
Elements of Performance
• EP # 10 (M, DI, C)
• Use a standardized protocol for maximum
sterile barrier precautions during central
venous catheter insertion.
• EP # 11 ( M, DI, C)
Use an antiseptic for skin preparation during
central venous catheter insertion that is cited
in scientific literature or endorsed by
professional organizations.
187
NPSG. 07.04.01
Elements of Performance
• EP # 12 (D, DI, A)
Use a standardized protocol to disinfect
catheter hubs and injection ports before
accessing the ports.
• EP # 13 (DI, A) Evaluate all central
venous catheters routinely and remove
nonessential catheters.
188
NPSG 07.05.01
Implement best practices for
preventing surgical site
infections.
189
NPSG 07.05.01
Elements of Performance
• EP # 1 (M, C) AMB
The hospital educates health care
workers involved in surgical procedures
about health care associated
infections, surgical site infections, and
the importance of prevention. Education
occurs upon hire, annually thereafter,
and when involvement in surgical
procedures is added to an individual’s
job responsibilities.
190
NPSG 07.05.01
Elements of Performance
• EP # 2 (M, C) AMB
• Educate patients and their families as
needed, who are undergoing a surgical
procedure about surgical site infection
prevention.
191
NPSG 07.05.01
Elements of Performance
(M, DI, C) AMB
The hospital implements policies and
practices aimed at reducing the risk
of surgical site infections that meet
regulatory requirements and are
aligned with evidence-based
standards.
• EP # 3
192
NPSG 07.05.01
Elements of Performance
• EP # 4 (A) AMB
• The hospital conducts periodic risk
assessments for surgical site
infections.
• Selects surgical site infection measures
using best practices or evidence-based
guidelines, monitors compliance with
best practices or evidence based
guidelines.
• Evaluates the effectiveness of
prevention efforts.
193
NPSG 07.05.01
Surgical Site Infection
Implement evidence-based practices for
preventing surgical site infections
EP # 5
– Measure surgical site infection rates for the
first 30 or 90 days following surgical
procedures (that do not involve inserting
implantable devices and for the first year
following procedures involving implantable
devices based on the National Healthcare
Safety Network (NHSN) codes.
NPSG 07.05.01
Surgical Site Infection
Note 1:- Surveillance may be targeted to
certain procedures based on the
organization’s risk assessment.
Note 2: The NSHN is the Centers for Disease
Control and Prevention’s health care
associated tracking system. NHSN provides
facilities, states, regions, and the nation with
data needed to identify efforts, and ultimately
eliminate health care-associated infections.
NSHN Procedural Codes
NHSN Procedural Codes may be found at
http://www.cdc.gov/nhsn/CPTcodes /ssicpt.html
NPSG 07.05.01
Elements of Performance
• EP # 6 (A) AMB
Provide process and outcome
measures to key stakeholders.
197
NPSG 07.05.01
Elements of Performance
• EP # 7 (M, DI, C) AMB
Administers Antimicrobial agents for
prophylaxis used for a particular procedure or
diseases are administered according to
methods cited in scientific literature or
endorsed by professional organizations.
• EP # 8 (DI, A)
When hair removal is necessary, use a
method that is cited in scientific literature or
endorsed by professional organizations.
198
NPSG.07.06.01
Implement evidence-based practices to
prevent indwelling catheter-associated
urinary tract infections (CAUTI).
(Not applicable to Pediatrics)
199
NPSG.07.06.01
Elements of Performance
EP # 1: During 2012, plan for the full
implementation of this NPSG by January
1, 2013.
Note: Planning may include a number of
different activities, such as assigning
responsibility for implementation activities,
creating timelines, identifying resources,
and pilot testing.
200
NPSG.07.06.01
Elements of Performance
EP # 2: Insert indwelling urinary catheters
according to established evidence-based
guidelines that address the following: Limiting use and duration to situations
necessary for patient care - Using aseptic
techniques for site preparation, equipment,
and supplies
201
NPSG.07.06.01
Elements of Performance
EP # 3: Manage indwelling urinary
catheters according to established
evidence-based guidelines that address
the following:
202
NPSG.07.06.01
Elements of Performance
- Securing catheters for unobstructed urine
flow and drainage
- Maintaining the sterility of the urine
collection system
- Replacing the urine collection system
when required
- Collecting urine samples
203
NPSG.07.06.01
Elements of Performance
EP # 4: Measure and monitor catheterassociated urinary tract infection
prevention processes and outcomes in
high-volume areas by doing the following:
204
NPSG.07.06.01
Elements of Performance
- Selecting measures using evidence-based
guidelines or best practice.
- Monitoring compliance with evidencebased guidelines or best practices
- Evaluating the effectiveness of prevention.
205
NPSG.07.06.01
Elements of Performance
Note: Surveillance may be targeted to
areas with a high volume of patients using
in-dwelling catheters. High-volume areas
are identified
206
Organization of 2013 Infection
Control Standards
Implementation
A. Activities (revised 02.01.01)
B. Medical Equipment, Devices, and
Supplies (revised 02.02.01)
C. Transmission of Infections (revised
02.03.01)
D. Influenza Vaccinations (revised 02.04.
01)
III. Evaluation (revised 03.01.01)
II.
207
Morning of Survey
• Requested Infection Control manual to
include plan.
• Requested IC or other committee meeting
minutes—according to how program is
structured and business conducted.
• Ensure minutes of last meeting are
completed as soon as feasibly possible and
placed in centralized location for survey
day.
208
Morning of Survey
• Listing of patient in Isolation, type, room
location available for IC tracer.
• If no current patient in isolation:
–
–
–
–
Fever of Unknown origin
Ventilator Associated Pneumonia
RSV
Surgical Wound Infection
209
IC. 01.03.01
The organization identifies
risks for acquiring and
transmitting infections.
210
Risk Assessment
• The foundation of the Infection Control
program.
• Many types of templates available for use.
• Ongoing assessments to identify risks for
acquisition and transmission of infectious
agents.
• Problems with Risk Assessments
–
–
–
–
Poorly organized/Not thorough and credible
Misunderstanding of responsibilities by staff
Lack of inclusion of all services (clinics)
Should be ongoing because of potential for rapid
change.
211
Implementation Issues
During IC Tracer
Tracer Issues
Protective Garb use
High level disinfectant
Separation of clean from dirty (traffic,
equipment)
Flash sterilization
Expired supplies, syringes in anesthesia carts
Adherence to regulatory and professional
standards for single-use items
213
Tracer Issues
Isolation patient
– Inappropriate/incorrect signage
– Confidentiality issues
– Supplies on Isolation Cart
– Inadequate staff/housekeeping knowledge
about terminal cleaning in isolation room
– Handoff Issues/Training
214
Tracer Issues
Airborne Isolation Room
– Staff knowledge of testing of room
– How often tested, how tested, who tests
– May lead to Engineering if answers not
sufficient—Labeling of Roof Exhausts
Other issues
– Chart documentation supporting patient/family
education
– Describe the two patient identifiers used for
drawing blood cultures
215
Tracer Issues
Staff knowledge of measures to decrease
incidence of ventilator associated
pneumonias
Do not use abbreviations for Antibiotic
orders
Compliance with TB skin testing as
appropriate
Pet therapy
Appropriateness of Antibiotics
216
Level of Disinfection
IC.02.02.01, EP # 2
• Effective April 1, 2011
• The organization reduces the risk of
infections associated with medical
equipment, devices and supplies.
• EP.# 2 has basically been changed to
prohibit the use of intermediate level
disinfection for cleaning specula. The
recommendation is high level or sterilization.
Refer to
www.cdc.gov/hicpac/Disinfection_sterilization
/acknowledge.html
217
Flash Sterilization
218
Flash Sterilization
• Preliminary Denial of Accreditation being
awarded in organizations because of
“casual” flash sterilization. An “immediate
threat to life” is being declared by
surveyors.
• IC minutes are not reflective of anything
typically but the sterilizer’s performance.
• Poorly defined definition of “flash”
sterilization operationalized internally.
219
Issues Causing Renewed Interest
in Flash Sterilization
• Terminology used to describe the
sterilization process-flash described as a
process that does not use the full cycle.
• Flash for the purposes of the Joint
Commission is 3 minutes at 270F at 2728lbs pressure.
• Previous surveys were focused on the
sterilization cycle or method.
220
Renewed Interest in Flash
Sterilization
• Surveyors are now reviewing more closely
all aspects of the sterilization method or
cycle.
• Findings result from a high percentage of
steam sterilization using less than the full
cycle, or exclusive use for certain types of
instruments. (Eye)
221
Critical Steps of Reprocessing
• Cleaning and decontamination-removal of
visible soil.
• Following manufacturer’s
recommendation-was the tray
designed/tested for flash sterilization?
• Brushing or disassembling may be
required.
222
Critical Steps of Reprocessing
• Sterilization-Steam-must meet time, temperature
•
•
•
•
and pressure requirements.
Storage or return to the sterile field- Care must
be made not to re-contaminate.
Full steam cycles require the instruments to be
wrapped and sealed.
Non-full cycle sterilized instruments can be
transported in flash pans or other specially
designed containers to prevent contamination.
AORN no longer supports the open pan method
for flashing.
223
Survey Activities
• Observe instruments from the time they
leave one operating room to when they
are returned to the next.
• Ask for manufacturers’ instructions and
describe and demonstrate how
instruments are being cleaned and
decontaminated in accordance with the
instructions. (One Source software)
• Observe instrument cleaning.
224
Survey Activities
• Verify appropriate PPE to include head cover,
impervious gown, face protection, cuffed gloves,
shoe covers.
• Observe the sterilization process-will need to
provide manufacturers’ instructions for the
sterilizer, wrapping or packing and the
instruments.
• Review sterilization logs-parametric, chemical
and biologic indicators.
• Observe the return of instruments to the sterile
field and verify protection from recontamination.
225
Flash Sterilization
• Flash sterilization is steam sterilization of
items needed for immediate use.
• AAMI, AORN and CDC do not
recommend the flash sterilization of
implants, except when there is no other
option.
• Concerns about flashing do not have to do
with the sterilizer but with the proper
cleaning prior to sterilizing with aseptic
transport and deliver to the sterile field.
226
Flash Sterilization
• One major concern about flash
sterilization is the potential for shortcuts
to be taken.
• Cataract trays are among the more
commonly flash-sterilized instrument
sets.
• Flash is best accomplished with the use
of a closed tray ( flash pack) which
reduce the risk of contamination during
transport of the item from the sterilizer
to the sterile field.
227
Flash Sterilization
• Most manufacturers no longer
provide flash instructions, therefore
the sterilizer operator would be liable
for any sterility issues.
228
Unacceptable Reasons for
Flash Sterilization
• Specialty instruments- flashed due to insufficient
•
•
•
•
inventory.
One-of-a-kind, custom-manufactured
instruments-flashed because of insufficient time
between the cases for sterilization to be done by
CSR.
General instruments-flashed for convenience
and time-saving purposes, i.e., scissors, forceps
needle holders.
Vendor owned-arrival on day of procedure.
Placing surgeon’s schedule ahead of patient
safety.
229
Steps to Reduce Flash Sterilization
• Increase inventory of specialty item by
service.
• Case scheduling practices should be
adjusted to relieve the demand for one-ofa-kind instruments in back-to-back
scheduled cases.
• More general instruments can be bought.
230
Steps to Reduce Flash Sterilization
• Awareness of staff that when an instrument is
needed other sufficiently inventoried sets would
be retrieved rather than flashing.
• Vendor agreements established that ensure
vendor-owned instrument sets 24 hours prior to
surgery.
• All decontamination and sterilizing to be
completed in the CSR. (Move out of Surgery)
• Purchase computerized instrument tracking
system where as much as $80,000 can be
saved.
231
Competency
• More and more surveyors are asking for
scrub-tech’s /circulator’s annual
competency assessment in operating the
sterilizer. (Article)
• Do not forget other departments who are
involved in equipment processing.
232
Influenza Vaccination
Influenza Vaccination
EP # 1: The hospital establishes an annual
influenza vaccination program that is
offered to licensed independent
practitioners and staff. (A)
EP # 2 The hospital educates licensed
independent practitioners and staff about,
at a minimum, the influenza vaccine; nonvaccine control and prevention measures;
and the diagnosis, transmission, and
impact of influenza. © (M)
234
Influenza Vaccination
EP # 3 -The hospital provides influenza
vaccination at sites and times accessible
to licensed independent practitioners and
staff. (A)
EP # 4 The hospital includes in its
infection control plan the goal of improving
influenza vaccination rates. (A)
235
Influenza Vaccination
EP # 5- The hospital sets incremental
influenza vaccination goals, consistent
with achieving the 90% rate established in
the national influenza initiatives for 2020.
(D) (A)
236
Influenza Vaccination
EP # 6-The hospital has a written
description of the methodology used to
determine influenza vaccination
rates.(D)(A)
The National Quality Forum (NQF) Measure Submission
and Evaluation Worksheet 5.0 provides
recommendations for the numerator and denominator for
NQF performance measure #0431 Influenza Vaccination
Coverage Among Healthcare Personnel (see
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkId
entifier=id&ItemID=68275 )
237
Influenza Vaccination
EP # 7-The hospital evaluates the reasons
given by staff and licensed independent
practitioners for declining the influenza
vaccination. This evaluation occurs at
least annually.(A)
EP #8-The hospital improves its
vaccination rates according to its
established goals at least annually
238
Influenza Vaccination
EP # 9-The hospital provides influenza
vaccination rate data to key stakeholders
which may include leaders, licensed
independent practitioners, nursing staff, and
other staff at least annually.
239
SEDATION:
A Discussion of Moderate and
Deep Sedation
Stephen M. Dorman, M.D.
www.redandgold.com
240
Definitions
The administration of sedation agents for
the purpose of performing procedures.
Not: pain management
Not: seizure control
Not: anxiolysis
241
Definitions
Goal: to change the patient’s level of
consciousness in order to perform
procedures.
RISK: What is the risk of the medication
that is being administered under normal
circumstances? Can it reasonably be
expected to change the level of
consciousness?
242
Confusing Scenarios
Fentanyl and Midazolam administered
together before a procedure even begins.
Fentanyl given during procedure because
the patient is experiencing pain.
Midazolam given during the procedure
because the patient is anxious.
GOAL: To change level of
consciousness?
243
Standard of Practice
When these sedating medications are
administered, especially two medications
with anticipated synergistic effects, it is
generally considered as placing the patient
“at risk” of being sedated.
You will never be 100% certain in advance
that you will obtain the right goal.
244
Standard of Practice
You must measure outcomes to know how
often you are sedating patients
appropriately by collecting data.
– Change in level of consciousness. Does the
patient respond to verbal commands or not?
– Unanticipated changes in vital signs:
hypotension, hypoxia, intervention into airway
245
Standard of Practice
CMS: 482.52 requires the establishment of
a QAPI:
Survey procedure:
– Confirm that the director’s responsibilities
include at least the following….
Evaluating the quality and appropriateness of the
anesthesia services provided to patients as part of
the hospital’s QAPI program.
246
Standard of Practice
Based on these outcomes, you can make
a case for any surveyor that you are:
1. Not moderately sedating the patient
This is “anxiolysis” not moderate sedation.
2. Not deeply sedating the patient
This is moderate sedation, not deep sedation.
247
General Rules
It is always better to advocate for the
safest care possible because there is
always risks of adverse drug reactions.
1. Single medication administered in normal
doses: Fentanyl 50-100 mcgm alone.
2. Midazolam: single agent, adult < 2 mg
3. Any combination should be considered at
least moderate sedation because of risk.
248
General Rules
When trying to define what type of
sedation it is, and which standards apply,
it is helpful to remember the agents being
used.
Fentanyl and Midazolam CAN produce the
deeply sedated state, but it generally takes
a lot of medication to do this in normal
healthy adults.
249
General Rules
It is important to remember that moderate
sedation is defined by CMS as:
A drug-induced depression of
consciousness during which patients
respond PURPOSELY to verbal
commands, either alone or accompanied
by LIGHT tactile stimulation.
250
General Rules
It is extremely easy to produce the deeply
sedated state when using any anesthesia
induction agents (as defined by
manufacturer).
Propofol, Etomidate, Brevital, Ketamine all
have a VERY high risk of producing deep
sedation.
None of these agents are reversible.
251
General Rules
Generally this is actually the goal. The
reason the agent is being chosen is
because:
1. It is acts rapidly.
2. It provides PROFOUND sedation for
extremely painful procedures.
3. Otherwise a less risky agent would be
chosen.
252
General Rules
Do not buy the argument that these agents
can be used and the patient remain
conscious. This would be a rare
exception. Most anesthesiologists would
tell you that to use one of these agents in
a way that the patient remains conscious
and responding verbally is extremely
difficult and, in fact, not desirable.
253
Performance Improvement
In any case, you will have to prove with
data that you are hitting your goal and that
patients are not exceeding the planned
(and usually consented to) sedation.
Example: <1% of patient planned for
moderate sedation obtained the deeply
sedated state.
254
CMS Settles the Argument
CMS released the standard on this issue
and has been updating it. However,
based on examples cited, the conclusion
is that the use of any anesthesia induction
agent (as defined by the manufacturer) for
the purpose of sedation is: deep sedation.
255
CMS Settles the Argument
The next is the most sweeping statement
that essentially changed our practice:
DEEP SEDATION IS MONITORED
ANESTHESIA CARE (MAC): A-1000
482.52 Definitions of MAC: Line 5: Deep
sedation/analgesia is included in MAC.
256
Monitored Anesthesia Care
Now that it is clear that deep sedation is
MAC, the following applies:
1. MAC is anesthesia, NOT sedation.
2. All anesthesia must be under the
DIRECT supervision of the Director of
Anesthesia Services. A-1000, 482.52
257
Monitored Anesthesia Care
The anesthesia services must be under
the direction of one individual who is a
qualified doctor of medicine or doctor of
osteopathy.
258
Monitored Anesthesia Care
Hospital anesthesia services policies and
procedures are expected to also address
the minimum qualifications and
supervision requirements for each
category of practitioner who is permitted to
provide analgesia services.
259
Monitored Anesthesia Care
Privileging must include RESCUE
competency:
Rescue from deeper levels of sedation
than intended requires an intervention by a
practitioner with EXPERTISE in airway
management and ADVANCED LIFE
SUPPORT.
260
Monitored Anesthesia Care
Based on the American Society of
Anesthesiologists, the Director of
Anesthesia Services must follow the ASA
practice guidelines.
Other organization “guidelines” can be
used, but would not supersede the director
of anesthesia services requirement to
comply with ASA guidelines. (Legal
matter).
261
Monitored Anesthesia Care
Privileging: recommended by the Director
of Anesthesia services as are all other
requests for any procedure in the
Anesthesia privilege delineation.
262
Monitored Anesthesia Care
What is the privilege?
A-1001, 482.52(a):
– The organization of anesthesia services must
be appropriate to the scope of the services
offered. Anesthesia may be ADMINSTERED
ONLY BY….
263
Monitored Anesthesia Care
Who may request privileges?
– A qualified anesthesiologist
– A doctor of medicine or osteopathy
– A dentist, oral surgeon (State law)
– A certified CRNA (immediately supervised)
– An Anesthesiolgist’s assistant (immediately
supervised)
264
Monitored Anesthesia Care
Nowhere in the CMS COP does it permit
RNs who are not CRNAs to ADMINISTER
MAC. (see previous slide). Also nowhere
in the COP does it permit nurses to be
SUPERVISED to administered MAC
unless they are CRNAs.
Conclusion: RNs may not administered
agents of deep sedation for sedation
purposes.
265
Monitored Anesthesia Care
The section that follows 284.52 (a) and (c)
goes into great detail on who may
ADMINSTER anesthesia (remember MAC
is anesthesia).
The COP also stated that patients must be
monitored by those who are permitted to
administer anesthesia.
266
Monitored Anesthesia Care
Fortunately it appears that CMS will
accept a trained RN at the head of the
table to monitor the patient, as long as the
procedurist CAN be interrupted to
immediately intervene and keeps his/her
eyes on the monitoring.
This could easily change overnight based
on survey results.
267
Monitored Anesthesia Care
From the CMS Definition:
– Because of the potential for the inadvertent
progression to general anesthesia in certain
procedures, it is necessary that the
administration of deep sedation/analgesia be
delivered or supervised by the practitioner as
specified in 42CFR 482.52(a).
– Supervision refers to CRNAs and AAs
268
Interim Summary
1. Moderate sedation results in the ability
to verbally respond to commands (100%
of the time).
2. The use of anesthesia induction agents
can only be considered MAC.
3. MAC can only be administered by
privileged providers.
269
Monitored Anesthesia Care
All anesthesia standard apply to MAC:
– A pre-anesthesia assessment performed by
an individual with privileges.
– A plan for anesthesia care.
– Immediate re-assessment prior to ‘induction’.
– Monitoring per ASA standards including
capnography and every 5 minute recording
– Post- anesthesia recovery by staff who have
anesthesia recovery competencies.
270
Monitored Anesthesia Care
– A dedicated (albeit short) Phase 1 recovery.
– Criteria for discharge from Phase 1 to Phase
2.
– Post-anesthesia evaluation (based on an
actual evaluation) that the patient has
recovered and has no complications. The
note is structured by CMS requirements and
are rigid. A note to the effect that there are
“no complications” is not sufficient.
271
Monitored Anesthesia Care
Since this is MAC, it will be expected that
nurses who recover these patients have
competencies (demonstrated) that they
are skilled to recover patients from
ANESTHESIA.
Can be tailored to the type of patient being
recovered.
272
Questions to be considered
1. How often is it necessary to use MAC
in non-anesthesia settings?
2. Rather than creating a process, would
be it be more efficient (based on volume)
to simply have anesthesia cover this need
on an emergency basis?
273
Things to be done
1. Separate Deep Sedation policy
(anesthesia) from the moderate sedation
policy (not anesthesia).
2. The MAC policy should be a
comprehensive anesthesia policy that
applies to all MAC whether administered
by an anesthesia provider or nonanesthesia provider.
274
Things to be done
3. Develop criteria for privileges for
monitored anesthesia care and
recommend these privileges from the
director of anesthesia to the department
chairmen where it will be administered
(emergency department).
4. Train staff who recover these patients
in anesthesia recovery.
275
Joint Commission Standards
LD.04.01.01: Hospital complies with law
and regulation (place to generically score
CMS non-compliance)
276
Joint Commission Standards
PC.03.01.01: PLANNING
1: Individuals administering moderate or
deep sedation and anesthesia are
qualified and have credentials to manage
and rescue patients at whatever level of
sedation or anesthesia is achieved,
intentionally or unintentionally.
277
2: Sufficient number of qualified personnel.
5: RN supervises nursing care.
6. Available equipment (capnography for
MAC).
7. Equipment to administer IVs,
medications and blood.
8: Resuscitation equipment
278
10: Anesthesia (MAC too) is administered
by the following individuals:
Anesthesiologist
MD/DO, DPM
CRNA/AA
Trainee
279
FPPE for MAC Privileges
Technical competence required (airway
skills). Can be demonstrated through
intubation venues (observed, simulation,
certification)
Medical Care decisions: patient selection
(aspiration or health risk), policy followed,
drug dose appropriate, concurrent review
of outcomes for cases.
280
FPPE for MAC Privileges
Appropriate consultation for high risk
patients (physiologic or NPO status)
Appropriate consultation for high risk
airways
281
OPPE for MAC Privileges
Adverse outcomes:
– Intubation required
– Airway support required
– Transfer to higher level of care
– Unplanned admission
– Hypotension, hypoxia, hypercapnia
– Aspiration
282
Thank you.
Stephen M. Dorman, M.D.
6800 West Gate Blvd, Suite 132-322
Austin, TX 78745
www.redandgold.com
283
Telemedicine
CMS REQUIREMENTS
Definitions
Hospital: location where patient receives
telemedicine services
Distant Site: where the physician is
remotely who is providing services
Entity: a non-hospital providing location
285
Governing Body
(Hospital) Agreement to provide services
with “distant site.”
Governing body of “distant site”
responsible for compliance in writing.
(Hospital) May locally privilege using
documents provided by distant site.
Distant site is a “contractor” for services.
286
Governing Body
Distant site provides these services in a
manner that allows the hospital to be
compliant.
287
Medical Staff
Medical staff may rely on credentialing and
privileging decision of distant site (proxy).
1). Distant site must be Medicareparticipating hospital.
2). Privileged at distant site, and list
provided to hospital.
3). Individual holds license in state where
patients are located.
288
Medical Staff
4). Hospital performs internal review of
performance and sends to “distant site.”
5). Includes all adverse events and
complaints.
289
Medical Staff
Requirements if the “distant site” is not a
Medicare participating hospital but is a nonMedicare participating “entity”.
•1). Agreement requires that the services be
furnished in a manner that permits the
hospital to be in compliance with CMS
requirements.
290
Medical Staff: ENTITY
2). Distant entity credentialing and
privileging process meets CMS standards.
3). Distant entity providers privilege
list/delineations.
4). Holds license in state where patient
located.
5). Hospital sends performance review to
distant entity.
291
Medical Staff: ENTITY
6). Criteria for privileging established.
292
Critical Access Hospitals
Requires distant site to have:
1). Medical staff structure that complies
with CMS medical staff requirements.
All other structures are same as for
hospitals.
293
Critical Access Hospitals
1). Quality and appropriateness of the
diagnosis and treatment reviewed by:
– One hospital in the network
– One QIO
– One qualified entity defined by state rural
health plan
– Written agreement with hospital
294