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Lunch and Learn Series Joint Commission Update 2017 PharMEDium Lunch and Learn Series LUNCH AND LEARN Joint Commission Update 2017 June 9, 2017 Featured Speaker: Kurt A. Patton, MS, RPh President Emeritus Patton Healthcare Consulting, LLC CE Activity Information & Accreditation ProCE, Inc. (Pharmacist and Tech CE) 1.0 contact hour Funding: This activity is self‐funded through PharMEDium. It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Mr. Patton has served as a consultant for Patton Healthcare Consulting. 2 ProCE, Inc. www.ProCE.com 1 Joint Commission Update 2017 PharMEDium Lunch and Learn Series Online Evaluation, Self-Assessment and CE Credit . Submission of an online self‐assessment and evaluation is the only way to obtain CE credit for this webinar . Go to www.ProCE.com/PharMEDiumRx . Print your CE Statement online . Live CE Deadline: July 7, 2017 . CPE Monitor – CE information automatically uploaded to NABP/CPE Monitor upon completion of the self‐assessment and evaluation (user must complete the “claim credit” step) Attendance Code Code will be provided at the end of today’s activity Attendance Code not needed for On‐Demand 3 Ask a Question . Submit your questions to your site manager. Questions will be answered at the end of the presentation. Your question. ? 4 ProCE, Inc. www.ProCE.com 2 Joint Commission Update 2017 PharMEDium Lunch and Learn Series Resources . Visit www.ProCE.com/PharMEDiumRx to access: – Handouts – Activity information – Upcoming live webinar dates – Links to receive CE credit 5 + Joint Commission Update 2017 - PharMEDium Kurt A. Patton MS, R.Ph. President Emeritus Patton Healthcare Consulting, Inc. Former Executive Director Hospital Accreditation The Joint Commission. 6 ProCE, Inc. www.ProCE.com 3 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Pressures on the Hospital Pharmacy Director Workload New service requests Staffing Drug budget Budget impact of healthcare reforms Quality Anticipated survey by Joint Commission Adverse outcome Potential survey by CMS/state surveyors Corrective actions and follow up for either survey 7 + Who is the Joint Commission? Private, not for profit accrediting body with a Board of Directors from AHA, AMA, ACS, ACP, ADA, 6 public members and 4 at large specialty members, RN, BHC, HC, LTC. Standards are developed using a PTAC (Professional Technical Advisory Committee) an advisory group with 50 different professional associations represented including ASHP. TJC has “deemed status” with CMS, previously in law, now a periodic approval process. TJC actually comes around regularly, full survey at least every 3 years and when they receive significant complaints or media reports. 8 ProCE, Inc. www.ProCE.com 4 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Joint Commission Survey Teams Physicians Nurses Behavioral healthcare specialists Ambulatory specialists Some pharmacists at larger teaching hospitals and for cause events Home infusion pharmacists Life safety code specialists All clinical surveyors conduct patient tracers and report to each other their observations One surveyor will conduct a MM System tracer in depth. 9 + Joint Commission and USP Chapter <797> The physician and nurse surveyors know a little about USP 797 and to a limited extent apply the requirements if your state has adopted USP 797 as state regulations. The physician, nurse and life safety code specialist all understand air pressure relationships. TJC has just started a medication compounding certification program. Surveyors usually either perform accreditation or certification surveys, but not both. The now published medication compounding standards are a good learning tool for hospital surveyors however. 10 ProCE, Inc. www.ProCE.com 5 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Joint Commission and USP Chapter <800> Nothing definitive on the horizon at this time from TJC or CMS. However: The life safety code specialists will probably be spending more time looking at environmental safety issues relative to hazardous medications The consulting arm JCR (firewall between) has done an excellent web-based hospital self assessment tool, which has the potential to also be an excellent marketing tool to those who need the most help in preparing. http://www.jcrinc.com/safe-handling-of-hazardous-drugs/ 11 + 12 New TJC Scoring System All surveys beginning 1/1/17 now use a new risk assessment methodology to score standards. No A or C elements, no direct or indirect 1 observation of noncompliance = Requirement For Improvement (RFI) You must respond on how you fixed the noncompliance Two variables will be considered. How wide spread is the defect? How critical, how important is the defect? Examples: 1 expired oral medication in one location. Multiple expired sterile medications in multiple locations 12 ProCE, Inc. www.ProCE.com 6 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Project Refresh Onsite SAFER Matrix Survey Analysis for Evaluating Risk (SAFER) Matrix Help you prioritize Visual – on report Can sort & filter 13 Scope + How Will Surveyors Assign Risk? Surveyor experience and expertise based on “scope” and “likelihood to harm” Talking amongst the team Impact of risk assignment: Guldens mustard color and red require additional content on leadership involvement and sustainability in evidence of standards compliance (ESC). As of 3/20/17, 26% of findings are red or dark mustard color. 14 ProCE, Inc. www.ProCE.com 7 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + What Might Be Red in Medication Management? The most difficult and complex medication issue on surveys today - improper medication titration in the ICU setting. Nurses practicing outside the scope of licensure Protocols not in the chart or not referenced Incremental dose missing from titration orders Assessment criteria missing from the order Failure to assess How and where this gets scored is very diverse so this does not show in stats published by TJC. 15 + Why Do Surveyors Like to Score the Medication Management Chapter? Its objective: you did it or you did not. TJC shares lots of medication safety information with surveyors including the ISMP newsletter. Compare with the more subjective PC standards regarding the quality of a history and physical or the accuracy of a pre- sedation assessment. TJC does not perform peer review. 16 ProCE, Inc. www.ProCE.com 8 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Most Frequently Scored Medication Management Standards 17 + Joint Commission Standards Structure Standard xx.xx.xx – a high level concept that is not directly evaluated by the surveyors There are also National Patient Safety Goals which are just like standards developed using a different process Elements of performance (EP)1, 2, 3, etc. – More finite and specific requirements each of which must be in place for the standard to be scored as compliant. Some elements of performance have a “D” icon, meaning documentation is mandatory. A failure on any one element of performance causes the standard to be scored non compliant. This results in a requirement for improvement and you must tell TJC how you fixed the issue. Too many standards scored noncompliant is a problem. 18 ProCE, Inc. www.ProCE.com 9 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + MM.04.01.01 – Seems Easy, But it is Not and it may be Red The most problematic standard today. The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use. This includes, PRN, standing orders, titration orders, taper orders, range orders, etc. Hospitals did not specify enough order details so TJC has posted an FAQ with the minimum requirements. 19 + Titration Order Minimum Elements Medication name Medication route Initial or starting rate of infusion Incremental rate the infusion can be increased or decreased Frequency of rate adjustments Maximum rate of infusion Objective clinical endpoint, Richmond Agitation Sedation Scale (RASS), blood pressure (BP), etc. 20 ProCE, Inc. www.ProCE.com 10 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Sedation Titration Example Propofol 5-50 mcg/kg/min, start at 5 mcg and increase by 5 mcg every 5 minutes to a maximum dose of 50 mcg/kg/min to achieve a RASS of -3. If this is in a structured order set in an EMR or a paper order form, practitioners don’t need to remember all the required order details. If you allow ad hoc EMR or paper orders you are likely to have many gaps requiring clarification. 21 + Sedation Titration Survey Follow up Simple RFI, document in ESC how you fixed it and sound convincing, easy. If survey outcome is Accreditation with follow up survey (AFS), preliminary denial of accreditation (PDA) or Pharmaceutical Service Medicare condition out, document in ESC how you fixed it and sound convincing, but TJC surveyors are coming back to validate and you must be 100% compliant, all titrations all charts - and this is hugely different. MM Condition out less than 45 days PDA you have about 60 days AFS you have about 4 months to make it perfect. 22 ProCE, Inc. www.ProCE.com 11 Joint Commission Update 2017 PharMEDium Lunch and Learn Series + Sedation Titration, Real Example of Survey Disaster Full survey, hospital cited for improperly written and documented sedation titrations. Survey outcome AFS ESC submitted said a titration protocol was prepared for nursing staff with instructions on how to titrate sedating agents. AFS follow up survey conducted, nursing staff interviewed and replied: “we just use our clinical judgment”. Accreditation status changed to PDA, hospital now decides to develop detailed order sets in EMR. 23 + MM.01.01.03 High Alert/Hazardous Medications EP 1: The hospital identifies in writing its high alert and hazardous medications.
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