Joint Commission Intra Cycle Monitoring(ICM) Survey Results Joint - - PowerPoint PPT Presentation

Joint Commission Intra Cycle Monitoring(ICM) Survey Results

Joint Conference Committee February 28,2017

Agenda

• Overview Upcoming Surveys
• TJC Update
• Survey Methodology Changes
• Post Survey Response Changes

2

Upcoming Surveys

• Commission on Cancer, American College of

Surgeons

• May 25, 2017
• California Department of Public Health(CDPH)

Skilled Nursing Care Survey

• Unannounced
• The Joint Commission Triennial Accreditation

Survey

• Expected survey window: 1/1/17 – 7/18/17
• Joint Commission Lab Accreditation Survey
• Scheduled Survey

3

NEW TJC Survey Process

SAFER: Survey Analysis For Evaluating Risk

• New survey scoring methodology
• Based on estimated level of risk to patients, staff, and visitors
• Helps organizations prioritize and focus corrective actions
• Provides one comprehensive visual representation of survey

findings

• Effective January 2017

SAFER MATRIX

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Immediate Threat to Life (a threat that represents immediate risk or may

potentially have serious adverse effects on the health of the patient, resident, or individual served)

Likelihood to Harm a Patient/Staff/Visitor HIGH (harm could happen at

any time)

MODERATE (harm could

happen occasionally)

LOW (harm could happen,

but would be rare)

LIMITED (unique

• ccurrence that is not

representative of routine/regular practice)

PATTERN (multiple occurrences

with potential to impact few/some patients, visitors, staff and/or settings)

WIDESPREAD (multiple

• ccurrences with potential to

impact most/all patients, visitors, staff and/or settings)

Scope

Additional Changes

• No more Direct Impact and Indirect EP (Elements of Performance)

designations

• Consolidated ESC into one 60 day timeframe
• Elements of performance will no longer be categorized as A or C
• Follow up will be customized and prioritized according to placement

within SAFER Matrix

• All findings (including single instances of non-compliance) will be

included in the survey report and will require a response

• This approach emanates from the CMS position: “If you see it, you cite it .”
• Findings rated at higher risk level on SAFER matrix will require plan

describing how compliance will be achieved and sustained

6

Evidence of Standards Compliance Leadership Change

For High/Moderate Matrix findings

• Leadership Involvement
• Success and sustainability are highly influenced by

support from the executive level of leadership

• The measure of the success of change is in its

sustainability within organizations

• Preventive Analysis

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ZSFG Joint Commission ICM Findings:

2/24/2017 Zuckerberg San Francisco General Hospital and Trauma Center 8

 Infection control (high level disinfection and transportation of probes) (Corrected in real time)  A three hour gap for a provider to complete a face-to-face evaluation

• f a restrained patient

 Missing ventilator order  Looped endoscope (Corrected in real time)  Blanket warmer temperatures out of range (Corrected in real time)  Incomplete documentation of use of interpreter services  Potential ligature points identified in Acute Psychiatry  Storage of Dantrolene in the OR without an accompanying risk assessment  Lack of privacy for triage in PES  Range orders without specific parameters  Education and orientation of outside law enforcement  Dirty pill cutter ( Corrected in real time )  Bronchoscopy performed in a non-negative air pressure room  Missing restraint documentation  Missing elements from the Infection Control Annual Risk Analysis  Incomplete dialysis consent form  Open EKG electrodes (Corrected in real time)  Non-specific patient care planning  Lack of wayfinding cues for assisting SNF residents with dementia.

• 2017 ICM Survey: SAFER MATRIX

ZSFG 2017 Hospital Survey Findings

• 2 | P age

Thank you

Zuckerberg San Francisco General Hospital and Trauma Center 10