TJC & CMS Update 2017 Kimberly Merritt, MHA, BSN, CNOR, GRCP, - - PowerPoint PPT Presentation

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TJC & CMS Update 2017 Kimberly Merritt, MHA, BSN, CNOR, GRCP, - - PowerPoint PPT Presentation

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TJC & CMS Update 2017 Kimberly Merritt, MHA, BSN, CNOR, GRCP, HACP Jill Ryan, CPHQ, HACP 2 Disclosures Courtemanche & Associates is accredited as a provider of continuing nursing education by the American Nurses Credentialing

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TJC & CMS Update 2017

Kimberly Merritt, MHA, BSN, CNOR, GRCP, HACP Jill Ryan, CPHQ, HACP

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Disclosures

  • Courtemanche & Associates is accredited as a provider of continuing nursing education by the

American Nurses Credentialing Center’s Commission on Accreditation.

  • Continuing Education Contact Hours will be awarded upon full attendance of the program and

receipt of the participant course evaluations. In order to receive CE credit hours for your participation in the session, the electronic evaluation feedback form must be completed within 2 weeks of the educational activity.

  • The planners and presenters for this session are: Sharon Dills, MSN, RN, HACP, GRCP

Kimberly Merritt, MHA, BSN, CNOR, GRCP, HACP and Jill Ryan, CPHQ, HACP

  • The planners and presenters noted above have disclosed no influencing relationships or

commercial support relating to this activity.

  • Participation in an accredited activity does not imply endorsement by the provider or ANCC of

any commercial products displayed in conjunction with this activity.

  • Courtemanche & Associates does not discuss any products for use for a purpose other than that

for which they were approved by the Food and Drug Association.

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Session Outline

  • Accreditation & Regulatory Compliance – The Foundation for Patient Safety
  • TJC Survey Process Updates
  • TJC Top Scoring Findings & Strategies for Success
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Session Objectives

  • At the conclusion of the session, learner will be able to:
  • Identify at least one impact of TJC’s SAFER Matrix TM methodology
  • Identify at least one frequently scored standard and one strategy to achieve sustained

compliance

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Accreditation & Regulatory Compliance: The Foundation for Patient Safety

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Highlights of the Patient Safety Journey

This report is widely regarded as the precipitator of the patient safety movement. In follow‐up to his C+ rating in 2004, Wachter gives the industry a B‐ for safety efforts. Chassin and Loeb identify actions leaders can take to create more highly reliable healthcare organizations One of the six competencies is Patient Safety. “To Err Is Human: Building a Safer Healthcare System” Estimates between 44,000 and 98,000 hospital deaths annually due to medical errors 1999 IOM Report “Patient Safety at Ten: Unmistakable Progress, Troubling Gaps”

2009

“High‐Reliability Health Care: Getting There from Here”

2013 2017

NAHQ Publishes HQ Essentials: Competencies for the Healthcare Quality Professional

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Reducing Risk

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Impact of A&R Compliance on Care

JAMA Internal Medicine Study

  • Significant decrease in 30‐day mortality rate for admissions during TJC survey weeks
  • Greatest impact – major teaching hospitals

What do we think about that?

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One Organization’s Experience

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TJC founding in 1950s to provide voluntary accreditation. Initial members – ACS, ACP, AHA, AMA, Canadian Medical Association

2000s

Siloed approach – requirements by department Survey process focused

  • n meetings, document

and medical record review.

1980s

  • Survey results in a % score
  • “Agenda for Change”
  • Survey process focuses on cross‐

department functioning

1990s

  • Requirements associated with risk

– direct and indirect impact

  • Survey process more robust
  • TJC required to participate in CMS

deemed status application process

  • Patient Safety Systems chapter

2010s Today

Survey activity focused on risk, leadership involvement in creating and modeling culture of safety and sustaining change SAFERMatrix TM

  • “Shared Visions New Pathways”
  • Standards & survey process

focused on integrated systems and functions

  • Survey results based on

thresholds

  • Tracer methodology

TJC Survey Process Journey

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TJC Survey Process Updates

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TJC’s Project REFRESH

Quick Recap

  • Enhancements to pre/intra/post survey process
  • Review of standards and EPs
  • Post survey process – clarifications and ESC
  • Process for healthcare organizations with Preliminary Denial of Accreditation (PDA02)

Decisions

  • SAFER Matrix TM
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TJC’s Project REFRESH

Still Underway

  • Still underway
  • Accreditation report – coming soon
  • PDF and Excel versions
  • User‐friendly views
  • Effectiveness of follow‐up surveys
  • SIG support during survey
  • Intracycle monitoring
  • Engaging physician leadership
  • And more
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Review of Standards/EPs

  • Methodology
  • Eliminate duplication and redundancy or implicit in another EP
  • Allow for organization discretion in defining policy, procedure
  • Reduce requirements addressed by law and regulation
  • Eliminate requirements for things already embedded in
  • perations

Take‐Away – Gone but not forgotten – often embed/scored at other EPs

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PDA02 – Repeat Findings, Trends, Patterns

  • Optional clarification – within 10 days
  • Plan of correction – 10 days from clarification being waived or completed
  • Typically condition‐level deficiencies – within 45 days
  • PDA validation survey – within 60 days
  • Accreditation with follow‐up survey – typically 4‐6 months
  • Must participate in intracycle monitoring
  • Following survey around 18 month mark
  • Touchpoint discussions with TJC COO and/or CMO
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ESC Timeline – High Level

  • Report posted within 10 days
  • Clarification (optional) within 10 business days
  • If Condition Level Deficiencies – survey within 45 days
  • Recommend having corrective actions in place at 30 days with ESC drafted
  • If Time Limited Waiver needed (LS RFIs) – recommend submitting by 30 days
  • All ESC due at 60 days
  • If Accreditation with Follow‐up Survey – timeframe varies
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ESC Content

Revised & More Robust

  • Assigning accountability
  • Who is ultimately responsible
  • Leadership involvement (if red or dark orange on SAFER)
  • Who and how involved
  • Correcting the non‐compliance
  • Preventive analysis (if red or dark orange)
  • What actions have been taken and when
  • Ensuring sustained compliance
  • What procedures/activities put in place to monitor compliance?
  • Frequency of that monitoring
  • What data will be collected?
  • Where and how often will data be reported
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SAFER MatrixTM

TJC Hospital Executive Briefings, 10/5/2017

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TJC’s Top Clinical Findings

January – June 2017 – TJC Hospital Executive Briefings, October 5, 2017

Standard Issue Percent of Hospitals Scored Non‐compliant IC.02.02.01 Cleaning, disinfection, sterilization 70% RC.01.01.01 Content of medical record – dating/timing 57% PC.02.01.03 Implementing current orders 57% IC.02.01.01 Infection control surveillance 52% MM.04.01.01 Medication orders – meet requirements 49% MM.03.01.01 Medication storage and security 48% PC.01.03.01 Care planning 45% PC.02.02.03 Food and nutrition services 42% PC.02.01.11 Resuscitation equipment/supplies 38% PC.01.02.03 Assessment and reassessment 31%

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TJC’s Top Physical Environment

January – June 2017 – TJC Hospital Executive Briefings, October 5, 2017

Standard Issue Percent of Hospitals Scored Non‐compliant LS.02.01.35 Managing fire extinguishing systems 86% LS.02.01.30 Maintaining building and fire protection features 74% EC.02.05.01 Maintaining utility systems (includes air pressure, temperature, humidity) 73% EC.02.06.01 Maintains safe environment 68% LS.02.01.10 Building and fire general requirements 66% EC.02.02.01 Hazardous materials 62% LS.02.01.20 Egress issues 60% EC.02.05.05 Managing equipment 60% EC.02.03.03 Fire drills 47% EC.02.05.09 Cylinder storage/handling 35% EC.02.03.05 Fire alarm and sprinkler testing requirements, etc. 16%

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Immediate Threat to Life (ITL)

  • Ligature and Suicide Risks
  • Findings in APR, LD, EC, HR, NPSG, PC
  • High Level Disinfection & Sterilization
  • Findings in IC, LD, HR, EC
  • Nationally, ligature/suicide risk is a focus of every survey
  • 70% of ITL decisions were related to HLD/Sterilization first half of 2017
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High Risk (Red) Findings

  • Infection Prevention
  • Air pressure relationships (outside of OR)
  • Cleaning, disinfection, sterilization
  • Environment of Care
  • Air pressure relationships (in OR)
  • Availability of emergency equipment
  • Safe, suitable conditions
  • Management of medical equipment
  • Management of hazardous materials
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High Risk (Red) Findings

  • Infection Prevention
  • Air pressure relationships (outside of OR)
  • Cleaning, disinfection, sterilization
  • Environment of Care
  • Air pressure relationships (in OR)
  • Availability of emergency equipment
  • Safe, suitable conditions
  • Management of medical equipment
  • Management of hazardous materials
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High Risk (Red) Findings

  • Provision of Care
  • Following most recent orders (usually related to meds)
  • H&P not timely
  • Restraint assessments
  • Patient Rights
  • DNR documentation (ambiguous/incomplete)
  • Leadership
  • Failure to comply with COPs
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Moderate Risk (Dark Orange) Findings

  • Human Resources
  • Staff competencies
  • Defined
  • Timely
  • Based on job responsibilities
  • Life Safety
  • Availability of fire extinguishing features
  • Documentation of testing requirements
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Moderate Risk (Dark Orange) Findings

  • Human Resources
  • Staff competencies
  • Defined
  • Timely
  • Based on job responsibilities
  • Life Safety
  • Availability of fire extinguishing features
  • Documentation of testing requirements
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Moderate Risk (Dark Orange) Findings

  • Medical Staff
  • Requirements for H&P in Bylaws
  • Primary Source Verification
  • Following Bylaws and Rules & Regs
  • Leadership
  • Failure to follow policy and procedure
  • Staff accountability
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Moderate Risk (Dark Orange) Findings

  • Medication Management
  • Medication orders (therapeutic duplication, range orders, PRN orders)
  • Safety & security (temperature, vaccine)
  • Sterility (pill crushers)
  • Sample medications
  • Labeling (multi‐dose vials)
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Moderate Risk (Dark Orange) Findings

  • NPSG
  • Environmental risk assessment for suicide
  • Provision of Care
  • Storage of patient food
  • Diet manual not approved by medical staff
  • Assessments (timeliness, content, pain, etc.)
  • H&P
  • Care/Meds based on most recent order
  • Restraint (d/c as soon as possible)
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Moderate Risk (Dark Orange) Findings

  • Record of Care
  • Dating and timing
  • Immediate post‐op note
  • Patient Rights
  • Informed consent (processes not followed)
  • Transplant Safety
  • FDA certificates not available
  • Logs not complete/missing
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Lower Risk (Light Orange/Yellow) Findings

  • Environment of Care
  • Fire drills (no variation in timing)
  • Hazardous materials
  • Testing requirements
  • Blocked electrical panels
  • Life Safety
  • Door latching
  • Penetrations
  • 18” rule
  • Escutcheon gaps
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Strategies First – Avoid ITL!

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Ligature & Suicide Risk

  • TJC convened an expert panel, including CMS representation
  • Guidance coming from CMS – expected to focus on
  • Psychiatric hospitals and psychiatric units in acute care
  • Definition of ligature resistant
  • Applicability
  • Patient rooms
  • Patient bathrooms
  • Patient corridors
  • Common patient areas
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Ligature & Suicide Risk

  • Guidance will also address specific requirements around items such as doors,

ceilings, etc. in these areas

  • Guidance for general acute care areas where suicidal patients may sometimes be

seen will address

  • Risk assessment
  • Removal of items potentially used for self‐harm
  • Training, competence assessment of staff
  • Monitoring of the suicidal patient
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Ligature & Suicide Risk

  • Guidance for emergency departments will address both “safe rooms” and main ED

areas and include

  • Risk assessment
  • Screening and assessment of patients
  • Protocols for placing, caring for and monitoring suicidal patients
  • Guidance for the actively suicidal patient
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Ligature & Suicide Risk

In the meantime . . .

  • Identify areas (dedicated and non‐dedicated) where psychiatric patients are cared for
  • Conduct robust environmental risk assessment
  • Engage senior (C‐suite) leadership, behavioral health, facilities management, ED, etc.
  • Determine mitigation strategies
  • Long term – capital investment
  • Short term – immediately reduce risk
  • Short term strategies might include
  • Moving service to safer area
  • Providing additional staff
  • Increasing monitoring of patients – (1:1 when warranted)
  • Consideration of services provided
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Ligature & Suicide Risk

In the meantime . . .

  • Review policies, processes
  • Screening
  • Assessment/reassessment
  • Placement of patients
  • Resource allocation
  • Provide staff education and, where appropriate, determine competence
  • Suicide risk awareness !!
  • Screening/assessment/reassessment
  • Sitters
  • Assure appropriate committee involvement
  • Document, document, document
  • All actions taken
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High Level Disinfection

  • First and foremost – know where it is occurring!
  • Take inventory
  • Validate through rounds
  • Risk assessment? Centralized vs Decentralized
  • Assure process follows current manufacturer’s instructions for use (IFU)
  • Assure staff competency (initial and ongoing) by someone qualified to do so
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HLD Workflow

Endoscopes (includes but not limited to: flexibles, duodenoscopes)

Per IFU. Manual cleaning with detergent and brushing Cleaning Per IFU Leak Testing Point of use removal of gross debris Pre-Cleaning Per IFU. Use the appropriate amount and the type of water recommended Rinsing Manual or per automated endoscope reprocesser (AER) HLD/Rinsing Forced air cabinet Drying & Storage

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HLD Workflow

Probes

Per IFU. Manual cleaning with detergent and brushing Cleaning Per IFU. Point of use removal

  • f gross debris

Pre-Cleaning AER, soak station, hydrogen peroxide Determine type of processer Per IFU. Use the appropriate amount and the type of water recommended Rinsing Manual or per automated endoscope reprocesser (AER) Drying Per IFU. Storage

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Sterilization Workflow

Adequate workspace, illumination, tools

Prep and Inspection Manual, ultrasonic, washer disinfector Decontaminate/Clean Point of use removal of gross debris Pre-Clean Peel packs, wraps, rigid container systems Package Parameters, biologicals, documentation Sterilize Environmental parameters Store

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Overarching Strategies for Success

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Strategies

  • Unrelenting focus
  • Ligature/Suicide risk
  • HLD & Sterilization
  • Physical Environment
  • Review findings from previous report
  • Validate sustained compliance through tracer activity, document review, discussions
  • Modify non‐compliance processes, educate, assure competence, monitor
  • Engage leadership in active, robust, visible participation in these processes
  • Rounds, tracers, patient safety huddles
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Strategies

  • Risk assessment (and reassessment!)
  • When to do a risk assessment
  • Complicated, high risk processes
  • New or revised processes
  • Data from incident reports, infection prevention and physical environment rounds, safety events,

last survey, top findings

  • Interdisciplinary process
  • Engage key constituents
  • Review evidence based guidelines, professional recommendations, etc.
  • Document the process
  • Report through appropriate committee structure
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Summary

  • With an abrupt wake up call in 1999, the healthcare industry set the

wheels in motion to “make patients safe”

  • Concepts from very dissimilar industries provide the tools to decrease

variability and create highly reliable healthcare organizations

  • Using regulatory and accreditation requirements as the foundation

upon which we lay robust process improvement, evidence based practice and clinical guidelines helps to achieve our aim of Zero Harm

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Implementation Strategy What Leaders Can Do To Foster Change

Create infrastructure that supports patient safety in all aspects of the

  • rganization from onboarding through daily activities. Drive highly

reliable processes.

1 2

Resist losing momentum once achievements have been made. Continually strive to achieve the next level of excellence.

3

Keep communication lines open by transparently, yet respectfully sharing lessons learned. Incentivize ongoing commitment to Zero Harm by recognizing and celebrating successes.

4

Prioritize A&R and Patient Safety as Strategic Imperatives Change the Landscape Periodically Reassess and Raise the Bar Acknowledge Lessons Learned and Celebrate Successes Visualize your organization with a strong and resilient safety culture that protect patients and staff from unsafe conditions, and safety

  • events. Articulate that vision consistently and often to all

constituents.

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Final Thoughts . . .

  • It’s about patient safety
  • Not about survey
  • The priority is reducing risk and variation
  • Not because we’re required to do something
  • The focus is on the next patient
  • Not the next survey
  • We strategize solutions that work for our organization
  • Not those that someone said “are the best”
  • We do it because it’s the right thing to do
  • Not because a regulator or accreditor tells us to
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Questions & Sharing

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References

  • Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human:

Building a Safer Health System. Washington, DC: National Academy of Sciences.

  • Chassin, M. R., & Loeb, J. M. (2013). High‐Reliability Health Care: Getting There

from Here. Milbank Quarterly,91(3), 459‐490. doi:10.1111/1468‐0009.12023

  • Wachter, R.M. (2010). Patient Safety at Ten: Unmistakable Progress, Troubling
  • Gaps. Health Affairs,29(1), 165‐173. doi:10.1377/hlthaff.2009.0785.
  • USA, Department of Health & Human Services, Centers for Medicare and Medicaid
  • Services. (2015, November 20). State Operations Manual Appendix A. Retrieved

August 26, 2017, from https://www.cms.gov/Regulations‐and‐ Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

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References

  • The Joint Commission E‐dition [Computer software]. (2017). Oakbrook Terrace, IL:

The Joint Commission.

  • History of the Joint Commission. (n.d.). Retrieved August 26, 2017, from

https://www.jointcommission.org/about_us/history.aspx

  • Barnett, M. L., Olenski, A. R., & Jena, A. B. (2017). Patient Mortality During

Unannounced Accreditation Surveys at US Hospitals. JAMA Internal Medicine,177(5), 693. doi:10.1001/jamainternmed.2016.9685

  • The Joint Commission Hospital Executive Briefings [Conference]. (2017, October 5).

New York.

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