A Game Plan To Surviving A Joint Commission Survey

MSHP Annual Meeting 2017A Game Plan to Surviving aJoint Commission SurveyMay Adra, BS Pharm, PharmD, BCPSObjectives Describe key components of a JointCommission accreditation visit Identify changes to medicationmanagement standards Develop a roadmap for preparing for TheJoint Commission visit

MSHP Annual Meeting 2017Survey Structure and FormatSurvey team cialistLife SafetySpecialistsFormatPeopleProcessPolicy3Tracer MethodologyIndividual TracerSystem Tracer

MSHP Annual Meeting 2017Project Refresh A series of initiatives that focus on the presurvey, onsite survey , and post surveyprocesses Goals: Simplification and relevancy Major initiatives: Survey Analysis for Evaluating Risk (SAFER )MatrixFollow-up activitieshttps://www.jointcommission.org/webinar replay refresh safer matrix/Patient Safety Assessment: PastThe Joint Commission revised its scoringand decision process, effective January 2017 Elimination of categories pertaining to: Scoring categories (A or C)Measures of Success (M)Patient care impact (direct or indirect impactrequirements)Changes to time frames for responding tosurvey findings

MSHP Annual Meeting 2017SAFER matrixThe Joint Commission Perspectives. 2017:1;37.Applying the SAFER Matrix toMedication Management StandardsConcentratedelectrolytes placedin ADCs with nosafeguards in placeLack of adherenceto policies onmedication ordersOne expiredtablet ofibuprofenfound

MSHP Annual Meeting 2017Survey Findings All Requirements for Improvements (RFIs) Submission of Evidence of Standards Compliance Due date changes from 45 or 60 days to 60days onlyRFIs for higher risk findings will require: Leadership involvementPreventive AnalysisQ&A Changes to the TJC survey process include:A.B.C.D.A new SAFER matrix for assessing impacton patient safetySubmitting Evidence of Standards Compliancein 60 days onlyAdding leadership and preventative strategiesinto the RFI for the higher risk areas in theSAFER matrixAll of the above

MSHP Annual Meeting 2017Medication Management (MM) Chapter:Deletions MM.03.01.05 EP 3 Informing prescriber and patient if medicationsthat are brought in are not permittedMM.08.01.01 EP 4 Reviewing literature and external sources onnew technologies and best practicesMedication Management Chapter:Additions Many standards now also apply to samplemedications Radiopharmaceuticals Antimicrobial stewardship program

MSHP Annual Meeting 2017Radiopharmaceuticals MM.03.01.01 EP24 The hospital maintains records of the receipt anddisposition of radiopharmaceuticals.MM. 06.01.01 EP13 Before administering a radioactive pharmaceuticalfor diagnostic purposes, staff verify that the doseto be administered is within 20% of the prescribeddose, or, if the dose is prescribed as a range, staffverify that the dose to be administered is withinthe prescribed range.New MM Standard: MM.09.01.01Antimicrobial Stewardship MM.09.01.01 The hospital has anantimicrobial stewardship program basedon current scientific literature.

MSHP Annual Meeting 2017Top Non-Compliant MedicationRelated StandardsMed Storage and SecurityClarity of Med OrdersMed Order ReviewMed labeling in ORs/procedures20162015Med Reconciliation2014Med LabelingHigh-Alert and Hazardous MedsLook-Alike Sound-Alike Meds0%5%10%15%20%25%30%35%40%Medication Orders Clarity of medication orders Failure to clarify unclear, illegible or incompleteordersLack of indication for PRN ordersUse of prohibited abbreviationsTherapeutic duplication Pain medications Anti-emetics Medications for constipationConsistency in interpreting range ordersTitration orders

MSHP Annual Meeting 2017Components of Titration Orders Medication NameMedication routeInitial or starting rate of infusion (dose/min)Incremental units the rate can be increased ordecreasedFrequency for incremental doses (how oftendose (rate) can be increased or decreasedMaximum rate (dose of infusion)Objective clinical endpoint (RASS score, CAMscore, etc.)Titration Orders

MSHP Annual Meeting 2017Medication Security and StoragePrevention of diversion Removal of expired medications Appropriate storage conditions(temperature monitoring) Single-Dose, multi-dose vials Medication Storage

MSHP Annual Meeting 2017Multiple Dose VialA Pharmacist Review of MedicationOrders Requirements for a pharmacist to reviewmedication orders Exceptions to the requirementsAreas of interest Pre-operative holding areasPost-Anesthesia Care Units (PACUs)Oncology areasOverrides

MSHP Annual Meeting 2017Medication LabelingQ&A Medication related standards that continueto make TJC’s list of top non-compliantstandards include all of the following,except:A.B.C.D.Medication storage and securityReview of medication eventsMedication labeling in procedural/operativelocationsClarity of medication orders

MSHP Annual Meeting 2017MM.09.01.01 Antimicrobial StewardshipMM.09.01.01 The hospital has an antimicrobialstewardship program (ASP) based on currentscientific literature. Core components include: ASP Structure Performance Improvement Leadership Tracking Accountability Reporting Drug expertise Education Action Staff PatientOrganization Priority Leaders establish antimicrobialstewardship as an organizational priority. Budget plansInfection prevention plansPerformance improvement plansStrategic plansUsing the electronic health record to collectantimicrobial stewardship data

MSHP Annual Meeting 2017Antimicrobial Stewarship Team The hospital has an antimicrobial stewardshipmultidisciplinary team that includes the followingmembers, when available in the setting: Infectious disease physicianInfection preventionist(s)Pharmacist(s)PractitionerProtocols The hospital's antimicrobial stewardshipprogram uses organization-approvedmultidisciplinary protocols. Antibiotic restrictions IV to PO conversion protocols Infection/Disease guidelines

MSHP Annual Meeting 2017Data Collection The hospital collects, analyzes, andreports data on its antimicrobialstewardship program.Action The hospital takes action on improvementopportunities identified in its antimicrobialstewardship program.

MSHP Annual Meeting 2017Staff Education The hospital educates staff and licensedindependent practitioners involved inantimicrobial ordering, dispensing,administration, and monitoring aboutantimicrobial resistance and antimicrobialstewardship practices. Education occurs upon hire or granting of initialprivileges and periodically thereafter, based onorganizational need.Patient Education The hospital educates patients, and theirfamilies as needed, regarding theappropriate use of antimicrobialmedications, including antibiotics.

MSHP Annual Meeting 2017Tools for Patient EducationResources

MSHP Annual Meeting 2017Antimicrobial Stewardship Program(ASP)Do you have an ASP inplace?Yes Perform agap analysisNo Partner withhospital leadershipPolling Question Key components of an antimicrobialstewardship program includeA.B.C.D.A multidisciplinary antimicrobial teamPatient and staff educationPerformance improvement activitiesAll of the above

MSHP Annual Meeting 2017USP 797 CMS – currently surveying TJC – revision of standards TJC- offering of Certification forCompounding CMS o/Downloads/Survey-and-Cert-Letter-16-01.pdf

MSHP Annual Meeting 2017Compounding Certification ProgramAvailable for all compounding pharmacies Initial rollout Pharmacies operating in or shipping to stateswith regulations requiring compliance with USP 797 and/or USP 795 TJC’s Initiatives Pertaining to USP 800 Self-assessment tool with consultativerecommendation www.hazmedsafety.com

MSHP Annual Meeting 2017TJC’s Initiatives Pertaining to USP 800 On-Demand Webinars Accessible at ugsUSP 800 What You Need to Know and Toolsto Support Your JourneyUSP 800 Hazardous Drug Handling: WhatNurses Need to KnowAccreditation and Regulatory Perspectives forUSP 800 - Directions of the JointCommission and CMSISMP Best Practices

MSHP Annual Meeting 2017Sentinel Event Alerts (SEAs) SEA 57: The essential role of leadership indeveloping a safety culture SEA 55: Preventing falls and fall-relatedinjuries in health care facilities September 28, 2015SEA 53: Tubing Misconnections March 1, 2017August 20, 2014SEA 52: Misuse of injectable agents June 16, 2014

MSHP Annual Meeting 2017Injectable MedicationsSingle-Dose VialsMultiple-Dose Vials Intended for only one dose ofthe drug for one patient Typically contains NOantimicrobial preservatives May serve as a source ofinfection if used for more thanone dose**Size of vial does NOT determine if it is a single- ormultiple-dose vial Intended to be used formore than one dose of thedrugUsually containsantimicrobial preservativesto prevent the growth ofmicroorganismsWhen the vial is opened,must be dated with a 28-dayexpiration unlessmanufacturer specifies ashorter expiration date45About Beth Israel DeaconessMedical Center638,449Outpatient Visits651 licensed beds40,217 InpatientDischarges56,959 ED visits348,183Radiology visitsBowdoin Street Health CenterBeth Israel Deaconess HospitalNeedhamBeth Israel DeaconessHealthCare-Chestnut HillBeth Israel DeaconessHealthCare-ChelseaBeth Israel DeaconessHealthCare-Lexington

MSHP Annual Meeting 2017Areas of macyWallsPharmacyPremisesPharmacy PremisesAppearances and first impressions Scope of services and contracted services Orientation/training/competencies Strategies for look-alike and high-riskmedications IV rooms Environment of Care/Life Safety Tracers

MSHP Annual Meeting 2017Boots on The GroundObservations Interviews Review of policies and documents Tools Education Conducting ObservationsAsk to beinvitedConductvisit withstaffProvidefeedback

MSHP Annual Meeting 2017TakeawaysPharmacy takes the lead in coordinatinghospital-wide initiatives on medicationmanagement Align your policies and practices Ensure consistency between policies andpractice and, consistency in practicesConduct as many observations as feasible Use the tracer methodology, educate staffthrough simulation of a TJC survey

MSHP Annual Meeting 2017 Top Non-Compliant Medication Related Standards 0% 5% 10% 15% 20% 25% 30% 35% 40% Look-Alike Sound-Alike Meds High-Alert and Hazardous Meds Med Labeling Med Reconciliation Med labeling in ORs/procedures Med Order Review Clarity of Med Orders Med Storage and Security 2