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StayingSafe–NewSEAonWorkplaceViolence:
LeadershipSession–BePreparedforChanges:The lead article in the June edition of Perspectivesdiscussesanimportantchangeeffectivethismonthinthesurveyprocessfortheleadershipsession.That'snotalotofnoticeforhospitals,butforthoseofyouwhoreadourMarch 2017 issue of thisnewsletterwhenwe discussedfutureimplicationsofSentinelEvent57wepredictedthischangewas on the horizon. In addition, CAS consultingclients who began using our 2018 Leadership SystemTracer tool should be well versed in this new content.Effective immediately TJC is requiring yourmost recentsafetyculturesurveyresultstobeincludedwithyourdayonedocuments.TJCindicatesthatsurveyorsmaywanttoreviewthisdocumentevenbeforetheopeningconference,sobeprepared tohave that available immediatelyupontheirarrival.Theyalsoindicatethatsurveyorsmayaskforaudiovisual arrangements to be made so that they canshowtheJointCommission’svideoentitled:“LeadingtheWaytoZero”.Ifthiscannotbedone,surveyorscanshowitontheirtablets.MoreimportantlyJointCommissionwillbemorecriticallyevaluating what is done and the results relative to theculture of safety survey. They have identified 3 specificleadershipstandardsthatwillbeexploredand6specificelements of performance thatwill beevaluated. TJChasidentifiedquestionsaboutthecultureofsafetythatwillbedirected to leaders, and other questions that will bedirectedtostaff.Ideallyyouwouldlikeyourresponsestothesequestionstobe,“yeswedo,”,“yeswehave”and“yes,hereiswhatwedid.”
Perspectives Inside This Issue: ü Perspectives
� LeadershipSession–BePreparedforChanges� SAFER™MatrixPlacementUnderReview-#
RFIsStillImportant� NottoMiss–NewAPRRequiresYoutoNotify
TJCifYouLoseDeeming� ActionItem:ExactingCompetency
RequirementsforUSP797Listed� ChangestoLigatureScoringandanOSHA
ReportingRequirement� PediatricHospitalstoGetExperienced
SpecializedTJCTeams� IntracycleMonitoring(ICM)CallsSuspendedby
TJC
ü ECNews� ActiveShooter� SuggestionsforSprinklerPipe–AvoidCommon
Findings
ü QuickSafety� ActionItem–EnsureyouhaveaContinuityof
OperationsPlan
ü CMSUpdate
June 2018 Phc newsletter
News from CMS and Joint Commission
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PATTON HEALTHCARE CONSULTING NEWSLETTER – JUNE 2018
The type of issues surveyors may ask of leaders willinclude:• Howdoyouassess thecultureofsafetyandwhat
tooldoyou use?Bear inmind, themost frequentmistakewehear in response to thisquestion is adiscussion about employee engagement and thepercentresponserate.Thecultureofsafetycanbeintegrated with an engagement survey, but moreoftenitisthestand-aloneAHRQsurveythatisusedtoassesstheculture.
• Do you include cultural improvement goals for theleadersormiddlemanagement?
• Is the board involved in setting expectations orimprovingthesafetyculture?
• Doyouuseinternalorexternalbenchmarks?Hereisagoodopportunitytodiscussyourownimprovementsovertimeorsubsequentsurveys,andincomparison,tootherorganizationsusingthesametool.
• What quality improvement projects have youconducted to improve your scores on the culture ofsafetysurvey?
• Doyouhaveauniformcodeofconductthatisusedforbehavioralissuesforallphysiciansandstaff?Arethedisciplinaryproceduresequitableandtransparent?
• What process do you have for reporting near misserrorsorclosecallsthatdidnotreachthepatient?
• Intheeventofaharmeventhowdoyoudetermineitisablamelesserrororablameworthyerror?
Inadditiontotheneedforleadershiptobeabletodescribewhattheyhavedone,(talkthetalk)JointCommissionwillbeaskingstaffwhattheyhaveseendone,(walkthewalk).Thesestaffdirectedquestionsmayinclude:• Have youever completeda culture of safety survey,
have you seen the results and does your supervisordiscusstheresultswithyou?
• Does your hospital have a formal mechanism forreporting intimidating behavior and would you feelcomfortablereportingsuchbehavior?
• When an error occurs, do you have confidence thatyourleadershipwilltakeanappropriatelookathowthesystemorprocessisaccountablevsanindividual?
• Whatprocessdoyouhaveforreportingclosecalls?• Does leadership conduct root cause analysis of any
closecallsthatarereported?
We believe these changes announced by TJC could besignificant. The leadership session is something TJC hastriedtoimproveovermanyyears,andtheyhavenoticedalackofscoringonthe3standardsand6EP’sdiscussedinthisarticle.Duringconsultationvisitsweoftennotealackofreadinesstodiscussthecultureofsafetyresultsandalackofawarenessatastaff level,so thismay take someefforttobeprepared.SAFER™MatrixPlacementUnderReview-#RFIsStillImportant:Perspectives has another article on improving thereliability and consistency of their surveys, in particularuse of the SAFER Matrix. They have identifiedinconsistency among surveyors in how they assessfindingsusing this tool.Theyareattemptingtoevaluateindividual surveyor patterns in an effort to improveconsistency.Wewouldnotordinarilydiscussthistypeofissue in our newsletter, however it is important thatorganizations not get too annoyed by placement offindings in the SAFER Matrix. We frequently encounterhospitals that want to clarify placement on the matrixwhileacceptingthefinding,howeverwehavelearnedthatTJCitselfisnotthatenamoredwithitsowntool,nordoesitappeartobeusingittodifferentiateaccreditationstatus.Thetotalnumberoffindings,thenumberofCOP’soutandrepeatfindingsseemtobegreaterinfluencers.NottoMiss–NewAPRRequiresYouNotifyTJCifYouLoseDeeming:PerspectivesalsoannouncesanewAPR01.03.01,EP2thattakes place effective July 1, 2018. Many readers mayremembertheWallStreetJournalarticlelastyearcriticalofTJCforcontinuingtoshoworganizationswheredeemedstatus has been removed as fully accredited and out ofsynchwithwhatCMSisshowing.PartofthatdisparitywasTJCnothearingfromCMSwhentheymakethesedecisions.Well,thisnewAPRwilltakecareofthis.AsofJuly1,ifyouhaveaCMSsurveyandCMStemporarilyremovesdeemedstatus, requiring clearance by the state agency youwillhave tonotify TJC. The EP states thatwhen you receivesuch notice fromCMS youmust immediately notifyTJC.The term immediately is not defined, but it is yourbestinteresttodoitthatsameday.TJCindicatesthatitwillnotperformroutineresurveysifyourdeemedstatushasbeenremoved.CMSintheirmemoQSO18-12issuedJanuary12,
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2018 stated that: “No accreditation decisions orrecommendationsmade by an AO based on a Medicareaccreditation survey conducted while a supplier orprovider is under state agency jurisdiction will beacceptedbyCMS.” If theJointCommissiondoesnothearaboutthisdeemedstatusremovalandthesurveyorsshowupatyourdoor,andthenhearaboutit,youwillbechargedforthesurvey,butitwillnotbecompleted.Iftheyconductthesurveybecauseyoudidnotinformthem,itsoundslikeCMSwillnot accept the results and youwill have to gothroughanother surveyafterdeemedstatus is returned.TheJointCommissionasks thatyounotifyyourAccountExecutive via email should you receive this notice fromCMS.Wewouldsuggestthatyoukeepacopyofyouremailreadilyavailableintheeventasurveygetsscheduledandthereisanypotentialdisputeaboutbilling.Action Item: Exacting CompetencyRequirements forUSP797Listed:Theothermajornewsthismonth is the columnentitledConsistent Interpretation. This column reinforces thewarningwehavebeenprovidingaboutJointCommissionapplying the exacting details of USP Chapter 797 in thesurveyprocesseven though therearenonewstandardsthat say this. In this article TJC provides 3 detailedexamples of competency validation requirementsrequiredforsterilecompounding.The first example is competencies required of staff thatwill perform sterile compounding. In this example thehospital required a didactic test but did not establish apassing score for that test. TJC states the organizationmust identifyapassingscoreonsuchatest. Inaddition,there must be an observational component to thecompetency for sterile compoundingwhichwill includeproper adherence to hand washing and garbing. Theremustalsobeanoutcomecompetency,inthiscaseamediafill test and gloved fingertip sampling. Lastly, staff whoprepare hazardous sterile compounds must have anadditional competency assessment verifying compliancewiththoseprocessesforself-protection.
Thesecondcompetencyissuedescribedisinteresting.Thestandard is HR.01.06.01, EP 3 that requires staff to bedeemed competent by someone with the educationalbackground, experience and knowledge related to theskillsbeingassessed. Inthiscase,theydescribethestaffassignedtocleanthesterilenon-hazardousorhazardousmedication compounding area. Joint Commission pointsout that the evaluator for this competencymust be thecompoundingsupervisor,nottheEVSmanager.The third example TJC discusses is that staff who willpreparesterilecompoundsmustbeassessedascompetentbeforetheymayprepareanysterileproducts forpatientuse.Specifically,TJCstatesthattheymustpassthe:• didacticexam• visualobservationofhandhygiene• visualobservationofgarbinganduseofPPE• mediafilltest• glovedfingertiptestingX3• and it prepares hazardous sterile compounds
additionalcompetenciesforthatfunction.Themostimportanttakeawayfromthisistoknowandbeprepared for a thorough evaluation of USPChapter797next time TJC arrives at your door. Your pharmacydirectors should undertake a thorough review of allrequirements in USP Chapter 797 and self-assess toidentifyareaswhichmayneedimprovementpriortoyournext survey.Wewouldencourage readers toobtainanduse either the Medication Compounding Certificationstandards or the Home Care Medication Compoundingchapter.ThesetoolsprovidemoreuseableEPleveldetailoftherequirementsinUSPChapter797thatarescatteredthroughoutalongnarrativedocument.Changes to Ligature Scoringand anOSHAReportingRequirement:There are also 4 simple announcements in Perspectivesthismonth.Thefirstisthatligaturehazardswillnolongerbe scored against the physical environment but insteadagainstthepatient’srightsCOP.ThesecondisareminderthatOSHAisexpectingyourcalendaryear2017employeeinjuryreportstobeelectronicallysubmittedbyJuly1thisyear.Nextyeartheduedateforthe2018reportswillbeMarch2,2019.
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PediatricHospitalstoGetExperiencedSpecializedTJCTeams:TJC also announced that pediatric hospitals will haveexperiencedpediatricphysiciansandnursesassigned tothe survey. We assume this is welcome news to thesehospitalstohavesurveyorsmorefamiliarwiththeuniqueservices and needs of pediatric patients. In addition,general hospitals with inpatient pediatric services willhave these specialized surveyors assigned providing atleast2ofthefollowingcriteriaaremet:1. ThehospitalhasaseparateEDforpediatricsstaffby
pediatricpractitioners2. ThehospitalhasalevelIIIorIVneonatalICU3. ThehospitalhasanADCininpatientpediatricsof6or
moreIntracycleMonitoring(ICM)CallsSuspendedbyTJC:Lastly,TJCannouncedtheyaresuspendingtheirICMcallsformostorganizationsatthistime.Wedon’tbelievetherewillbemuchpushbackintheindustryasthesecallswereperceived by some as more burdensome rather thanenlightening.ThereisasmallsubsetofhospitalsthatwereinPDA02statusthatwillhavetocontinuewiththecallsfornow.ActiveShooter:Whilethisisnotasubjectanyofuswouldliketofocuson,itisbecomingarecurringeventintoomanylocations.Thelead article in this month’s edition discusses an activeshooter eventat a hospital andprovides their advice tohelp you prepare. There is also an extensive list ofresources you can reference as you conduct yourpreparation. These references include the JointCommission’s emergency management resources page,which has resources beyond just the active shootersituation.ThesearehighlightedinECNewsinthearticlefollowing the one on active shooter. This particularhospitallearnedthattheircodesilveralertwasnotclearenoughanduniversallyunderstoodsotheyhavedecidedto abandon that term and just use the plain language:“active shooter/violence with weapon.” They also
identifiedthattheyhadtheabilitytolockdownunits,butitrequiredaninterventionbysecuritystaffwhomaynotbe immediately available. They have now added amechanismfornursingstaffandmanagersontheunittomanuallylockthosedoors.Suggestions for Sprinkler Pipe – Avoid CommonFindings:There is also an article detailed EP level scoring forLS.02.01.35 which was scored noncompliant in 86% ofsurveys in 2017. As anticipated, the number 1 mostfrequently scored EP is the one about extraneousmaterialsbeing tiedtoor touching sprinklerpipeabovethe ceiling. This is a chronic issue for hospitals withcontractors and vendors running IT cable, where theyconveniently tie it to the sprinkler pipe. Far too oftenhospitalsfixthatareacitedbyTJCduringsurveybutdon’texpandbeyondthatlocationtofindoutotherareasofthehospital with the same problem. You really need a 2-prongedstrategy,thefirsttopreventthecreationofnewproblems by having an inspection process above theceiling after each vendor completes their work. Thesecond is a long-term inspection and correctionprocessforallareasofthehospital,tolearnhowmanyofthesameflawyouhaveandgetthemfixed.ActionItem–EnsureyouhaveaContinuityofOperationsPlan:Joint Commission published a new issue of their QuickSafety Newsletter this past month on emergencymanagementand the continuityofoperationsplan.ThiswasanewEMrequirementaddedforCMSinEM.02.01.01,EP12thatwehaveseenscorednoncompliantintoomanyhospitals thus far in 2018. It would appear that manyorganizationsdidnotwritethisplanorperhapsdidnotknowwhattowriteinthisplan.TheterminologyCMSusedsounds too similar to the emergency operations planhospitalsalreadyhad,butonecomponentofthecontinuity
Quick Safety
EC NEWS
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PATTON HEALTHCARE CONSULTING NEWSLETTER – JUNE 2018
ofoperationsplanthatwasnotasdetailed intheEOPissuccessionplanningforkeyleaders.Thereshouldalsobedelegationofauthoritytothosesuccessorssothattheyareauthorizedtocarryoutessentialfunctionsforthehospital.This issueofQuickSafety isagood tool touse to createyourcontinuityofoperationsplan ifyoudidnotwrite itlastfall.
TherewerenonewQSOmemosissuedtothehospitalindustrythispastmonth.
CMS Update
Consultant corner DearReaders,Wewishyouallawonderfulandsafesummer!Thank you, Jennifer Cowel, RN, MHSA [email protected] Kurt Patton, MS, RPh [email protected] John Rosing, MHA [email protected] Mary Cesare-Murphy, PhD [email protected]
