Joint Commission Update Forum 2017 - Schedschd.ws/.../28/Joint_Commission_Update_Forum_2017.pdf · Members may be removed by automatic suspension, summary suspension or termination

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Joint Commission Update

CAMSS State Association ConferenceJune 1, 2017

Client name/ Presentation Name/ 12pt - 2

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Objectives

Identify updates and changes to the survey process

Indicate common standards that could impact the Medical Staff

Provide examples of compliance for common findings on survey


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SAFER Matrix


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SAFER Matrix


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SAFER Matrix


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SAFER Matrix


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Top Three Challenging Medical Staff StandardsMS. 01.01.01, Medical Staff BylawsMS.08.01.01, Focused Professional

Practice EvaluationMS.08.01.03, Ongoing Professional

Practice Evaluation


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Medical Staff Bylaws and MS.01.01.01MS.01.01.01 - Medical staff bylaws

address self-governance and accountability to the governing body. (37 Elements of Performance)

Medical Staff Bylaws must address all Elements of Performance 12 - 36


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MS.01.01.01, EPs 12 - 36

Review the Bylaws for each EP 12 – 36 of standard MS.01.01.01

Each element must be included in the bylaws although the detail may be contained in another document (Example: Credentialing Manual)

Any missing element must be scored at that EP plus EP 3

Do the Bylaws describe a Structure (12) for the Medical Staff?


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MS.01.01.01, EPs 12 - 36

Membership on the Medical Staff is defined by Qualifications to be a member (13) A process described to delineate privileges and

renewal of privileges (14) Members are assigned to categories of the medical

staff with defined duties and privileges (15) Members that may vote are defined (17) A process described to credential and recredential

membership on the medical staff (26) A process described to appoint and reappoint (27)


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MS.01.01.01, EPs 12 - 36

Members may be removed by automatic suspension, summary suspension or termination or reduction of privileges

Indications are described for automatic (28), summary (29) and termination/reduction (30) of privileges

A process is described for automatic (31), summary (32) and termination/reduction (33) of privileges


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MS.01.01.01, EPs 12 - 36

Members have a right to appeal decisions through a fair hearing

The process to schedule (34) and conduct (34) a fair hearing is described

The composition of the fair hearing committee is described (35)

Full descriptions may be contained in a Fair Hearing and Appeal Manual


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MS.01.01.01, EPs 12 - 36

Officers of the Medical Staff Are listed in the Bylaws (19) A process is described to select and

remove officers (18)


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MS.01.01.01, EPs 12 - 36

Medical Executive Committee Function and Size is described (20) Selection and removal of members is described (21) Composition including MDs and others is described

(22) MEC authority is described and when MEC acts for

the Medical Staff (23) Conflict Resolution: MEC and the Medical Staff (20)


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MS.01.01.01, EPs 12 - 36

Bylaws—process to adopt and amend (24) Rules and Regulations and Policies—process to

adopt and amend (25) When Departments exist the bylaws contain the

qualifications for Chairs and their roles and responsibilities (36)

The bylaws describe basic requirements for H&P, practitioners that may perform the H&P and update requirements (16)


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MS.08.01.01, FPPE (4 of 9 EPs)

EP 1: A period of FPPE is implemented for all initially requested privileges

EP 3: The performance monitoring process is clearly defined and includes each of the following elements:– Criteria for conducting performance monitoring– Method for establishing a monitoring plan specific

to the requested privilege– Method for determining the duration of

performance monitoring– Circumstances under which monitoring by an

external source is required


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MS.08.01.01, FPPE (4 of 9 EPs)

EP 4: Focused professional practice evaluation is consistently implemented in accordance with the criteria and requirements defined by the medical staff

EP 5: The triggers that indicate the need for performance monitoring are clearly defined


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MS.08.01.01, FPPE (4 of 9 EPs)

EP 1: FPPE requirement for all new applicants with privileges, all existing medical staff requesting new privileges and all for cause indications– Effective January 1, 2008– No exceptions, even if data is difficult to

gather (Advanced Practice Providers)


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MS.08.01.01, FPPE (4 of 9 EPs)

EP 3: the FPPE process is clearly predefined with criteria, monitoring methods, monitoring duration, and circumstances for monitoring by an external source– Activity or time period

– Time period may not allow complete privileges to be utilized

– High volume provider has provided significant patient care before time period ends

– Activity or time period, depending on which is met first


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MS.08.01.01, FPPE (4 of 9 EPs)

EP 4: All aspects of EP 3 are consistently implemented

EP 5: Triggers indicating a need for focused review are clearly defined– A single incident—Perforation– A trend—exceeds a number of validated

patient or staff complaints, exceeds peer use of reversal agents for sedation


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MS.08.01.03 (2 of 3 EPs)

EP 1: There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice

EP 3: Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege (s)


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MS.08.01.03 (2 of 3 EPs)

EP 1: Each practitioner type has a defined process for evaluation

EP 3: OPPE information is used to determine continuation, limitation, or revocation of any existing privilege(s)– Advanced practitioner provider

– Approach to evaluation is different and not defined

– Data lacking to formulate useful objective information for decisions


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The Challenge for These StandardsRelevant information for performance

evaluation of advanced practice providers may not be readily available

Most information is tagged to the attending physician rather than the advanced practice provider


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What Information Can Be Used

Periodic chart reviewDirect observationMonitoring of diagnostic and treatment

techniquesDiscussion with other individuals

involved in the care of each patient including consulting physicians, assistants, and nursing and administrative personnel


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Best Practice

Direct observation and evaluation of a patient encounter

Performed by sponsoring physician or a peer advanced practice provider

Evaluation form used to track observations


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Evaluation Form

Questions about care, treatment and services answered with a Yes, No or Not Applicable

Patient medical record number used to document the specific patient encounter

Medical staff determines how many observations are required


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Examples of Questions

History and Physical appropriate and pertinent?

Progress notes adequate to follow the patient’s course?

Appropriate lab and imaging studies?Appropriate medication ordering?Appropriate and timely consultations?


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Examples of Questions

Medication reconciliation completed?Informed consent obtained?Sterile technique observed?Appropriate participation in the time

out?Overall evaluation for this reporting

period? Satisfactory or Unsatisfactory


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Other Challenging Medical Staff StandardsMS.01.01.01, EP 5: The medical staff complies with

the medical staff bylaws, rules and regulations, and policies

MS.06.01.01, EP 1 and EP 2: Privileges are delineated and approved only after determination the hospital has the required resources

MS.06.01.05, EP 2: Evaluation of all of the following are included in the criteria:– When renewing privileges review of the

practitioner’s performance within the hospital


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MM.09.01.01, Antimicrobial StewardshipCDC: 20% to 50% of antibiotics

prescribed unnecessarily or inappropriately

CDC: annually 2 million illnesses and 23,000 deaths due to antibiotic resistant bacteria in the US


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EP 1: Leadership

Leaders establish antimicrobial stewardship as an organizational priority

Examples-Accountability documents -Budget plans -Infection prevention plans -Performance improvement plans -Strategic plans -Using the electronic health record to collect antimicrobial stewardship data :


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EP 2: Education of Staff and LIPs The [critical access] hospital educates staff and licensed

independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire or granting of initial privileges and periodically thereafter, based on organizational need.

Acceptable materials and methods of education are determined by the organization and should be based on acceptable practice. Examples include: Written materials, presentations, online education, classes, conferences, annual education days, CMEs etc.


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EP 3: Education of patients

The [critical access] hospital educates patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics

o Emergency department patients who are prescribed antimicrobials. o Ambulatory and clinic patients surveyed under the hospital program who are prescribed antimicrobials. o Hospitalized patients who will be discharged on antimicrobials.


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EP 4: Antimicrobial Stewardship Multidisciplinary TeamThe [critical access] hospitals and NCC

has an antimicrobial stewardship multidisciplinary team that includes the following members, when available in the setting:– Infectious disease physician – Infection preventionist(s) – Pharmacist(s) – Practitioner


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EP 5: Core Elements

The [critical access] hospitals antimicrobial stewardship program includes the following core elements– Leadership commitment– Accountability– Drug expertise– Action– Tracking– Reporting– Education


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EP 6: Multidisciplinary Protocols

The [critical access] hospitals and NCC antimicrobial stewardship program uses organization-approved multidisciplinary protocols (for example, policies and procedures)

Based on the population served and the services provided


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EP 6: Examples of Protocols

Antibiotic Formulary Restrictions Assessment of Appropriateness of Antibiotics for Community-Acquired

Pneumonia Assessment of Appropriateness of Antibiotics for Skin and Soft Tissue

Infections Assessment of Appropriateness of Antibiotics for Urinary Tract

Infections Care of the Patient with Clostridium difficile (c.-diff) Guidelines for Antimicrobial Use in Adults − Guidelines for

Antimicrobial Use in Pediatrics Plan for Parenteral to Oral Antibiotic Conversion Preauthorization Requirements for Specific Antimicrobials Use of Prophylactic Antibiotics


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EP 7: Data

The [critical access] hospitals collects, analyzes, and reports data on its antimicrobial stewardship program.

The collection, analysis and reporting on outcomes of the program establishes actual implementation


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EP 8: Action

The [critical access] hospital takes action on improvement opportunities identified in its antimicrobial stewardship program


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Key References

Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs (See http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. Washington, D.C.: NQF, May 2016


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Focus on Reducing Inpatient SuicideFor inpatient psychiatric hospitals,

inpatient psychiatric units in general acute care hospitals, and non-behavioral health units DESIGNATED for the treatment of psychiatric patients (i.e. special rooms/safe rooms in Emergency Departments or Medical Units)


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Environment of Care

EC.02.06.01, Element of Performance 1require hospitals to establish and maintain a

safe, functional environment. Element of Performance # 1 states “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided”. Therefore, ligature and self-harm risks must be identified and eliminated


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Focus on Reducing Inpatient Suicides1200 to 1500 inpatient suicides each

year in the United States70 to 75 percent by hangingLigature risks no longer acceptable in

areas specified for treatment of behavioral health care patients with suicide risk


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Approach to Ligature Risks

Identify all ligature risks in the environmentWhen possible immediately eliminate all

ligature risksWhen immediate removal is not possible--

While risks are in the process of being eliminated, policies and procedures must be developed and implemented to mitigate the harm posed by such risks.


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Mitigation Plans for Ligature Risk

• Ensuring that leadership and staff are aware of the current environmental risks• Identifying patients’ risk for suicide or self-harm, then implement appropriate interventions based upon risk.• Ongoing assessments and reassessments of at-risk behavior as defined by the organization.• Ensuring the proper training of staff to properly identify patients’ level of risk and implement appropriate interventions


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Mitigation Plans for Ligature Risk

• Incorporating suicide risk and self-harm reduction strategies into the overall Quality Assessment/Performance Improvement (QAPI) program - see LD.01.03.01 EP 21.• If equipment poses a risk but is necessary for the safe treatment of psychiatric patients (i.e. medical beds with side rails on a geriatric unit), the organization must consider these risks in patients’ overall suicide/self-harm risk assessments, then implement appropriate interventions to diminish those risks


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Non-Behavioral Health Care UnitsIn non-behavioral health units (i.e.

Emergency Rooms or Medical Inpatient Units) that are NOT DESIGNATED specifically for the treatment of psychiatric patients; however, where psychiatric patients may temporarily reside, ligature/self-harm environmental risks must also be identified.


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Non-Behavioral Health Care UnitsAll physical risks not required for the

treatment of the patient that can be removed, must be removed. Furthermore, an appropriate level of effective surveillance must be implemented if self-harm risks remain in the environment. Organizational policies and procedures must adequately guide staff in the assessment of patients’ risk for suicide/self-harm and the implementation of interventions based upon the patients’ individual needs.


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Resources

Sentinel Event AlertsBooster PacksDesign Guide for the Built Environment

of Behavioral Health Facilities, April 2017, Edition 7.2, James M. Hunt, AIA, NCARB and David M. Sine, DrBE, CSP, ARM, CPHRM


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Orientation of Medical Staff

MS.01.01.01, EP 36: If departments of the medical staff exist, the roles and responsibilities of the department chair, which are defined by the organized medical staff, include the following:– Orientation and continuing education of all

persons in the department or service


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Orientation of the Medical Staff

PC.01.01.01, EP 24:– Provides orientation and training to any

clinical and nonclinical staff in effective and safe care, treatment, and services (for example, medication protocols, de-escalation techniques)


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PC.03.05.17, EP 2– The hospital trains staff on the use of

restraint and seclusion, and assesses their competence, at the following intervals–At orientation–Before participating in the use of

restraint and seclusion–On a periodic basis thereafter


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WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent

EP 1: Responsibility for orientation and training EP 2: LIPs who perform waived testing receive orientation according

to hospital services and documented EP 3: LIPs have been trained for each test and the training is

documented EP 4: LIPs who perform waived testing requiring an instrument have

been trained on its use and maintenance and documented EP 5: Competency is validated by two of four methods per test EP 6: Competence is assessed at least at the time of orientation and

at least annually thereafter, and documented. LIPs may include this in credentialing and privileging if the test falls within the specialty and testing does not involve an instrument (Provider-performed microscopy is not a waived test)


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Continuing Medical Education

MS.12.01.01Continuing education if an adjunct to

maintaining clinical skills and current competence

EP 4: Must be documented by transcript or attestation depending on state

EP 2 and 4: Documentation of restraint education for those who provide restraint and seclusion only

Documents

Joint Commission Update Forum 2017 - Schedschd.ws/.../28/Joint_Commission_Update_Forum_2017.pdf · Members may be removed by automatic suspension, summary suspension or termination