Online Evaluation, Self-Assessment and CE Credits3.proce.com/res/pdf/Quorum2017AprHandout.pdfnewsletter. Compare with the more subjective PC standards regarding the quality of a history

Joint Commission Update 2017Quorum Health Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1

2017 Pharmacy Education Series

April 27, 2017Joint Commission Update 2017

Featured Speaker:

Kurt A. Patton, MS, RPhPresident EmeritusPatton Healthcare Consulting, LLC

Providing Continuing Education For Healthcare Professionals

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Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar

Go to www.ProCE.com/QuorumRx

Webinar attendees will also receive an email with a direct link to the web page

Print your CE statement of completion online

– Credit for live or enduring (not both)

Deadline: May 26, 2017

CPE Monitor (applicable to pharmacists)

– CE credit automatically uploaded to NABP/CPE Monitor upon completion of post‐test and evaluation (user must complete the “claim credit” step)

Online Evaluation, Self-Assessmentand CE Credit

Attendance Code

Code will be provided at the end of today’s activity



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Robert Fink, Pharm.D., MBA, FACHE, FASHP, BCNSP, BCPS

VP – Ancillary Services & Chief Pharmacy Executive

QUORUM Health

Update on Current Pharmacy Initiatives and Strategies

April 27, 2017Joint Commission Update 2017

Featured Speaker:

Kurt A. Patton, MS, RPhPresident EmeritusPatton Healthcare Consulting, LLC

Providing Continuing Education For Healthcare Professionals

It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Mr. Patton has served as a consultant for Patton Healthcare Consulting.

Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature. 6



CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist)

– 2.0 contact hours

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Funding:This activity is self‐funded through Quorum Health.

Joint Commission Update 2017

Kurt A Patton

Patton Healthcare Consulting, Inc.

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New TJC Scoring System

All surveys beginning 1/1/17 now use a new risk assessment methodology to score standards. No A or C elements, no direct or indirect

Two variables will be considered. How wide spread is the defect? How critical, how important is the defect?

Examples: 1 paper medical record entry missing a time. All endoscopes improperly processed

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Project RefreshOnsite SAFER Matrix

Survey Analysis for Evaluating Risk (SAFER)Matrix

Help you prioritize

Visual – on report

Can sort & filter

Scope10



How Will Surveyors Assign Risk

Surveyor experience and expertise based on “scope” and “likelihood to harm”

Talking amongst the team

Impact of risk assignment: Guldens mustard color and red will require coaching session with TJC leadership and additional content on leadership involvement and sustainability in ESC.

As of 3/20/17 26% of findings are red or dark mustard color.

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What Might Be Red in Medication Management? The most difficult and complex medication issue on

surveys today - improper medication titration in the ICU setting.

Nurses practicing outside the scope of licensure

Protocols not in the chart or not referenced

Incremental dose missing from the order

Assessment criteria missing from the order

Failure to assess

How and where this gets scored is very diverse so this does not show in stats published by TJC.

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Why Do Surveyors Like to Score the MM Chapter?

It’s objective: you did it or you did not.

TJC shares lots of medication safety information with surveyors including the ISMP newsletter.

Compare with the more subjective PC standards regarding the quality of a history and physical or the accuracy of a pre-sedation assessment.

TJC does not perform peer review.

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The Most Problematic MM Standard Today

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MM.04.01.01 – Seems Easy, But it is Not and it may be Red

The most problematic standard today.

The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use.

This includes, PRN, standing orders, titration orders, taper orders, range orders, etc.

Hospitals did not specify enough order details so TJC has posted an FAQ with the minimum requirements.

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Titration Order Minimum Elements

Medication name

Medication route

Initial or starting rate of infusion

Incremental rate the infusion can be increased or decreased

Frequency of rate adjustments

Maximum rate of infusion

Objective clinical endpoint, RASS, BP, etc.

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Sedation Titration Example

Propofol 5-50 mcg/kg/min, start at 5 mcg and increase by 5 mcg every 5 minutes to a maximum dose of 50 mcg/kg/min to achieve a RASS of -3.

If this is in a structured order set in an EMR or a paper order form, practitioners don’t need to remember all the required order details.

If you allow ad hoc EMR or paper orders you are likely to have many gaps requiring clarification.

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Sedation Titration Pitfalls

The order is written well, but the hospital policy is to document a RASS every 2 or 4 hours.

You will not have documentation that an adjustment was needed.

You will not have documentation that the adjustment reached the therapeutic endpoint.

You need an assessment of RASS to adjust the dose, and you need a reassessment of RASS after that adjustment.

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More Sedation Titration Pitfalls

If the order is written well, and the nurses are diligent about documenting RASS But the patient has a head injury creating a level of

sedation greater than the RASS goal… The patient has pain and nursing staff want to

adjust propofol. The patient is on a paralytic The patient has a second drip, e.g., fentanyl or

Versed The staff are having difficulty maintaining a systolic

BP The patient is having ventilator asynchrony

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Sedation Titration Solutions

Use a structured order set, not a secondary document as a reference with the order details.

Modify the RASS target or therapeutic endpoint for head injury patients.

Discuss patient management with the ICU nurses and physicians to document how to manage SBP, ventilator asynchrony, pain, use of paralytics.

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Sedation Titration Survey Follow up

Simple RFI, document in ESC how you fixed it and sound convincing, easy.

If survey outcome is AFS, PDA or MM Medicare condition out, document in ESC how you fixed it and sound convincing, but TJC surveyors are coming back to validate and you must be 100% compliant, all titrations all charts - and this is hugely different.

MM Condition out less than 45 days

PDA you have about 60 days

AFS you have about 4 months to make it perfect.

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Sedation Titration, Real Example of Survey Disaster Full survey, hospital cited for improperly written

and documented sedation titrations.

Survey outcome AFS

ESC submitted said a titration protocol was prepared for nursing staff with instructions on how to titrate sedating agents.

AFS follow up survey conducted, nursing staff interviewed and replied: “we just use our clinical judgment.”

Accreditation status changed to PDA, hospital now decides to develop detailed order sets in EMR.

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Other Frequently Scored MM Standards

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MM.01.01.03 High Alert

EP 1: The hospital identifies in writing its high alert and hazardous medications.

The hazardous list is often missing. TJC does not mean dangerous, they mean hazardous just like NIOSH.

This was moved from EC to MM a decade ago and still often missing.

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MM.01.02.01 LASA

EP 3: The hospital annually reviews its list of LASA medications. Date the list? You incentivize the surveyor to drill

down if your list is undated. Need to find reauthorization in minutes. You get no credit if its 2 years old.

Staff on the units need to be able to find the list. Write your enhanced safety strategies describing

what you do and where you do it. If hospital practices vary, mention it, e.g. these strategies occur in the pharmacy itself, while these are required for nursing, etc.

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Frequently Scored, but Much Easier to Manage MM.03.01.01 – Medication storage temperatures Paper logs – gaps and failure to act on out of range

conditions is the problem Automated data loggers – failure to document

actions taken is the problem Failure to document what happened over the

weekend in a 5 day/week clinic Failure to document vaccine storage per CDC Data loggers required, no dorm refrigerators.

Failure to track or document fluid and contrast warmer storage conditions and shortened expiration dating.

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MM.03.01.01 Medication Security

Non controlled drugs can be secured by supervision or locking Your hospital sets the standard for non-

controlled drug security. You identify those authorized. If you say licensed professionals only, TJC

holds you to that. No materials management or central

sterile supply delivery of IV fluids No unlocked storage in a clean utility

room on the floor

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MM.03.01.01 Medication Security

If you say the area is secure, but the surveyor walks in and there are no staff around…

If you say the OR is secure, but the surveyor walks in and only the housekeeper is present cleaning up after a case and there are medications present….

Crash carts in areas not open 24/7 and supervised must be placed in locked storage when closed.

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MM.03.01.01 Medication Security –New Spin 2017

Pharmaceutical waste and sharps bins in non-secure locations like a dirty utility room, or in a pick up cart in the hallway, or on the back loading dock, and even in the OR with the housekeeper.

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MM.03.01.01 Medication Expiration

EP 7: All meds are labeled with contents and an expiration date. MDV – not a date opened, an expiration date Short stability meds like propofol need a time of

expiration even from anesthesia Warmers – not a date placed, an expiration

date Remember the One and Only campaign: If a

MDV has been brought into a procedure room is becomes an SDV and any residual is discarded after the procedure.

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MM.03.01.03 Emergency Medications

EP 3: Whenever possible, emergency medications are available in unit-dose, age specific, and ready to administer form. Magnesium sulfate is often stocked 1G/2 ml Broselow tape for 3-4 Kg infants calls for doses

150mg, 225 mg Can staff in a crisis situation easily calculate

the volume of magnesium sulfate to administer? Test your own ED staff, but consider a volume

table as an aide.

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MM.04.01.01 Medication Orders

EP 13: The hospital implements its policies for medication orders.

A PRN without indication

An unclear order not clarified

A range order not adherent to your policy

TJC does not prohibit range orders, but it would be easier if they did. Consistency in application is the problem.

Go and interview 10 nurses and check the documentation in the record

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MM.04.01.01 Minutiae and Gotcha’s EP 7: The hospital reviews and updates preprinted

order sheets… EP 15: Processes for the use of preprinted and

electronic standing orders, order sets and protocols include: 4 bullet points that only reference standing orders and protocols. Regular review by medical, nursing, pharmacy

leadership. CMS tag A-0457 is clearer that basic order sets do

not require this 3 department approval. However EP 7 above does call for the hospital to be

involved in approval.

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Ambiguous Definitions

Suggestion:

Order sets – basic preprinted or electronic orders that a physician will make selections from individually or in its entirety.

Standing order – an order that authorizes a nurse to administer a medication prior to a physician actually writing that order.

Protocol – details about medication dosing or administration not included in the body of the order.

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MM.05.01.01 Pharmacist Review of Orders EP 1: Pharmacist reviews the new order prior to

administration, unless LIP control. Exemptions: ED, radiology if radiologist is present

to intervene and urgent situations anywhere in the hospital. What do you do in PACU and outpatient clinics?

EP 8: Pharmacist reviews for therapeutic duplication. *** Duplicative PRN analgesics, antiemetic's Advice: stratify your order sets Analyze your interventions; ID root cause and fix

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MM.05.01.01 EP 8 Complication The order is written well with all the details such as

Tylenol for mild pain, Percocet for moderate pain and Dilaudid for severe pain.

The patient with a pain of 9 requests Percocet instead of Dilaudid because they don’t want….

New FAQ, you can do it if approved in policy

The patient with a pain of 3 requests Dilaudidbecause they just saw the physical therapist walk down the hallway and they know their pain will spike during therapy.

You can’t do it

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MM.05.01.07 IV Preparation

TJC hospital surveyors are not expert in all things relative to USP 797.

Over time they may gain knowledge from their colleagues performing the new Medication Compounding certification or these standards.

They are very familiar with specialized air pressures and may carry a vaneometer.

If you have wall meters, be ready and able to discuss what those meters are measuring.

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MM.05.01.07 IV Preparation EP 2: Staff use clean or sterile techniques and

maintain clean, uncluttered, and functionally separate areas for product preparation to avoid contamination.

Surveyors readily ID filth, clutter and too close a proximity to sinks in medication rooms.

Sometimes pill crushers and tablet splitters are the problem.

Make these patient specific with patient labels

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MM.06.01.03 Self Administration

Seldom scored, except in the sleep lab. Policies are often well written for the inpatient

units describing pharmacist verification of the patients own medication and a specific physician order to self administer or use own medication. Sleep labs routinely advise patients to bring

their medications and to self administer before going to bed.

Suggestion: Define your policy for inpatients only.

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MM.07.01.03 Errors and ADR’s

Often a topic of discussion at the MM System Tracer.

Bring your data

Describe your actions in response

Describe your actions to increase ADR reporting

Only scored if there is failure to act, failure to analyze, failure to try and enhance ADR reporting.

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MM.08.01.01 PI FOR MM

7 Elements of performance stating you collect information, you analyze it, you compare over time, you review best practices in the literature and you take action.

Consider an annual report addressing each of these elements.

You may be able to scramble and piece it together, but prepared is always better.

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MM.09.01.01 Antibiotic Stewardship

Nicely written new set of requirements, 1 standard, 8 elements of performance.

Consistent with CDC and NQF guidance

Survey process design is about the best seen for any new requirements.

ASP designed to be explored in 6 different survey sessions. Patient tracers, competence assessment session, medical staff, data management system tracer, MM system tracer, leadership

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ASP EP 1

Leadership has identified ASP as an organizational priority.

Accountability documents

Budget plans

IC plans

PI plans

Strategic plans

EMR used to collect ASP data

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ASP EP 2

The hospital educates staff, and LIP’s involved in ordering, dispensing, administration and monitoring about antimicrobial resistance and ASP practices. Upon hire and “periodically”.

You are going to want some evidence this was done, even though this is not a D element.

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ASP EP 3 The hospital educates patients and their families as

needed, regarding appropriate use of antimicrobials.

TJC suggests CDC document: http:www.cdc.gov/getsmart/healthcare/index.html

Suggest using EMR patient teaching logs even though there is no D.

Surveyors may interview patients or families of patients being discharged on antibiotics.

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ASP EP 4

The hospital has an ASP team that includes:

ID physician

ICP

Pharmacist

Practitioner

Part time, consultants and telehealth are all acceptable.

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ASP EP 5 The ASP includes core elements:(same as CDC) Leadership commitment Accountability (single leader) Drug expertise Action Tracking Reporting Education

What are you going to show to TJC to convince them you have all these elements? D for documentation This document is requirement #49 in Day one

document list.

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ASP EP 6 The hospitals ASP uses organization approved

multidisciplinary protocols. Examples: Formulary restrictions Community acquired pneumonia Skin and soft tissue infections UTI infections C. diff care Appropriate use in pediatrics Parenteral to oral conversion Preauthorization Use of prophylaxis

D for documentation – be ready to discuss and show at MM system tracer session

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ASP EP 7

The hospital collects, analyzes and reports data on its ASP.

D for documentation

Be prepared to discuss and show at the data use system tracer and potentially MM system tracer.

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ASP EP 8

The hospital takes action on improvement opportunities identified in its ASP.

Be careful how you word minutes of meetings, don’t point fingers.

Get it done, don’t whine

Be ready to discuss accomplishments in MM system tracer.

Provide leadership some bullet points in the event this is asked at the leadership session.

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ASP Conclusion Meticulously written requirements, consistent with

other expert groups.

Superb survey process written for surveyors for these new standards.

So far in 2017, not seeing scoring on this issue.

May be due to surveyor training, may be due to newness

Be prepared to pro-actively discuss if you have accomplishments at MM, Data.

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NPSG.03

Label medications in procedural settings. The OR usually does this well Surveyors look in outpatient procedural settings, bedside

procedures and ED procedures. No one can be compliant if you don’t give them the

tools to be compliant – sterile labels in procedure kits.

Try to convince anesthesia that even propofol needs a label. Try to convince radiology that contrast and saline in a

power injector needs a label. PS – the saline is single dose, the contrast if manufactured,

labeled and used appropriately may be MDV. This safety goals is scored way too often and it will be red.

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NPSG.03

Anticoagulation safety goal, seldom scored today. Sometimes EP 2: Use approved protocols for the

initiation and maintenance of anticoagulants. You want to be able to say: “yes we have

protocols and here they are” If the protocol is used by an LIP to aide in

decision making the protocol does not need to be in the chart.

PC.02.01.03 – Top 10, 46% of hospitals getting hit for failure to include the protocol used by a dependent practitioner in the EMR. If the protocol is used by a dependent practitioner, a copy

of the protocol must be in the chart. Not easy to do with most EMR’s

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NPSG.03 Medication reconciliation: Seldom scored today.

Sometimes EP 3: Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies.

Many times staff during a tracer are unable to display the end result of med rec drug by drug.

“I reconciled” button is a problem

Errors of omission are a problem

User security and viewing is a problem

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D for Documentation

The MM chapter has 24 elements of performance identified as D.

Do you really have 24 policy statements addressing all these EP’s?

Remember a written policy is different from “our practice, or usually we..”

If you think you do, congratulations, you will be the first I have encountered.

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Obscure D MM.03.01.01: The hospital has a written policy addressing the

control of medication between receipt by the individual healthcare provider and administration of the medication, including safe storage, handling, security, disposition and return to storage. Can a nurse or respiratory therapist take multiple patient doses out

of an ADC at one time? If they do, where may it be stored until administered? If it is not administered, how can they return it to stock and cancel

the transaction? Can an anesthesiologist carry sedating agents from the OR, down

to MRI to help sedate a patient? How do they carry it? If they inadvertently carry it out of the hospital, can it be returned to

stock? What if it was in their car trunk? What if it is a controlled drug?

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D with an Invisible Component

MM.04.01.01, EP 2: The hospital has a written policy that defines the required elements of a complete medication order.

You probably have this one, but…

Day one document list #46 says you must make this policy available and include your definition of therapeutic duplication.

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Preparing for the MM System Tracer

Plan for a conference room, but the surveyor may surprise you and want to go trace a patient with you. Come prepared and bring that which is good

about your practices and be prepared to discuss. Take the initiative. Come prepared to discuss, defend, prevent

potential findings you have heard about from the morning briefings. Everyone invited should come prepared,

knowing what they are invited to talk about.

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Examples for the MM System Tracer If ASP is significant, do show and tell

If you did an annual report for MM.08…

Bring your medication error data and be sure to include good catches that never reach the patient.

Bring your ADR data

Bring your interventions data

Coach and rehearse what to say with your planned attendees

TJC looks to you for MM leadership throughout the hospital, not just within the 4 walls of the pharmacy.

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Questions?

[email protected]

To review past monthly newsletters, or to subscribe go to:

www.Pattonhc.com

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Documents

Online Evaluation, Self-Assessment and CE Credits3.proce.com/res/pdf/Quorum2017AprHandout.pdfnewsletter. Compare with the more subjective PC standards regarding the quality of a history