Posted October 3, 2008 10:33 PM
by Lisa Eddy, RN,CPHQ
Related Categories:
National Patient Safety Goals
In the 2008 (March 2008) FAQ regarding NPSG 3C managing Look Alike, Sound Alike medications. The FAQ requires that error (interchange error) prevention stragegies should occur at all phases of medication management. This would include procurement, storage, transcribing, ordering, dispensing and administration. The FAQ continues to say that in addition to interchange error protection, prevention methods should include differing strengths of drugs. Therefore, staff involved at all levels of medication management processes should know the error prevention stragegies put into place to protect against interchange and dosing errors. Previously, many organizations focused on the Pharmacy and the site of administration only. Now organizations are to expand their scope to assure prevention strategies are implemented at each step of the medication management processes.
Posted September 29, 2008 12:04 PM
by Lisa Eddy, RN,CPHQ
Related Categories:
Regulatory Readiness
Good News!! A new accrediting body joins The Joint Commission and the American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP) in accrediting healthcare organizations for participation in the Medicare and Medicaid programs. Det Norske Veritas Healthcare, Inc., (known as DNV) has been granted, deemed status by CMS, and presents as another approved accreditation alternative. DNV’s accreditation program is called the National Integrated Accreditation for Healthcare Organizations (NIAHO).
The accreditation program is so named because it integrates the International Organization for Standardization 9001 quality management system standards (which originated in the manufacturing arena, however, now expand to multiple industries), with the CMS Conditions of Participation. DNV accredits annually and allows for organizations to become ISO 9001 compliant over time. Because the DNV accreditation program so closely incorporates the Conditions of Participation into their accreditation process, there is the anticipation that there will be less disparity and perhaps less duality of purpose in meeting the DNV standards.
DNV is focused on quality and will place the same focus on leadership as CMS (meaning, we know CMS looks intently on the role of the Governing Body, and leadership in quality assessment and performance improvement.) And DNV will visit annually, not with the intention to remove the accreditation status of the organization, but to help the organization meet its predetermined quality goals and to move the organization to ISO 9001 compliance.
Bottom Line: Healthcare organizations have another alternative to an effective accreditation pathway. However, understand there is no requirement for DNV accreditation, just as participation in the TJC and HFAP accreditation programs is voluntary, so is participation in the DNV program. This new option does however, give your organization more ability to choose an accrediting body that may more closely fit the needs and desires of your facility. Visit the DNV’s website to review this option for yourself: National Integrated Accreditation for Healthcare Organizations - NIAHO
Posted September 25, 2008 12:24 AM
by Lisa Eddy, RN,CPHQ
Related Categories:
Provision of Care, Treatment and Services
In reviewing the 2009 Provision of Care chapter from TJC I stumbled across another change that (according to information obtained at Executive Briefings "isn't a change".) Under PC standard 03.01.03 EP 8 the "hospital" is required to reevaluate the patient immediately before administering sedation or anesthesia. Frankly, I don't see how a building can assess a patient, but semantics aren't everything. With this new wording, the anesthesia provider is clearly not required to be the individual conducting the immediate reevaluation. Which means the nurse can take the patient's vital signs and conduct a brief assessment and document this appropriately as the immediate reassessment. While most organizations have imbedded the anesthesia provider's immediate reassessment into their procedure forms, if your organization is having difficulty with compliance by your anesthesia providers, you may want to reconsider how the immediate assessment process really works in your facility and make changes as appropriate. Stay tunned, as we continue to drill down into the 2009 standards, there are bound to be more changes coming our way.
Posted September 21, 2008 11:49 PM
by Lisa Eddy, RN,CPHQ
Related Categories:
2009 TJC Standard Changes
At the September 19, 2008 Executive Briefings hosted in Los Angeles, California, presented by The Joint Commission, Dr. Angood discussed the increased requirements for the Universal Protocol. Particular attention was paid to the 2009 requirement calling for the UP to be applied to all procedures that involved percutaneous puncture or insertion, opposed to the previous wording which essentially invoked the UP for procedures that placed the patient at risk. Dr. Angood cited with finality, that insertion of a urinary cathether would not call the UP into action (which has been a general understanding since the 2009 goals were published this summer), however, when asked if hospitals would be able to perform a risk assessment and "opt out" of the UP for minor procedures such as lumbar puncture, Dr. Angood stated this concept (anything involving percutaneous puncture/insertion versus "at risk" procedures) would be clarified in upcoming FAQs about the UP. Dr. Angood also stated that simple angiocatheter insertion for IV antibiotics would not call the UP into action, however currently almost every other type of invasive procedure may. There was information provided in handouts at the LA Executive Briefings that the UP would apply to "all invasive and surgical procedures with more than mnimal risk to patients," which of course differs from the 2009 wording of when the requirements come into play. So, the healthcare public are to keep their collective eyes on the FAQs awaiting more definition from UP revision. Dr. Angood gave his committment to "make every attempt" to release FAQs for the NPSGs with the same frequency FAQs are addressed and released for other program standards.
Dr. Angood also stated that whenever there will be more than one procedure performed, the UP is called into action for each procedure. This means the UP process is conducted for a patient undergoing a C-Section, once for the spinal and again for the C-Section itself.
What to do in the meantime? Do what makes good clinical sense. Should the nurse stop and make sure she has an order to insert an angiocath for IV fluids in the correct patient using 2 patient identifiers? Yes. Should she go through all elements of the UP? No, most of the components don't apply.
On another note, Angood indicated the efforts undertaken by organizations to comply with the UP since its inception haven't really proven that effective, with a fairly high number of wrong site surgeries continuing to be reported to the Joint Commission. While it has been said that the definition of insanity is repeating the same thing expecting different results (thus the question, if the UP hasn't been working, why are we adding more steps to a process that may be broken?) we encourage our clients to look at their procedural processes in light of the requirements of the UP, and determine if there are other issues which may assist in preventing wrong site/patient surgeries. We support the concept of a procedural pause and suspension of activities to ascertain and assure the correct patient and procedure are matched. However, applying all of the UP requirements to every procedure that requires a percutaneous puncture or insertion may not prove fruitful in reducing and eliminating wrong site/patient surgery.
Posted September 19, 2008 11:27 AM
by WendySue Woods, RN, MHSA
Related Categories:
2009 TJC Standard Changes
As the Joint Commission continues to make the needed changes before 2009, 4th quarter PPR's will be affected. The PPR tool will not be available on-line from December 1, 2008 to January 1, 2009. This will allow the Joint Commission time to "load" the new standards and EP's.
As a result of these changes here is the new schedule:
- Organizations with PPR due dates from October 1, 2008 through December 31, 2008 are not required to submit a 2008 PPR.
- Organizations that wish to document Plans of Action for requirements for improvement (Full PPR or post-survey Option 2 PPR) must submit the 2008 PPR by Sunday, November 30, 2008 at 11? p.m. Central Time.
When the PPR is back up and loaded, the following program will need to repopulate the Open PPR:
- ambulatory care
- critical access hospital
- home care
- hospital
- office-based surgery
In addition:
- PPR Option 2 and 3 surveys will not be scheduled in November or December 2008. PPR Option 2 or 3 surveys scheduled for 2009 will be conducted using the 2009 standards.
For organizations with PPR due dates in January, February, or March 2009, the "Begin Submission" link will not be activated in the Open PPR during the fourth quarter of 2008; it will become available on January 1, 2009.
For more information go to the Joint Commission's website at: http://www.jointcommission.org/Library/jconline/jconline_sept_2008.htm or contact your Greeley Company's Center for Healthcare Accreditation Advisor.
Posted September 17, 2008 5:54 AM
by Bud Pate, REHS
Related Categories:
Medication Management,Provision of Care, Treatment and Services,Environment of Care
Some surveyors have recently discovered EC.6.20 (preventive maintenance) as a way of citing occasional missed crash cart checks. You see, surveyors don't know what to do when they come across a crash cart logs with a missing entry or two. There is no standard that directly pertains to this issue (in other words, the Joint Commission does not require crash cart checks). The standards require the placement of emergency medications and equipment, but they do not specifically require that this equipment be checked ... ever. Yet we all know (including surveyors) that these checks are very important. We've learned that having the complete and functional crash carts is essential. So we certainly don't mind when the surveyors look for this.
However, because there's no specific standards related to this, surveyors have begun citing the equipment maintenance standard (EC.6.20, EP.3). This EP requires preventive maintenance for life saving / sustaining equipment and, as a category A element of performance, does not allow for a single missed inspection. Depending on the defibrillator, these PM checks only need to be done every 3 to 9 months. Some surveyors, however, have applied this EP to the routine (daily or each shift) crash cart check.
We had one client with over 98% compliance with crash cart checks. But because the issue was cited at EC.6.20, that was not good enough. The RFI held up even after clarificaiton. We believe that the main reason this RFI did not go away is that the equipment management program documents were unclear and non-specific.
We recommend that your equipment maintenance plan (based on your risk assessment) be clear that the daily crash cart checks are not part of the program. We also recommend that the crash cart testing policy be equally clear: the routine checks are merely to verify that a functioning defibrillator is present and that they are not considered part of your equipment management program. This will give you the ammunition you need in case a surveyor chooses to take infrequent blanks on a crash cart log sheet and make it into an RFI. (98% is achievable ... with over 30 years in the business I've concluded that 100% is impossible.)
