Question of the Month
Each month, The Center for Healthcare Accreditation selects a Question of the Month that is designed to highlight best practices, help organizations deal with common challenges, and encourage professional development. The question of the month requires no login, and allows you to submit questions at a time convenient to you.
If you would like to submit a question on any topic, please email us. Your question will be reviewed by our consulting experts. If you are a member, please contact your senior advisor for immediate response to your question(s). Please note, although the experts will try to answer as many questions as feasible, there is no guarantee that all questions will be answered. Your question may be edited for content.
2008
October
- How often does ongoing professional practice evaluation have to be reported?
The frequency of the evaluations is to be defined by the medical staff. Obviously every two years is too long, and in the 2007 TJC teleconferences and the August 2008 FAQ on the subject, TJC noted that they felt 12 months was too long. So nine months is acceptable, but nine months is a difficult time period to systematically conduct this type of review, it simply doesn't "fall" within a routine time frame, and may be too cumbersome. Therefore six months is probably a good time period to report OPPE. Many credentialing and quality individuals feel obtaining data for this six month period will be difficult. We encourage everyone to think about all of the routine review that is conducted for various reasons. For example the core measure data is available and can be used for OPPE. Routine morbidity and mortality review can provide additional information, as can review for certain studies. Currently many hospitals are focusing on the Hospital Acquired Conditions and are reviewing those elements for which CMS will not provide reimbursement. If there is any physician related care involved in the outcome, this may be another source of data. And let's not forget positive data. When outcomes improve, when complication rates decrease or there are zero mortalities, this type of data can also be reported.
September
- Does the Joint Commission require that care givers perform hand hygiene after coming into contact with equipment near the patient’s bed?
No. The Joint Commission requires that the organization comply with either CDC or WHO Category 1A, 1B and 1C guidelines. The recommendation to perform hand hygiene after touching patient care equipment is a Category II guideline for CDC but a Category 1B guideline for WHO. Therefore, if the institution choses CDC, it need not count failures to perform hand hygiene after touching patient care equipment.
August
Can an engraved basin with “sterile water” or “normal saline” be used as an approved label for the National Patient Safety Goal 3D for labeling of solutions on and off the sterile field?
No, while it is acceptable to use pre-filled, pre-labeled syringes that come in procedure trays (from the manufacturer), pre-labeling of containers that will hold medications and solutions in the procedural setting is not allowed. Because there is a risk of mixing up containers that are engraved and/or mixing up solutions to be poured into these basins, this is not an acceptable practice. TJC FAQ March, 2008
July
- Are there significant changes in Medication Reconciliation for 2009?
Yes. There are a few very significant changes. In 2008 there were 2 requirements (NPSG 8A and 8B) and many pages of "Frequently Asked Questions." In 2009 there are four requirements and no new FAQs...at least not yet. Some of the 2009 changes reflect the requirements from the previous FAQs and are nothing new. However, there are some significant and BRAND NEW requirements. For example:
- All medication orders must be reviewed against the list of current medications collected at the time of admission. Any differences in dose, changes in medications, etc. must be explained in the medical record. (NPSG.08.01.01 EP.3)
- When a patient is transferred from one unit to another, there must be communication between the current provider(s) and the receiving provider(s) about the up-to-date reconciled medication list and this communication must be documented (NPSG.08.01.01 EP.4). The Joint Commission has not yet explained exactly what they mean by "provider" (is this the responsible physician) or the "up-to-date" medication list (is this the current active medications or the medications the patient was taking at home). What role does pharmacy play in this communication? These and many other questions remain to be resolved.
- Whereas prior versions of medication reconciliation required one complete list of medications upon discharge from an outpatient setting, there is now a requirement for a separate list of "short term" medications given to the patient at discharge (NPSG.08.04.01).
We are in the process of modifying our solutions documents to try to make these new requirements practical. However, we anticipate a cascade of "clarification" and FAQs about some of these perplexing requirements. Stay tuned!
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