DOREEN FINN, RN, BSN, MBA Senior Associate Director Standards Interpretation Group Division of Healthcare Improvement 1

Faculty Introduction(s)

DOREEN FINN, RN, BSN, MBA Senior Associate Director Standards Interpretation Group Division of Healthcare Improvement 22

Welcome and Introduction

• – – – – This module is 1 out of 9 available to help prepare candidates towards the JCCAP exam. Additional webinar modules include: – – – Understanding the Joint Commission’s Accreditation Process Organizational Analysis How to Engage Your Medical Staff into The Joint Commission Accreditation Process – Environment of Care Leadership Performance Improvement Patient Safety Understanding the CMS Regulatory and Survey Process for Hospitals 33

Welcome and Introduction

• • Please note that all modules and Exam Questions related to the JCCAP product line are specifically related to The Comprehensive

Accreditation Manual for Hospitals, in addition to CMS related materials

JCCAP Questions – Please visit www.jcrinc.com/jccap – E mail questions to: [email protected]

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JCCAP Module 3: Standards Disclosure Statement

The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: – Speaker – – Program Manager Nurse Planner – Other planning team member The following staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products.

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Publications and Record Restrictions

• The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. 6

Learning Objectives

• • • Describe a Standard and Element of Performance Describe how each chapter supports quality of care and positively effects health outcomes Apply the information learned to continuous survey readiness 77

Tips for Using Module

• Optimize your experience – Viewers are encouraged to pause your screen at any time to bring other staff and faculty in to segments that you find appropriate for team building and/or communication – Take advantage of printing out the slides (pdf available on the left side bar) for easy note taking – Make sure to review attached links, documents and references mentioned throughout this module (available on the left side bar) 88

Anatomy of a Chapter

• Overview • Outline • Definition of Standards • Element of Performance (EP) 99

Human Resources (HR)

• • • • • • • Standards and EPs address the following: Staffing Qualifications Orientation Training and Education Competence Evaluation of Performance

Human Resources (HR)

• Pharmacist requirement HR.01.01.01 • • Staff qualifications HR.01.02.01 Current license and HR.01.02.07 Scope of Practice • Staff competency HR.01.06.01

• Staff evaluations HR.01.07.01

HR.01.01.01 Staffing

• • Deemed status purposes: A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department / services.

HR.01.02.05 Qualifications

• When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed.

HR.01.02.05 Qualifications

• The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities.

HR.01.02.05 Qualifications

• The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. • Criminal background checks are documented.

HR.01.02.05 Qualifications

• The hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital.

HR.01.02.07 Qualifications

• All staff who provide patient care, treatment, and services: 1. Possess a current license, certification, or registration 2. Practice within the scope of their license in accordance with law and regulation

HR.01.04.01 Orientation

• The hospital orients its staff to key safety content before staff provide care, treatment or services.

• Completion of this orientation is documented.

HR.01.05.03 Training and Education

• Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented.

HR.01.05.03 Training and Education

• The hospital provides education and training that addresses: 1. How to identify early warning signs of a change in a patient’s condition 2. How to respond to a deteriorating patient, including when to contact responsible clinicians 3. Participation is documented

HR.01.06.01 Competency

• Staff are competent to perform their responsibilities.

HR.01.07.01 Evaluations

• Staff are evaluated based on performance expectations that reflect job responsibilities • Evaluation is performed at least every three years

Infection Control (IC)

• Standards and EPs address the following: • Planning • Implementation • Evaluation

IC.01 Planning

• • • • • • Responsibility Resources Risks Goals Activities Influx IC.01.01.01

IC.01.02.01

IC.01.03.01

IC.01.04.01

IC.01.05.01

IC.01.06.01

IC.01.01.01 Responsibility

• The [organization] identifies the individual(s) responsible for the infection prevention and control program.

1. Clinical Authority (Program) 2. Daily management of infection prevention and control activities

IC.01.02.01 Resources

• Hospital leaders allocate needed resources for the infection prevention and control program.

IC.01.02.01 Resources

• The hospital provides equipment and supplies to support the infection prevention and control program.

IC.01.02.01 Resources

• • • • Other education Daily lab services Adequate number of isolation carts Available Personal Protective Equipment (PPE)

IC.01.03.01 Risk Assessment

• • The hospital identifies risks for acquiring and transmitting infections.

The risk assessment is the cornerstone upon which the IC program is built.

EXAMPLE: Food and Drink in clinical areas

IC.01.04.01 Goals

• Based on the identified risks, the hospital sets

goals

IC.01.04.01 Goals

• The hospital's written infection prevention and control goals include the following: 1. Improving compliance with hand hygiene guidelines.

2. Limit the transmission of infections

IC.01.04.01 Goals

• Limiting unprotected exposure to pathogens 1. Isolation systems 2. Bloodborne pathogens 3. Waste disposal

Infection Control (IC)

• There is a relationship of Goals to Evaluation ***Remember*** Your evaluation must address success or failure of goals. Be sure to consider this when formulating your goals.

IC.01.05.01 Written IC Plan

• When developing the plan, use evidence based national guidelines or, in the absence of such guidelines, expert consensus.

CDC- Center for Disease Control HICPAC- Healthcare Infection Control Advisory Committee NQF- National Quality Forum

IC.01.05.01 Written Plan

•

The surveyor:

– Will ask the ICP how these evidenced base guidelines have been considered in the design of interventions – Will ask about the newest one or two guidelines – the ICP should be able to discuss them – May want to reference them in policies and procedures

IC.01.05.01 Written Plan

The plan includes a written description of: 1. The activities to minimize, reduce or eliminate the risk of infection.

2. The process to evaluate the plan.

3. The process of investigating outbreaks of infectious disease.

Infection Control (IC)

• “The hospital describes, in writing, the process for investigating outbreaks of infectious disease.” The surveyor might ask – Has this been predetermined?

– Does the method chosen “close the loop”

IC.02 Implementation

• • • • Plan Implementation IC.02.01.01

Medical Equipment, Devices, and Supplies IC.02.02.01

Transmission of Infections Influenza Vaccinations IC.02.03.01

IC.02.04.01

IC.02.01.01 Implementation

• • Surveillance is used to minimize, reduce or eliminate the risk of infections.

Examples of findings that are frequently scored here are: • dirty ceiling tiles • dirty carts or wheelchairs, • ripped or cracked chairs/mattresses

IC.02.01.01 Implementation

Minimize the risk of infection when storing and disposing of infectious waste.

The surveyor might ask:

“How does IC work with facilities and housekeeping to prevent exposure?”

IC.02.02.01 Medical Equipment, Devices and Supplies

• • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

This standard is frequently scored among non-compliant standards for Hospitals.

IC.02.02.01 Cleaning and Disinfecting

• • The hospital implements IC activities when doing the following: Cleaning and performing low-level disinfection of medical supplies and devices.

Surveyors might question the staff about low level disinfection products and how they are used.

IC.02.02.01 High-Level Disinfection & Sterilization

• • • The hospital implements IC activities when performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.

See July 2009 Perspectives (Steam Sterilization) See HICPAC’s “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008”

IC.02.02.01 Storage

• • The hospital implements IC activities when storing medical equipment, devices, and supplies.

The surveyor will look for expired supplies, proper storage of medical equipment (how do you know equipment is clean)

IC.02.03.01 Staff Health Screening

• The hospital makes screening for exposure and/or immunity to infectious disease available to licensed independent practitioners (LIP) and staff who may come in contact with infections at the workplace.

IC.02.04.01 Influenza Vaccination

• • The hospital offers vaccination against influenza to licensed independent practitioners and staff annually.

The hospital includes in its infection control plan the goal of improving influenza vaccination rates.

IC.02.04.01 Influenza Vaccination

• The hospital educates licensed independent practitioners and staff about, at a minimum, 1. the influenza vaccine 2. non-vaccine prevention measures 3. the diagnosis, transmission, and impact of influenza

IC.02.04.01 Influenza Vaccination

• • The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.

The hospital takes steps to increase influenza vaccination rates.

IC.03.01.01 Evaluation

• The hospital evaluates the effectiveness of its IC plan’s risks, activities and goals.

• The organization must ask, “How did we do?”

IC.03.01.01 Evaluation

• Findings from the evaluation are communicated at least annually to the individuals or interdisciplinary group that manages the patient safety program.

Information Management (IM)

• • • Standards and EP’s address the following: Planning for the management of information Health Information – protecting the privacy, capturing, storing and retrieving data

Information Management (IM)

• • • Plan IM.01.01.01

Written plan for managing interruptions IM.01.01.03

Protects the privacy of health information (HIPAA) IM.02.01.01

Information Management (IM)

• • • Security and integrity of health information IM.02.01.03

Manages the collection of health information IM.02.02.01

Retrieves, disseminates, and transmits health information in useful formats IM.02.02.03

IM.03.01.01 Knowledge-based Resources

• • The hospital provides access to knowledge based information resources 24 hours a day, 7 days a week.

Provides knowledge-based information resources that are not available on site by cooperative or contractual arrangements

Medication Management (MM)

• • • • • Standards and EP’s address the following: High alert and hazardous medications Safe storage Ordering Labeling

MM.01.01.03 High Alert/Hazardous Medication

• • • Must be identified in writing Must have a process for managing and implement the process Must report abuses and losses of controlled substances, according to law and regulation

MM.01.02.01 Look-alike/ Sound-alike Medications

• • • Develop a look-alike/sound-alike list Take action to prevent errors Annually reviews and, as necessary, revises the list

MM.03.01.01 Safe Storage

• • • A process exists for ensuring that medications are stored safely and at the correct temperature.

All medications are stored in a secure area, and locked when necessary, in accordance with law and regulation.

This standard is frequently scored.

MM.03.01.01 Safe Storage

• Define the process to ensure labeling is occurring as required Example- multi dose vial (FAQ) • Refer to BoosterPak® MM.03.01.01

MM.04.01.01 Orders

• • • • • • Standing Order Must be approved by the Medical Staff Criteria to trigger standing order Must have an order to implement the standing order RN implements the order MD can sign latter

MM.04.01.01 Orders

• Written policy that defines what action to take when medication orders are incomplete,

illegible, or unclear

MM.05.01.13

• • • There is a process for providing medications when the pharmacy is closed to meet patient needs.

Store and secure medications approved for use outside the pharmacy.

Only trained, designated prescribers and nurses are permitted access to the approved medications.

National Patient Safety Goals (NPSG)

• • • • • • • • Standards and EP’s address the following: Importance of patient identification Communication among caregivers Safety of using medications Medication reconciliation Healthcare associated infections Identifying patients at risk for suicide Universal Protocol

Goal 1- Improve the Accuracy of Patient Identification

NPSG.01.01.01 Use two patient identifiers when providing care, treatment and services.

• • • Acceptable identifiers may be the individual’s: name assigned identification number telephone number, or other person-specific identifier

Goal 2 –Improve Communication Among Staff

NPSG.02.03.01

• Develop, implement and evaluate procedures for managing critical test results

Goal 3- Improve the Safety of Using Medications

• • NPSG.03.04.01

Label all medications, containers and other solutions on and off the sterile field The Joint Commission no longer prohibits pre labeling of syringes in the OR

NPSG.03.06.01

• • Document medications the patient is currently taking when admitted to the hospital or is seen in an outpatient setting Provide the patient or family, with written information on the medications the patient should be taking upon discharge

Goal 7 – Reduce the Risk of Health Care Associated Infections

• • NPSG.07.01.01

Comply with either the CDC or WHO hand hygiene guidelines

NPSG.07.06.01

• Implement evidence-based practices to prevent health care associated infections due to MRSA, central line associated bloodstream infection (CLABSI), prevent surgical site infections, and prevent indwelling catheter associated urinary tract infections (CAUTI).

NPSG.07.06.01

• • • Evidence-based guidelines for CAUTI located at: http://www.shea online.org/GuidelinesResources/Compendium ofStrategiestoPreventHAIs.aspx

http://www.cdc.gov/hicpac

Goal 15 – Identify Safety Risks Inherent in Patient Population

• NPSG.15.01.01

Identify patients at risk for suicide • BoosterPak® for NPSG.15.01.01

Universal Protocol

• • • UP.01.01.01- Conduct a pre-procedure verification process UP.01.02.01- Mark the procedure site UP.01.03.01- A time-out is performed before the procedure • Most frequently reported sentinel event

Provision of Care, Treatment and Services (PC)

• • • • • • Standards and EPs address the following: Plan Implement Special Condition Discharge and Transfer Blood Safety

PC.01.02.01 Assessment

• The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects.

PC.01.02.03 Assessment

• • • The hospital defines, in writing, the time frame for the patient’s initial assessment. The hospital assesses and reassesses the patient and his or her condition according to defined time frames. This standard is frequently scored among non-compliant standards for Hospitals.

PC.01.02.03 Assessment

• For an H&P examination that was completed within 30 days prior to inpatient admission, an update documenting any changes in the patient’s condition is completed within 24 hours after inpatient admission, but prior to surgery or a procedure requiring anesthesia

PC.01.02.03 Assessment

• If the LIP finds no change in the patient’s condition since the H&P was completed, he may indicate in the medical record that the

H&P was reviewed, the patient was examined and that no change in the patient’s condition has occurred.

PC.01.02.07 Pain Assessment

• A comprehensive pain assessment and reassessment is performed.

PC.01.02.08 Assessment

• The patient is assessed for a risk of falls and an intervention is implemented to reduce falls based on the patient’s identified risk.

PC.01.02.09 Abuse and Neglect

• The hospital has written criteria to identify those patients who may be victims of physical/sexual assault, sexual molestation, domestic abuse, or elder or child abuse and neglect.

PC.01.03.01 Care Plan

• The hospital plans the patient’s care, based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing.

PC.02.01.01 Providing Care

• The hospital provides the patient with care, treatment, and services according to his or her individualized plan of care.

PC.02.01.03

• Deemed Status – Prior to providing care, treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner.

PC.02.01.11

• Resuscitation services are available throughout the hospital.

PC.02.01.19

• • The hospital has a process for recognizing and responding as soon as a patient’s condition appears to be worsening.

Based on the hospital’s early warning criteria, staff seek additional assistance when they have concerns about a patient’s condition.

PC.02.01.21

• The hospital identifies the patient’s oral and written communication needs, including the patient’s preferred language for discussing health care. • • Reference Perspectives, January 2012 A Roadmap for Hospitals - 2010

PC.02.02.03 Coordinate Care

• The hospital prepares food and nutrition products using proper sanitation, temperature, light, moisture, ventilation, and security.

PC.03.01.03 Pre-procedure

• • Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital conducts a presedation or

preanesthesia patient assessment.

PC.03.01.05 During the Procedure

• The hospital monitors the patient during operative or other high-risk procedures and/or during the administration of moderate or deep sedation or anesthesia.

PC.03.01.07 Post-procedure

• A postanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services

Restraints

• For Deemed status Purposes Use PC.03.05.01 - PC.03.05.19

• For Non-Deemed status purposes Use PC.03.02.01 - PC.03.03.31

PC.03.05.01

• The hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others.

• Distinguish between restraints for violent, self destructive behavior and non-violent, non- self destructive behavior.

PC.03.05.05 Restraints

• • The hospital initiates restraint or seclusion based on an individual order.

The hospital does not use standing orders or PRN (also known as “as needed") orders for restraint or seclusion.

PC.03.05.11 Restraints

• An LIP responsible for the care of the patient evaluates the patient in person within one hour of the initiation of restraint or seclusion used for the management of violent or self destructive behavior.

PC.03.05.11 Restraints

• A registered nurse or a physician assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion; this individual is trained in accordance with the requirements in PC.03.05.17.

PC.03.05.17 Restraints

• The hospital trains staff to safely implement the use of restraint or seclusion.

PC.03.05.19 Restraints

• The hospital reports deaths associated with the use of restraint and seclusion to Centers for Medicare and Medicaid Services (CMS).

PC.04.01.05 Discharge Education

• Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care.

Record of Care (RC)

• Standards and EP’s address the following: • Plan • Implementation

RC.01 Plan

• • • • • Clinical Record Components RC.01.01.01

Authentication Timeliness Audit Retention RC.01.02.01

RC.01.03.01

RC.01.04.01

RC.01.05.01

RC.01.01.01 Medical Record

• • • The hospital maintains complete and accurate medical records for each individual patient.

All entries in the medical record are dated and timed.

This standard is frequently scored among non-compliant standards for Hospitals.

RC.01.02.01 Authentication

• Entries in the medical record are authenticated.

RC.01.04.01 Audits

• The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months.

RC.01.05.01 Retention

• The retention time of the original or legally reproduced medical record is determined by its use and hospital policy, in accordance with law and regulation.

RC.02 Implementation

• • • Care, treatment RC.02.01.01

Verbal Orders RC.02.03.07

Discharge Information RC.02.04.01

RC.02.01.01 Care, Treatment

• The medical record contains the patient’s race and ethnicity. (Perspectives, January 2012)

RC.02.01.03

• The patient’s medical history and physical examination are recorded in the medical record before an operative or other high-risk procedure is performed.

RC.02.01.03

• A procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

RC.02.03.07 Verbal Orders

• • Documentation of verbal orders includes: Date and the names of individuals who 1. Gave 2. Received 3. Recorded 4. Implemented the orders.

Rights and Responsibilities (RI)

• Standards and EP’s address the following: • Patient Rights • Patient Responsibilities Encourage patients to become more informed and involved in their care.

RI.01 Patient Rights

• Developing and Communicating Patient Rights Organization RI.01.01.01

Effective Communication RI.01.01.03

• Participation in Patient Care Decisions RI.01.02.01

RI.01 Patient Rights

• • • • • Informed Consent RI.01.03.01

Right to Know End of Life RI.01.04.01

RI.01.05.01

Personal Rights RI.01.06.03

Services to Protect Patient Rights RI.01.07.01

RI.02 Patient Responsibilities

• Written policy that defines patient responsibilities RI.02.01.01

RI.01.01.01 Patient Rights

• • There is a written policy on patient rights.

The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

RI.01.02.01 Participation in Care Decisions

• • The hospital involves the patient in making decisions about her care, treatment and services The patient is provided with written information about the right to refuse care

RI.01.03.01 Informed Consent

• • The hospital has a written policy on informed consent The informed consent process includes a discussion about reasonable alternatives to the patient’s proposed care, treatment, and services.

RI.01.03.01 cont.

• The discussion encompasses: 1. Risks, benefits, and side effects related to the alternatives 2. Risks related to not receiving the proposed care, treatment, and services.

RI.01.05.01

• The hospital has a written policy on advanced directives in accordance with law and regulation and implements this policy.

RI.01.07.01 Review of Complaint

• The hospital establishes a complaint resolution process.

During the survey process, the surveyor will talk with you about patient, family or visitor complaints.

Transplant Safety (TS)

• Standards and EPs address the following: • Donating and Procuring Organs and Tissue • Transplanting Organ and Tissue

TS.01.01.01 Donating Organs

• The hospital has a written agreement with an organ procurement organization (OPO) and follows its rules and regulations

Transplant Safety (TS)

• • Development and implementation of policies and procedures for the acquisition, receipt, storage, and issuance of tissue.

Retain tissue records on storage temperatures, procedure and publication for at least 10 years.

Waived Testing (WT)

• The hospital must obtain a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate to perform waived testing.

• http:/www.fda.gov/cdrh/clia/index.html

WT.02.01.01 Identify Staff

• • The hospital identifies staff responsible for performing and supervising waived testing The hospital provides orientation and training and assesses the competency of staff who perform waived testing. There is documented satisfactory competence.

WT.03.01.01 Staff Competency

• Competency for waived testing is assessed using at least two methods per person per test. (WT.03.01.01 EP5) • Competency for waived testing is assessed at least at the time of orientation and annually thereafter.

Closing Comments About JCCAP

• • For the most current copy of the Candidate Handbook and Frequently Asked Questions, please visit www.jcrinc.com/jccap Continuing Education Certificates and Instructions for obtaining your copy are found on the left side bar. For any difficulty or questions, please contact JCR Customer Service at 877-223-6866 (8 am - 8 pm EST)

DOREEN FINN, RN, BSN, MBA Senior Associate Director Standards Interpretation Group Division of Healthcare Improvement 127