Transcript TOP 10 MOST FREQUENTLY SCORED STANDARDS

PREPARING FOR JOINT COMMISSION
ACCREDITATION: ENSURING SUCCESS
WITH MEDICATION MANAGEMENT
Kurt A. Patton, MS, R.Ph. former Executive
Director Hospital Accreditation, Joint
Commission.
WHATS NEW I SHOULD WORRY
ABOUT THIS YEAR?
2
NEW STUFF FOR MM
• CMS and their S&C letter re the retirement
of the 30 minute rule.
• The One and Only Campaign.
• CMS surveyor worksheet drafts and their
perspective on multidose vials in
procedural settings
• New EP July 1 re formulary additions and
populations served
• The bar is being raised on expectations
FREQUENT FLIERS
• Perpetually difficult issues that have been
around for a long time that hospitals
continue to struggle with.
• Fix them by being more
intrusive/thorough/rigorous with peers in
other departments, your staff and yourself.
• Perform “Mother in law” inspections
TJC PRIMER, 101
• A elements, absolute performance
expectation or a policy mandate. You
have it, or you don’t
• Bulleted A – you have to fulfill all bullets
or it’s a failure
• C elements, 2 observations =RFI, but 90%
can clear the RFI through clarification.
• D = documentation required
D FOR DOCUMENTATION
• MM.01.01.01: The organization has a written policy that describes
that the following information about the patient is accessible to
licensed independent practitioners and staff who participate in the
management of the patient’s medications:
- Age
- Sex
- Diagnoses
- Allergies
- Sensitivities
- Current medications
- Height and weight (when necessary)
- Pregnancy and lactation information (when necessary)
- Laboratory results (when necessary)
- Any additional information required by the organization
D FOR DOCUMENTATION
• MM.01.01.03: The hospital identifies, in
writing, its high-alert and hazardous
medications. *
– Everyone has the high alert list
– The hazardous portion of this EP was added
several years ago, and frequently missed.
D FOR DOCUMENTATION
• MM.01.02.01: The hospital develops a list
of look-alike/sound-alike medications it
stores, dispenses, or administers.
Note: One source of look-alike/sound-alike
medications is The Institute for Safe
Medication Practices
– Gap here is often EP 3, annual review, or EP 2
actions to prevent interchange and a
breakdown in some location, often pharmacy.
D FOR DOCUMENTATION
• MM.02.01.01, 3 EP’S, seldom missed
• Members of the medical staff, licensed independent
practitioners, pharmacists, and staff involved in ordering,
dispensing, administering, and/or monitoring the effects of
medications develop written criteria for determining which
medications are available for dispensing or administering
to patients.
• The hospital maintains a formulary, including medication
strength and dosage.
• The hospital develops and approves written medication
substitution protocols to be used in the event of a
medication shortage or outage.
D FOR DOCUMENTATION
• MM.03.01.01: The hospital has a written
policy addressing the control of medication
between receipt by an individual health
care provider and administration of the
medication, including safe storage,
handling, security, disposition, and return to
storage.
• Often missed, huh? Get it and give it, right?
D FOR DOCUMENTATION
• MM.04.01.01: The hospital has a written
policy that identifies the specific types of
medication orders that it deems acceptable
for use.
– PRN qualifiers, range orders, titrations
• Scoring usually takes place at EP 13, the
hospital implements its policies for medication
orders.
MEDICATION ORDERS POLICY
• PRN – must have an indication in the body of
the order, or by policy that is universally
understood and always applied.
• Range orders – must be verbalized and
implemented uniformly by all nursing staff in
the organization. Advice: embed instructions
in order and/or MAR.
• Titration – must have a start point, must have
a therapeutic end point that is measureable
D FOR DOCUMENTATION
• MM.04.01.01: The hospital has a written
policy that defines the following: The
required elements of a complete
medication order.
– Name of drug, dose, frequency, route, rate,
etc.
– Most hospitals usually have this, breakdown is
performance at EP 13 again.
D FOR DOCUMENTATION
• MM.04.01.01: The hospital has a written
policy that defines the following: When
indication for use is required on a medication
order.
– You are writing the policy, make it only for PRN
orders and antibiotics if you want.
D FOR DOCUMENTATION
• MM.04.01.01: The hospital has a written
policy that defines the following: The
precautions for ordering medications with
look-alike or sound-alike names.
– What are you going to do differently to prevent
interchange of these LASA drugs?
– WARNING: You must do what you say you are
going to do, don’t be too uniform and
prescriptive.
D FOR DOCUMENTATION
• MM.04.01.01:The hospital has a written
policy that defines the following: Actions to
take when medication orders are
incomplete, illegible, or unclear.
– Usually everyone has this, but the failure to
take action is very common. Be especially
careful with PACU and ICU.
D FOR DOCUMENTATION
• MM.04.01.01: The hospital defines, in
writing, the circumstances for which weightbased dosing is required for pediatric
populations.
D FOR DOCUMENTATION
• MM.05.01.17: The hospital has a written
policy describing how it will retrieve and
handle medications within the hospital that
are recalled or discontinued for safety reasons
by the manufacturer or the U.S. Food and
Drug Administration (FDA).
– Everybody does it, but not everybody has a
written policy.
D FOR DOCUMENTATION
• MM.06.01.01: The hospital defines, in writing,
licensed independent practitioners and the
clinical staff disciplines that are authorized to
administer medication, with or without
supervision, in accordance with law and
regulation.
– Often missing, often to limited in detail.
– CMS has made this more complex now.
D FOR DOCUMENTATION
• MM.06.01.03: If self-administration of medications is
allowed, written processes that address training,
supervision, and documentation guide the safe and
accurate self-administration of medications or the
administration of medications by a family member.
– Make sure your policy does not conflict with what you do
in an infusion center, sleep lab or other outpatient setting.
D FOR DOCUMENTATION
• MM.06.01.05: The hospital has a written
process addressing the use of investigational
medications that includes review, approval,
supervision, and monitoring.
– Not usually an issue
D FOR DOCUMENTATION
• MM.07.01.03: 2 EP’S: The hospital has a written
process to respond to actual or potential adverse
drug events, significant adverse drug reactions,
and medication errors.
• The hospital has a written process addressing
prescriber notification in the event of an adverse
drug event, significant adverse drug reaction, or
medication error.
– Where would a surveyor see this documented?
MOST FREQUENT MISTAKES
• We can permit range orders because the
Joint Commission doesn’t say they are
prohibited.
• Our nurses know how to sort through
therapeutic duplication.
• CPOE fixes everything
• The nurses will just have to learn to date
the multidose vials correctly
MOST FREQUENT MISTAKES
• I think that area, those meds are secure
enough, don’t worry about it.
• I can only control what takes place in the
pharmacy.
• I’m not sure what that EP means, but I don’t
think its applicable to our hospital.
• Only pharmacists, nurses and physicians are
authorized to have access to medications.
THE MOST FREQUENTLY SCORED
MM STANDARD 31%
• MM.03.01.01
– There are many facets, 11 EP’s
– EP’s 2, 3, 6 and 8 cause most of the problems
• (Refrigerators, warmers), security lapses, expired
meds
• Have you looked at radiology, OR, ED and pharmacy
to look at warmed products.
• TJC published a “booster pack” just for this one standard
several years ago.
– This is where they changed to BUD
MEDICATION STORAGE AND
TEMPERATURE CONTROL
• You use paper logs, or you use electronic sensor
monitoring for refrigerators.
– Performance lapses with paper logs, missing days
– Failure to document actions taken when the temperature is
out of range. Paper and electronic
– Failure to include pharmacy in actions taken
– Failure to implement a system for 5 day operations
– Failure to know how to use the system for 5 day operations.
– Turning off alarms, knowledge deficits on zeroing out
recorded highs
• Did you know you had performance lapses, why not, or
why wasn’t it corrected?
MEDICATION STORAGE AND
TEMPERATURE CONTROL
• Failure to consider warmers, not knowing what
is being warmed and who is warming
medications.
• Failure to use manufacturers advice for warmed
medication max temp and duration
• Failure to implement the expiration dating
system for warmed products.
• Failure to recognize contrast is a medication
• Failure to recognize special requirements for
vaccines
TEMPERATURE CONTROL
• Remote sensor monitoring can help
– Do you have the capability to print a
retrospective log
– Do you have the capability to print actions
taken
– Implement a mandatory system for
documenting actions taken
– Trace these capabilities just like a surveyor
PROBLEM 2, SAME STANDARD,
MEDICATION SECURITY
• Policy and actual process must be consistent.
• “We only allow nurses, physicians,
pharmacists and respiratory therapists to have
access to medications”.
– What about radiology technicians?
– What about materials management staff?
– What about central supply staff?
– What about clean utility rooms used to store IV
bags?
MEDICATION SECURITY DRILL DOWN
• Go to radiology: how many different cabinets, how
many different rooms have contrast? Is the warmer
locked? Are these rooms/cabinets locked or open to
all staff and visitors who are present?
• Go to clinical units, ED, OR, central stores, materials
management: Where are IV’s stored, who has access
and who delivers supplies?
• How are crash carts replenished?
• Are the crash carts stored in observed locations or on
dead end corridors near an exit?
• Are secure, limited access areas like OR, really
secure? What about housekeeping and maintenance
staff? Weekends?
SECURITY OF MEDICATIONS POLICY
• Joint Commission and CMS permit concept of secure by
observation, but it has to be real.
• If your surveyor can wander without challenge its not
secure.
• Joint Commission and CMS don’t mandate which staff may
have access. Some state regulations may, but not TJC/CMS.
• Write policy loosely reflecting actual processes, not rigidly
reflecting a desired practice that does not exist.
• We need to create a new mindset of practicality
• Look at pneumatic tubes and crash carts. Document risk
assessment when doubtful
EXPIRATION DATE CONTROL, STILL
MM.03.01.01
• Pharmacy staff inspect the official storage locations: Joint
Commission surveyors look in unofficial locations.
– open every drawer and every cupboard, even when there should
not be any medications stored there.
– Go with the department head to every room, just like a surveyor
– GI lab, endo, trauma, anesthesia carts, ambulatory Tx rooms
• Multi-dose vial expiration system
– Use BUD date 28 days in the future, not date opened
– Check your system pre-survey to determine if it works. If not,
change it. Its not going to get better during survey.
– Consider expiration dating from day of dispensing
• Anesthesia carts – Do they have partial vials and syringes predrawn that should have been labeled with an EXP?
SECOND MOST FREQUENTLY SCORED
MM STANDARD MM.04.01.01
• 14 EP’s, Chief problems: clarity of range orders and prn
indications on orders. All performance lapses scored at EP
13. C, 90%
• Any range order, 5-10 mg must have absolute clarity, and
reproducibility among staff.
– Only way to succeed is to make the selection of dose
part of the order.
– If you think policy and training is an acceptable
alternative, conduct tracer interviews.
HAVE YOU GIVEN PEOPLE THE TOOLS
THEY NEED TO BE COMPLIANT?
• NPSG.03.04.01 labeling medications and
solutions during procedures.
– Go to ED, ICU, GI lab, Ambulatory procedure
rooms- do they have sterile labels for minor
procedures?
– Look for the silver color Mayo stand, ask how it is
used and prepared for a procedure.
– Are there any mental reminders about labeling,
consent, time out, don’t forget to label everything
• Yes, it still applies to 1 drug and sterile water
EMERGENCY MEDICATIONS
MM.03.01.03
• Are they accessible without risk of tampering or theft?
If in doubt, risk assess and document
• EP 3, Whenever possible, emergency medications are
available in unit dose, age specific, and ready to
administer forms.
• Broselow carts, tapes or other systems: Do they use
standardized concentrations or infinitely variable
concentrations? Have you searched for old tapes and
old instructions? 2002 too old, 2007A glucagon error
• If your instructions and your training call for a pediatric
concentration, you MUST have it or change the
instructions.
STERILE PRODUCT PREPARATION,
MM.05.01.07
• Does the pharmacy prepare all sterile infusions except in
emergent situations or short stability? Elastomeric pumps
too?
• Do you do this for infusion center and all outpatient
locations?
• How are you preparing radiopharmaceuticals and does
pharmacy or a physician supervise off hours compounding?
• Do you monitor performance of clinical contractors of
specialty prescriptions?
PREPARING FOR SURVEY
• Day one patient tracers may uncover MM
issues. Find out what was found.
• Prepare for MM system tracer. “Here is what
we were doing to prevent what you saw”. We
were aware, we were on top of it.
• Joint Commission views MM issues anywhere
in the organization as under your purview.
• Don’t describe your area of responsibility as
less than whole organization.
MM SYSTEM TRACER
• Reserve a room, but be ready to walk around
also.
• Have nursing and medical staff representatives
present.
• Consider rehearsal, filter out those staff that will
be a liability
• Come prepared to talk positively and
affirmatively about the good work you do.
• If the surveyor lets you, keep talking about the
great work you do.
MEDICATION RECONCILIATION
• 1 standard, 5 C EP’s not being scored as often as
the old one
• Problems exist in 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.
– Is continue, discontinue, change clear that decisions
were made and not errors?
– Who in your hospital has a documented competency
to conduct this medrec analysis?
ONE AND ONLY CAMPAIGN
• One needle, one syringe, one patient
• If staff use something as multidose, make sure
the FDA told you it was multidose. Contrast, IV
bags, irrigating fluids, lidocaine and sterile
water vials.
• Be cautious with the use of insulin pens
• Consider using multidose vials in procedural
settings as single dose only. CMS and AORN
CMS AND TJC ARE MORE CLOSELY
ALIGNED
• Keep up with the SOM/Interpretive
Guidelines, it can change how standards are
evaluated without seeing something new
from TJC.
PREPARATION OF DRUGS
TAG A-0405
• The 30 minute rule is gone, but the
replacement is complex.
• Medical staff must approve the P+P for
medication administration.
• P+P must identify the disciplines
authorized to administer medications and
the categories of medication they may
administer. E.g oral, IV, IM, inhaled
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PREPARATION OF DRUGS
TAG A-0405
Training for those administering medications
must include equipment, devices, special
procedures and or techniques required.
P+P must address the required components of
training and what can be provided via
orientation vs. additional or ongoing
training and what requires a documented
competency.
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PREPARATION OF DRUGS
TAG A-0405
Timing of med administration:
1. ID meds not eligible for scheduled dosing
times
Stats, first dose, one time, time
sequenced, PRN
2. ID meds eligible for scheduled dosing
times
BID, TID, ETC
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PREPARATION OF DRUGS TAG A-0405
• 3. Further divide your meds eligible for
scheduled dosing time into:
– Time critical, e.g. antibiotics, anticoag, insulin,
anticonvulsants, analgesics immunosupressives,
RX less than q4h
These may be given +/- 1 hr
– Non Time Critical, e.g. daily, weekly, monthly.
These may be given +/- 2 hr
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PREPARATION OF DRUGS TAG A-0405
• P+P must address what to do with missed
doses and what is a med error.
• Evaluate your timing policies for QAPI
• May adopt standing orders but include well
defined criteria for use and get practitioner
sign off after use.
– Monitor correct use of standing orders also
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PREPARATION OF DRUGS TAG A-0405,
SURVEY PROCEDURES
• Verify the hospital has P+P for:
– Meds not eligible for scheduled times
– Meds eligible and time critical
– Meds eligible and not time critical
• Verify windows do not exceed 1 hr for time
critical, 2 hr for not time critical, or 4 hr for
not time critical (daily’s or longer).
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PREPARATION OF DRUGS TAG A-0405,
SURVEY PROCEDURES
• Ask to see one or more standing orders and
evidence of training, periodic evaluation of
the use of the standing order including
adherence to policy.
• Interview nursing staff. Are they familiar with
P+P for standing orders and are they
following?
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QUESTIONS?
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