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TJC 2015 UPDATE PO Box 3187 Charleston, WV 25332 www. mckennaconsulting. com 304 -988 TJC 2015 UPDATE PO Box 3187 Charleston, WV 25332 www. mckennaconsulting. com 304 -988 -1047 1

The Joint Commission 2015 n Themes u. Utilization of Accreditation Process for Proactive Risk The Joint Commission 2015 n Themes u. Utilization of Accreditation Process for Proactive Risk Reduction u. Uniform Patient Care Process (High Reliability)-will impact PI 2015 u. Robust Process Improvement 2

The Joint Commission 2015 Scoring A’s and C’s only EP’s 0, 1, 2 Timeline The Joint Commission 2015 Scoring A’s and C’s only EP’s 0, 1, 2 Timeline for Correcting §Criticality and Immediacy of Risk 3

The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC. 02. 05. 01, EP The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC. 02. 05. 01, EP 6 53% Ventilation, air exchanges LS. 02. 01. 20, EP 13 52% Egress EC. 02. 06. 01, EP 1 & EP 13 51% Safe environment, temp & humidity 4

The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC. 02. 03. 05 50% The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 EC. 02. 03. 05 50% Fire Safety IC. 02. 01 50% Disinfection, sterilization LS. 02. 01. 10, EP 5 -7, EP 9 49% Fire barrier management 5

The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 RC. 01. 01 49% Dating The Joint Commission 2015 Top 10 Challenging Standards/NPSG 2013/2014 RC. 01. 01 49% Dating & Timing LS. 02. 01. 30 46% Smoke barriers LS. 02. 01. 35 44% Sprinklers, ceiling tiles, signage EC. 02. 01, EP 3 -5 36% PPE, hazardous waste & materials 6

The Joint Commission 2015 Chapters (Alphabetized) n n n Accreditation Participation Requirement (APR) Environment The Joint Commission 2015 Chapters (Alphabetized) n n n Accreditation Participation Requirement (APR) Environment of Care (EC) Emergency Management (EM) 7

The Joint Commission 2015 Chapters cont’d n n n Human Resources (HR) Infection Control The Joint Commission 2015 Chapters cont’d n n n Human Resources (HR) Infection Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) 8

The Joint Commission 2015 Chapters cont’d n n n Medication Management (MM) Medical Staff The Joint Commission 2015 Chapters cont’d n n n Medication Management (MM) Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR) Provision of Care (PC) 9

The Joint Commission 2015 Chapters cont’d n n n Patient Safety System (PS) Performance The Joint Commission 2015 Chapters cont’d n n n Patient Safety System (PS) Performance Improvement (PI) Record of Care, Treatment and Services (RC) 10

The Joint Commission 2015 Chapters cont’d n n Rights and Responsibilities (RI) Transplant Safety The Joint Commission 2015 Chapters cont’d n n Rights and Responsibilities (RI) Transplant Safety (TS) Universal Protocol (UP) Waived Testing (WT) 11

The Joint Commission 2015 Opportunities for Improvement (OFI) n n New section of TJC The Joint Commission 2015 Opportunities for Improvement (OFI) n n New section of TJC report Single observations of “C” EPs No ESC required No opportunity for clarification 12

The Joint Commission 2015 New for 2015 Patient Safety Systems Chapter n Informs & The Joint Commission 2015 New for 2015 Patient Safety Systems Chapter n Informs & educates on patient safety n No new requirements (not scored) n Road map for hospital leaders n Only in 2015 CAMH 13

The Joint Commission 2015 n 2 nd Generation Tracers –no changes yet § Cleaning, The Joint Commission 2015 n 2 nd Generation Tracers –no changes yet § Cleaning, Disinfectant and Sterilization § Contracted Services § OPPE/FPPE § Advance Diagnostic Imaging § Patient Flow and ED Overcrowding 14

The Joint Commission 2015 2 nd Generation Tracers cont’d § Clinical Information Systems § The Joint Commission 2015 2 nd Generation Tracers cont’d § Clinical Information Systems § Therapeutic Radiation § Competence Assessment Session § Credential Assessment Session § Survey Process Changes § More Staff Interviews § More Patient Interviews n 15

The Joint Commission 2015 National Patient Safety Goals 16 The Joint Commission 2015 National Patient Safety Goals 16

The Joint Commission 2015 National Patient Safety Goals No Changes Common Challenges § Hand The Joint Commission 2015 National Patient Safety Goals No Changes Common Challenges § Hand hygiene – no goal § Central Lines § Suicide Prevention 17

The Joint Commission 2015 Universal Protocol No Changes Common Challenges § Time Out – The Joint Commission 2015 Universal Protocol No Changes Common Challenges § Time Out – all involved § Site Marking - radiology 18

The Joint Commission 2015 Rights and Responsibilities of the Individual 19 The Joint Commission 2015 Rights and Responsibilities of the Individual 19

The Joint Commission 2015 Rights and Responsibilities of the Individual Changes § RI. 01. The Joint Commission 2015 Rights and Responsibilities of the Individual Changes § RI. 01. 01 – Patient/family informed of rights before care, when possible § RI. 01. 02. 01 – want family notified of admission? 20

The Joint Commission 2015 Rights and Responsibilities of the Individual Common Challenges § Advance The Joint Commission 2015 Rights and Responsibilities of the Individual Common Challenges § Advance Directives § Privacy § Pain Management § Informed Consent (per policy) 21

The Joint Commission 2015 Record Care, Treatment and Services 22 The Joint Commission 2015 Record Care, Treatment and Services 22

The Joint Commission 2015 Record Care, Treatment and Services Changes § RC. 02. 01 The Joint Commission 2015 Record Care, Treatment and Services Changes § RC. 02. 01 – include complications and Healthcare Associated Infection (HAI) 23

The Joint Commission 2015 Record Care, Treatment and Services Common Challenges § Dating of The Joint Commission 2015 Record Care, Treatment and Services Common Challenges § Dating of entries – and timing of entries § Post procedural note § Delinquency 24

The Joint Commission 2015 Record Care, Treatment and Services Common Challenges cont’d § All The Joint Commission 2015 Record Care, Treatment and Services Common Challenges cont’d § All orders in medical record (including protocols) § Verbal Orders/telephone orders 25

The Joint Commission 2015 Provision of Care 26 The Joint Commission 2015 Provision of Care 26

The Joint Commission 2015 Provision of Care Changes § PC. 01. 02. 03 – The Joint Commission 2015 Provision of Care Changes § PC. 01. 02. 03 – discharge planning as reason for reassessment § PC. 02. 01 – RN supervises patient care § PC. 03. 01 – Anesthesiologist supervises Anesthesia Assistant § PC. 04. 01 – Home Care agencies requested to be on list given to patients 27

The Joint Commission 2015 Provision of Care Common Challenges § Pain Assessment/Reassessment § Pain The Joint Commission 2015 Provision of Care Common Challenges § Pain Assessment/Reassessment § Pain management in the ED and outpatient areas § Screens § History and Physicals § Updates to H&P’s – examination § Problem list by the 3 rd visit 28

The Joint Commission 2015 Provision of Care Common Challenges cont’d § Restraints § Nonviolent The Joint Commission 2015 Provision of Care Common Challenges cont’d § Restraints § Nonviolent § Violent § Patient/Family Education § Moderate Sedation ASA and Airway Assessment 29

The Joint Commission 2015 Medication Management 30 The Joint Commission 2015 Medication Management 30

The Joint Commission 2015 Medication Management Changes § MM. 03. 01 – record receipt The Joint Commission 2015 Medication Management Changes § MM. 03. 01 – record receipt and disposition of radiopharmaceuticals 31

The Joint Commission 2015 Medication Management Common Challenges § Fanny packs and pockets § The Joint Commission 2015 Medication Management Common Challenges § Fanny packs and pockets § 1 st Dose Review § Radiology Protocols § Security-Anesthesia § Emergency Medications 32

The Joint Commission 2015 Medication Management Common Challenges cont’d § Contrast Media § Range The Joint Commission 2015 Medication Management Common Challenges cont’d § Contrast Media § Range Orders § Titrated Orders – Pitocin/Sedation for ventilator 33

The Joint Commission 2015 Medication Management Common Challenges cont’d § Blanket Orders § Disposal The Joint Commission 2015 Medication Management Common Challenges cont’d § Blanket Orders § Disposal high risk drugs - EPA § Therapeutic duplication § Zophran and Phenergan 34

The Joint Commission 2015 Medication Management Common Challenges cont’d § Compounding Pharmacies § Multidose The Joint Commission 2015 Medication Management Common Challenges cont’d § Compounding Pharmacies § Multidose vials – safe injection practices § Auto-injector use for contrast 35

The Joint Commission 2015 Medication Management Common Challenges cont’d § Refrigerator checks – weekends The Joint Commission 2015 Medication Management Common Challenges cont’d § Refrigerator checks – weekends § Sample medications § Management of drug shortages 36

The Joint Commission 2015 Infection Control 37 The Joint Commission 2015 Infection Control 37

The Joint Commission 2015 Infection Control No Changes Common Challenges § Emergency Management § The Joint Commission 2015 Infection Control No Changes Common Challenges § Emergency Management § Flu Readiness § Influx of patients § Flu vaccine (staff LIPs) 38

The Joint Commission 2015 Infection Control Common Challenges cont’d § Mop water (Big) § The Joint Commission 2015 Infection Control Common Challenges cont’d § Mop water (Big) § Red Bag Trash (Open) § Cleanliness – contact time/how you know it’s clean 39

The Joint Commission 2015 Infection Control Common Challenges cont’d § Bar Code Device Cleaning The Joint Commission 2015 Infection Control Common Challenges cont’d § Bar Code Device Cleaning § Sterile storage – 8”-10” off the floor § Sterile storage – solid bottoms for wire shelves 40

The Joint Commission 2015 Infection Control Common Challenges cont’d § Air Quality § Exchanges The Joint Commission 2015 Infection Control Common Challenges cont’d § Air Quality § Exchanges § Humidity/Temps § Pressure gradients 41

The Joint Commission 2015 Infection Control Common Challenges cont’d § Scope Management § Reprocess The Joint Commission 2015 Infection Control Common Challenges cont’d § Scope Management § Reprocess timeframes § Brushes (disposable or sterilized) § Eyewash 10 sec access § Hang freely § Scope cabinet surface – cleanable § Pressure gradient correct 42

The Joint Commission 2015 Infection Control Common Challenges cont’d § Scope Management cont’d § The Joint Commission 2015 Infection Control Common Challenges cont’d § Scope Management cont’d § PPEs § Impervious cover § TEE § Laryngoscopes § Mac. Gills § Vaginal Probes 43

The Joint Commission 2015 Infection Control Common Challenges cont’d § Intermediate and high level The Joint Commission 2015 Infection Control Common Challenges cont’d § Intermediate and high level disinfection, sterilization § All staff involved have duties in Job Description 44

The Joint Commission 2015 Infection Control Common Challenges cont’d § All staff involved have The Joint Commission 2015 Infection Control Common Challenges cont’d § All staff involved have standard competencies § Findings in IC could be immediate threat to life 45

The Joint Commission 2015 Transplant Safety 46 The Joint Commission 2015 Transplant Safety 46

The Joint Commission 2015 Transplant Safety n No Changes 47 The Joint Commission 2015 Transplant Safety n No Changes 47

The Joint Commission 2015 Transplant Safety Common Challenges § Records § Procedures for tissues The Joint Commission 2015 Transplant Safety Common Challenges § Records § Procedures for tissues § Receipt of tissues § Package integrity § Daily records of temperatures 48

The Joint Commission 2015 Transplant Safety Common Challenges § Bidirectional § Staff involved § The Joint Commission 2015 Transplant Safety Common Challenges § Bidirectional § Staff involved § Materials/Instruction to prepare § Investigation of tissue events 49

The Joint Commission 2015 Transplant Safety Common Challenges § Refrigerator temperatures § Ambient temperatures The Joint Commission 2015 Transplant Safety Common Challenges § Refrigerator temperatures § Ambient temperatures § Testing of alarms § FDA verification annually § Lot numbers of supplies missing 50

The Joint Commission 2015 Performance Improvement 51 The Joint Commission 2015 Performance Improvement 51

The Joint Commission 2015 Performance Improvement § No Standard Changes § Scoring Changes § The Joint Commission 2015 Performance Improvement § No Standard Changes § Scoring Changes § Leadership a problem, PI a problem § Working on the changes 52

The Joint Commission 2015 Performance Improvement § Common Challenges § Data Management Across Complex The Joint Commission 2015 Performance Improvement § Common Challenges § Data Management Across Complex Organization § Fall Effectiveness § Will increase 53

The Joint Commission 2015 Leadership 54 The Joint Commission 2015 Leadership 54

The Joint Commission 2015 Leadership Changes § LD. 01. 03. 01 – Governing body The Joint Commission 2015 Leadership Changes § LD. 01. 03. 01 – Governing body responsible for PI activities 55

The Joint Commission 2015 Leadership Common Challenges § Contracts – expectations must be outlined The Joint Commission 2015 Leadership Common Challenges § Contracts – expectations must be outlined – quality must be tracked § Policies and Procedures consistently implemented 56

The Joint Commission 2015 Leadership Common Challenges cont’d § Patient Flow § Safety for The Joint Commission 2015 Leadership Common Challenges cont’d § Patient Flow § Safety for boarded patients § Governing Body fails is any other condition fails (Medicare) – Now fail PI 57

The Joint Commission 2015 Environment of Care 58 The Joint Commission 2015 Environment of Care 58

The Joint Commission 2015 Environment of Care Changes § EC. 02. 03 – Fire The Joint Commission 2015 Environment of Care Changes § EC. 02. 03 – Fire Drills § Fire drills at unexpected times and varying conditions § 9: 00 PM – 6: 00 AM can turn off audible alarm 59

The Joint Commission 2015 Environment of Care Changes § EC. 02. 05. 01 – The Joint Commission 2015 Environment of Care Changes § EC. 02. 05. 01 – Utility systems § Written inventory of all utility systems § “High risk” includes life support § Manufacturer’s recommendations or alternative equipment maintenance (AEM) 60

The Joint Commission 2015 Environment of Care Changes § EC. 02. 05 § Test The Joint Commission 2015 Environment of Care Changes § EC. 02. 05 § Test utilities after major repairs § Terminology change from “life support” to “high risk” and “nonhigh risk” 61

The Joint Commission 2015 Environment of Care Common Challenges § Automatic transfer switches § The Joint Commission 2015 Environment of Care Common Challenges § Automatic transfer switches § Documentation of fire drills critiques § Eyewash station management 62

The Joint Commission 2015 Environment of Care Common Challenges cont’d § Fire Dampers § The Joint Commission 2015 Environment of Care Common Challenges cont’d § Fire Dampers § Main Strategy – know your own documentation even if controlled by a contractor 63

The Joint Commission 2015 Environment of Care Common Challenges cont’d § Ventilation Systems § The Joint Commission 2015 Environment of Care Common Challenges cont’d § Ventilation Systems § Doors propped open 64

The Joint Commission 2015 Environment of Care Common Challenges cont’d § Egress blocked (BP The Joint Commission 2015 Environment of Care Common Challenges cont’d § Egress blocked (BP cuffs, COWs, Linen Carts) § Re-locatable Power Taps (RPT) § Surge protectors – hospital approved 65

The Joint Commission 2015 Life Safety 66 The Joint Commission 2015 Life Safety 66

The Joint Commission 2015 Life Safety § Changes § PFIs on final report § The Joint Commission 2015 Life Safety § Changes § PFIs on final report § E-SOC changed § Categorical waivers § Equivalency Process Modification 67

The Joint Commission 2015 Life Safety § Common Challenges § Fire Doors § Two The Joint Commission 2015 Life Safety § Common Challenges § Fire Doors § Two hour fire door malfunction § Compressed tanks § Egress path blocked § Computers on wheels § B/P machines § Interim Life Safety Measures 68

The Joint Commission 2015 Life Safety § Common Challenges cont’d § Positive latching § The Joint Commission 2015 Life Safety § Common Challenges cont’d § Positive latching § Misdirected Exit Sign § Fusible Links 69

The Joint Commission 2015 Life Safety § Common Challenges cont’d § Penetrations § No The Joint Commission 2015 Life Safety § Common Challenges cont’d § Penetrations § No exit § Behavioral hardware 70

The Joint Commission 2015 Emergency Management 71 The Joint Commission 2015 Emergency Management 71

The Joint Commission 2015 Emergency Management No Changes Common Challenges § Critiques with no The Joint Commission 2015 Emergency Management No Changes Common Challenges § Critiques with no follow through § Exercises/actual not implemented § 96 hours sustainability § HVA priorities not addressed with Mitigation, Preparedness, Response and Recovery 72

The Joint Commission 2015 Human Resources 73 The Joint Commission 2015 Human Resources 73

The Joint Commission 2015 Human Resources Changes § HR. 01. 01 – Qualified Dietician The Joint Commission 2015 Human Resources Changes § HR. 01. 01 – Qualified Dietician § HR. 01. 02. 01 – Qualifications in accordance with standards of practice 74

The Joint Commission 2015 Human Resources Common Challenges § Unannounced § Organized files § The Joint Commission 2015 Human Resources Common Challenges § Unannounced § Organized files § Primary Source at Renewal 75

The Joint Commission 2015 Human Resources Common Challenges cont’d § Contractors and Vendors § The Joint Commission 2015 Human Resources Common Challenges cont’d § Contractors and Vendors § Meet all requirements § Non-employees § Surgical Assistants § High level disinfectant § Annual report includes staffing effect on Quality 76

The Joint Commission 2015 Human Resources 77 The Joint Commission 2015 Human Resources 77

The Joint Commission 2015 Information Management 78 The Joint Commission 2015 Information Management 78

The Joint Commission 2015 Information Management Common Challenges § Security of information § Automated The Joint Commission 2015 Information Management Common Challenges § Security of information § Automated Systems § Confidentiality § Accurate Computer Information 79

The Joint Commission 2015 Nursing 80 The Joint Commission 2015 Nursing 80

The Joint Commission 2015 Nursing Changes § NR. 02. 03. 01 – RN assigns The Joint Commission 2015 Nursing Changes § NR. 02. 03. 01 – RN assigns nursing case 81

The Joint Commission 2015 Nursing Common Challenges § Qualification Nurse Executive § Staffing 82 The Joint Commission 2015 Nursing Common Challenges § Qualification Nurse Executive § Staffing 82

The Joint Commission 2015 Medical Staff Standards 83 The Joint Commission 2015 Medical Staff Standards 83

The Joint Commission 2015 Medical Staff Standards Changes § MS. 03. 01. 03 – The Joint Commission 2015 Medical Staff Standards Changes § MS. 03. 01. 03 – patient admitted only on decision of LIP § MS. 06. 01. 05 – Roster of each practitioner’s surgical privileges 84

The Joint Commission 2015 Medical Staff Standards § Circumstances requiring FPPE § New Applicants The Joint Commission 2015 Medical Staff Standards § Circumstances requiring FPPE § New Applicants – must be privilege specific 85

The Joint Commission 2015 Medical Staff Standards § No activity to support reappointment § The Joint Commission 2015 Medical Staff Standards § No activity to support reappointment § Reach out to other places they practice § Peer Recommendations 86

The Joint Commission 2015 Medical Staff Standards § Temporary Privileges § Important patient care, The Joint Commission 2015 Medical Staff Standards § Temporary Privileges § Important patient care, treatment and service needed § New applicant – no concerns 87

The Joint Commission 2015 Medical Staff Standards Reminder § MS. 03. 01, EP 16 The Joint Commission 2015 Medical Staff Standards Reminder § MS. 03. 01, EP 16 for deemed status effective January 1, 2011 § Determine qualification of the radiology staff – must be approved by the Medical Executive Committee 88

The Joint Commission 2015 Medical Staff Standards Reminder § MS. 03. 01, EP 16 The Joint Commission 2015 Medical Staff Standards Reminder § MS. 03. 01, EP 16 for deemed status effective January 1, 2011 § Nuclear services director approved & qualification of staff approved by Medical Staff – must be approved by the Medical Executive Committee 89

The Joint Commission 2015 Waived Testing 90 The Joint Commission 2015 Waived Testing 90

The Joint Commission 2015 Waived Testing No Changes Common Challenges § Quality Controls § The Joint Commission 2015 Waived Testing No Changes Common Challenges § Quality Controls § Hemoccults § Glucose § Fern Testing § I stats § Reference Ranges 91

References § Joint Commission (2014). Comprehensive Accreditation Manual, Department of Publications and Education Joint References § Joint Commission (2014). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2014 § Pre-publication Joint Commission Executive Briefings for 2015, September 4, 2014 § AIA ACADEMY OF ARCHITECTURE FOR HEALTH, UNITED STATES. DEPT OF HEALTH AND HUMAN SERVICES. Guidelines for design and construction of hospital and health care facilities. American Institute of Architects Press, 2010 92

References n Centers for Disease Control http: //www. cdc. gov/hicpac/pdf/guidelines/ Disinfection_Nov_2008. pdf 93 References n Centers for Disease Control http: //www. cdc. gov/hicpac/pdf/guidelines/ Disinfection_Nov_2008. pdf 93

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