Joint Commission 2010- 2011 Update for Hospital Imaging ... · 19 The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON DEFICIENCIES ... FMEA – Failure Mode and Effect Analysis

Joint Commission 2010-2011 Update for Hospital Imaging Departments

Joint Commission 2010-2011 Update for Hospital

Imaging DepartmentsJudith M. Atkins, RN, MSN

www.mckennaconsulting.com304-988-1047

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The Joint Commission 2010-2011IMAGING

Patient Safety ApproachFunctional Standards

Proactive Risk Reduction Uniform Patient Care Processes

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The Joint Commission 2010-2011Chapters (Alphabetized)

Accreditation Participation Requirement (APR)Environment of Care (EC)Emergency Management (EM)Equipment Management (EQ) for HMEHuman Resources (HR)Infection Control (IC)


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The Joint Commission 2010-2011Chapters

Information Management (IM)Leadership (LD)Life Safety (LS)Medication Management (MM)Medical Staff (MS)National Patient Safety Goal (NPSG)Nursing (NR)

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The Joint Commission 2010-2011

ChaptersProvision of Care (PC)Performance Improvement (PI)Record of Care, Treatment and Services (RC)Rights and Responsibilities (RI)Transplant Safety (TS)Waived Testing (WT)

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CMS 2010-2011Conditions of Participation

CoP – Compliance with Federal, State and Local LawsCoP – Governing BodyCoP – Patients RightsCoP – Quality Assessment and Performance ImprovementCoP – Medical Record Services


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CMS 2010-2011

Conditions of Participation continuedCoP – Pharmaceutical ServicesCoP – Radiologic ServicesCoP – Laboratory ServicesCoP – Food and Dietetic ServicesCoP – Utilization ReviewCoP – Physical Environment

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CMS 2010-2011

Conditions of Participation continuedCoP – Infection ControlCoP – Discharge PlanningCoP – Organ Tissue and Eye ProcurementCoP – Surgical ServicesCoP – Anesthesia ServicesCoP – Nuclear Medicine

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CMS 2010-2011

Conditions of Participation continuedCoP – Outpatient ServicesCoP – Emergency ServicesCoP – Rehabilitation ServicesCoP – Respiratory Services


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The Joint Commission 2010-2011 UNANNOUNCED SURVEY

Prepare for the Next Patient –Not the Next Set of SurveyorsShouldn’t matter if TJC or CMS

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The Joint Commission 2010-2011 SURVEY PROCESS

Tracer Methodology

Sees Care and Services through the patients eyesBrings the surveyor to your various diagnostic areas based on the patient

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The Joint Commission 2010-2011 SURVEY PROCESS

Tracer MethodologyMeasures your systems and processes based on individual patients


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The Joint Commission 2010-2011 FORMAT

Standard-The goal you are trying to reachElement of Performance-action step you need to take to reach the goal

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The Joint Commission 2010-2011 MEASUREMENT METHODOLOGY

A = All or nothing

C = Frequency Based Percentage/Occurrence

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The Joint Commission 2010-2011 SCORING

2 = Compliant 90-100% or 1 occurrence

1 = Partial 80-89% or 2 occurrences

0 = Non-Compliant Less than 80% or 3 occurrences


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The Joint Commission 2010-2011Lost Automatic deemed status with CMSProduced additional Elements of Performance to align with the Condition of ParticipationNo SupplementalsRFI’s direct and indirect

= Direct

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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON

DEFICIENCIES Rights, Responsibilities, & Ethics

Rights/Responsibilities Posted Patient gets Copy Confidentiality

Board in NuclearComputer Screens Sign in Sheets Registration Areas

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DEFICIENCIESRights, Responsibilities, & Ethics

Privacy Gowns

Security Personal Belongings

Complaint Process - Grievance


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DEFICIENCIESProvision of Care

Assessment Data & Information MRI Screening Screening/Assessment Special Procedures/Radiology Interventional Victims of Abuse

Non-inpatient proceduresHistory and Physical

Key Question-Criteria for Identifying Victims

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DEFICIENCIES Education

Appropriate to Setting Pain

Restraints Competency for Removing/Replacing Not a Restraint if used During Procedure Monitoring

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DEFICIENCIESModerate Sedation

AssessmentMonitoringPhysician Oversight (Not Nursing)Post Anesthesia Visit – 48 hours


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DEFICIENCIES

Diagnostic TestingPerformed as OrderedTimely MannerRelevant Information Prior to a Test

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DEFICIENCIES

Resuscitation

Defibrillators (APR.01.02.01)Crash CartsTackle Boxes

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DEFICIENCIESLife Safety

Statement of Condition for Health Care OccupancyNPFA – National Fire Protection AssociationFire ExitsSmoke and Fire Doors – PropsPainted over tags


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DEFICIENCIESMedication Management

Contrast Media (Medication) Proper/Safe Storage- Warmers Orders Written Clearly/Transcribed Accurately Labeling – Injectors Security of MedicationsFirst Dose Review- Protocol Based when Radiology staff is giving – not appropriate if nurse given

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DEFICIENCIESMedication Management (Continued)

No High Concentrations of ElectrolytesNo Range Orders, No Blanket OrdersOrder driven from an L.I.P.In-house prep of radio-pharmaceuticals is done under the supervision of a pharmacist or MD or DO.

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DEFICIENCIES

Medication Management (Continued) Medication errors, adverse drug reactions and medication incapability's reported “immediately” to attending


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DEFICIENCIES

Emergency Medications Crash Cart Checks Age Appropriate Contrast Media Response Kits – controlled like crash carts

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DEFICIENCIESImproving Organizational Performance

Decreasing VariationsEmployee AwarenessSentinel EventsOver-Reads QCFMEA – Failure Mode and Effect Analysis (18 months)

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DEFICIENCIESLeadership

Same Standard of Care Key Question-Are Things Done the Same Way on Weekends?Integration Across the SystemContract for Outside Sources (Nuclear Med radiopharmaceuticals)


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DEFICIENCIESLeadership

Vendor Identification/requirements5 Pillars of LeadershipDoctor of Medicine or Osteopathy

Directs Anesthesia and Nuclear Medicine

Director of Radiology and NuclearRecommends qualifications to work as a tech in Radiology/Nuclear – must be approved by the Med Staff (not just directors, but the Med Exec or Medical Staff as a whole)

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DEFICIENCIESEnvironment of Care

Doors Propped Open BiomedStaff Awareness Cidex with Gludaraldehyde and without GludaraldehydeSafety rounds – find before and they find again – leadership issue

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DEFICIENCIESEnvironment of Care

Hot Lab Disaster Role Apron/Shields – inventory and consistencyLength of CordsOff Site IssuesManifest, permits


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DEFICIENCIESHuman Resources

Staffing Medical Staff Orientation- Vendor/ContractorCompetency

Patient Population Specific Performance Evaluations

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DEFICIENCIESHuman Resources (Continued)

Files Job Description with QualificationsLicense, Registration, Certification (Primary Source)Initial Assessment Ongoing Competency

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DEFICIENCIES

Human Resources (Continued)Files

Patient Population Specific Performance Evaluations EducationHealth Screening


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DEFICIENCIES

Information Management Confidentiality/PrivacySecurity

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DEFICIENCIESRecord of Care, Treatment and Services

Verbal OrdersPost Procedure Note-Can’t Be Documented Before the Procedure (APR.01.02.01)Key Question – Do You or Physicians Document Prior to Activities Actually Happening?

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DEFICIENCIESInfection Control

Hand HygieneCidex pHSterile SuppliesRefrigeratorsWarmers – temperature checks – dates on fluids-based on manufacturers recommendationGel (Based on your own risk assessment)Cleaning of hard objects –follow manufactures recommendations


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DEFICIENCIESMedical Staff

Credentials Involvement in PI Peer ReviewFT or PT consulting radiologist supervises ionizing radiology services

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DEFICIENCIES

Nursing An RN provides or supervises nursing services 24/7

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The Joint Commission 2010-2011 NATIONAL PATIENT SAFETY GOALS


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The Joint Commission 2010-2011NPSG Significant Changes

No new ones for 2010Retained as Goals

01.01.01 Two Identifiers01.03.01 Transfusion Identification02.03.01 Critical Results03.04.01 Label Medications03.05.01 Anticoagulant – changes

- Lab work not specified – now general

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Retained as Goals continued07.01.01 Hand Hygiene07.03.01 MDRO07.04.01 Central Line Infection-

changes-Deleted chlorahexidine-scientific, literature or evidence based practice

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Retained as Goals continued07.05.01 Surgical Site Infection-

changes-does not specify debilitories meet current scientific literature or evidence based practice

15.01.01 Suicide PreventionUniversal Protocol


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Entire Goal Integrated with Standard

02.02.01 Abbreviation03.03.01 Look Alike/Sound Alike09.02.01 Falls16.01.01 Early Response

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Deleted some requirements and Integrated with Standards

02.02.01 Read Back02.05.01 Hand Off Communication13.01.01 Patient Involvement

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The Joint Commission 2010-2011Deleted

Healthcare Associated Infection as a Sentinel Event


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Significant changes…Deletion of EP 1 from NPSG.01.01.01 on two identifiers:

When active patient involvement is not possible or the patient’s reliability is in question, the hospital will designate the caregiver responsible for identity verification.

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The Joint Commission 2010-2011Significant changes…

Burdensome to fieldTwo identifiers on armband more reliable than memory of third party staff memberNote contradicted intent of EP

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Significant changes…NPSG.02.02.01 on prohibited abbreviations moved to standards for all programs


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NPSG.02.03.01 addressing timely reporting of critical tests and critical results

Field considers confusing and burdensomeRevised to focus on critical test results (as defined by the HCO)

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NPSG.02.03.01 continued

Data collection requirements no longer prescriptiveApplies only to Hospital and Lab programs

Infrastructure not available in AmbulatoryNot a major safety concern in BHC, OME, and LTC

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Significant changes…NPSG.03.04.01 on labeling medications

EP 7 (which requires HCOs to retain medication vials until completion of procedure) deleted


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Significant changes…NPSG.03.04.01 continued

Further review of this goal is expected May be incorporated into MM chapterNeed for two individuals to verify labels under discussion

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NPSG.07.01.01 on hand hygiene Modifications are intended to reflect a more realistic approach

Existence of a programGoals and demonstrable efforts to improveNo observation of hand hygiene by surveyors

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Significant changes…NPSG.07.02.01 related to HAIs as a sentinel event

Deleted due to redundancy with sentinel event policy

Other HAI requirements were phased in for January 2010


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Significant changes…NPSG.16.01.01 related to recognition and response

Moved to standardsFocus is on process for recognition and response and not on a solution

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Universal ProtocolRetain focus on safetyMore achievableAddress Main Goals

Correct PatientCorrect SiteCorrect Procedures

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The Joint Commission 2010-2011UNIVERSAL PROTOCOL

Applies to all invasive proceduresReference to minimal risk deletedThree components can readily be incorporated in all sites


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Pre-procedureReference to where and when removedTerm checklist changed to standardized list

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Site MarkingSome modification for locationSite marking may be delegated

Permitted to participateFamiliar with the patientPresent during procedure

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Qualified through residency program, orLicensed and performs duties requiring collaboration and supervisory agreements with LIPs (APRNs and PAs)


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TimeoutPrior to incisionList of issues shortened

Correct PatientCorrect SiteCorrect Procedure

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ReferencesThe Joint Commission, 2010-2011 The Joint Commission on Accreditation of Healthcare Organizations, Department of Publications Joint Commission Resources, Oakbrook Terrace, Illinois, 2010-2011 http://www.jointcommission.org/patientsafety

CMS 42 Code of Federal Regulations 482http://www.access.gpo.gov/nara/cfr/waisidx_04/42

cfr482_04.html

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Thank [email protected]

McKenna ConsultingPost Office Box 3187Charleston, WV 25332

304-988-1047

Documents

Joint Commission 2010- 2011 Update for Hospital Imaging ... · 19 The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON DEFICIENCIES ... FMEA – Failure Mode and Effect Analysis