1. 1 PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047 TJC Survey Feedback 2016

2. 2 Survey Process Opening Conference Leadership (High Reliability) Medication Management Infection Prevention Control Data Management Environment of Care Emergency Management Competency Credentials

3. 3 Historical Approach Continuing  90 + % Receive Condition Level Findings  Results in Revisits  45 days for Medicare Condition  3-6 months regular resurvey

4. 4 Most Common Conditions  Physical Environment  Surgical Services  Nursing  Governing Body

5. 5 Life Safety and Environment of Care  Over 50% findings  Majority from observation  Significant findings from document

6. 6 Units/Depts Receiving the Most Deficiencies  Operative/Invasive Areas  OR, Cath Lab, Radiology, Sterile Processing, Endo, Rehab, Anesthesia, Doctors Offices, ICU  Behavioral  Emergency Department  Provide Based Clinics  Cancer Centers

7. 7 Document Findings  Inventory of Utilities  Autopsy Findings  Tissue Records

8. 8 Medical Records  Pain  ED  Units  Learning needs assessment  Operative Report  Diagnostic Results ED and Clinics  Falls Risk  H&Ps

9. 9 Accreditation Participation Requirements APR.01.02.01 The hospital provides accurate information throughout the accreditation process (Falsification of records-Crash Carts-OR records)  None for 2016  Some for 2015

10. 10 Environment of Care Safety & Security  Eyewash stations  X-ray aprons  Oxygen storage  Access to nurse call  Behavioral health safety issues

11. 11 Environment of Care Safety & Security  MRI safety  Smoking Policy  Staff badges  Infant/pediatric abduction  Control of security sensitive areas

12. 12 Environment of Care Hazardous Material & Waste  Identify soiled utility as containing hazardous waste  Unattended/unlocked housekeeping carts  Hot lab  Staff can access SDS  Spill kits

13. 13 Environment of Care Fire Safety  Fire drills  Medical gas panels/electrical panels blocked by equipment  Equipment checks/documentation  Fire doors propped open

14. 14 Environment of Care Medical Equipment  Patient owned  Loaner equipment  Use of manufacturer recommendations  Management of radiology equipment

15. 15 Environment of Care Utility Systems  Air quality  Air exchange rates  Ventilation systems  Emergency power testing

16. 16 Environment of Care Know your own documentation even if completed by vendor

17. 17 Emergency Management  Exercises not implemented  Exercise critique with no follow through  Complete inventory list  96 hour sustainability  Leadership accountability

18. 18 Life Safety  PFIs on final JC report  E-SOC changed  Categorical waivers  Equivalency Process Modification

19. 19 Life Safety  Egress path blocked  Fire doors  Exit signs  Penetrations  Interim Life Safety Measures

20. 20 Human Resources  Organized files  Primary Source Verification  Contractors/Vendors  Non-employees

21. 21 Human Resources  Provider-based practice employees  Competency  Annual report includes staffing effect on quality

22. 22 Medical Staff  Compliance with MS.01.01.01  Non-inpatient H&P requirements  Accurate privilege list  Setting specific privileges  FPPE  OPPE  Complete credentials file

23. 23 Nursing  Nurse executive qualifications  Nurse executive oversight to all areas providing nursing care

24. 24 Leadership  Emphasis on leadership responsibility and accountability  Contract management  Policies and procedures consistently implemented  Space  Disruptive behavior  Patient flow

25. 25 Performance Improvement  Use PI data to improve patient care processes  During tracers, evaluate staff knowledge related to PI

26. 26 Performance Improvement  During tracers, look for evidence of ongoing PI activities  Performance Improvement project for each area

27. 27 Provision of Care  History & Physical is current and updated with evidence of examination  Pain assessment/reassessment

28. 28 Provision of Care  Moderate sedation – ASA and airway assessment  Problem list by 3 rd outpatient visit  Care Planning

29. 29 Provision of Care  Patient/family education  Patient communication – preferred language  Restraints  Discharge planning  Crash cart checks  Nutrition management

30. 30 Transplant Safety  Record keeping:  Verification of package integrity upon receipt  Staff involved  Allows for bidirectional tracking  Lot numbers and expiration dates of supplies used  Annual verification of FDA approval

31. 31 Waived Testing  Dating of BGM reagents when opened  Quality controls  Staff competency

32. 32 Medication Management  Medication storage  Security  Temperature  Expiration  Contrast  Multi dose vials

33. 33 Medication Management  Medication orders  Blanket orders  Range orders  Titration orders  Therapeutic duplication  Sample medications

34. 34 Infection Control  Complete IC plan and risk assessment – annual evaluation  Separation of clean and dirty equipment  TEE scopes, laryngoscope blades, Magill forceps, vaginal probes  Contact time for disinfectant solutions

35. 35 Infection Control  High level disinfection/sterilization  Storage of sterile supplies  Scope storage  Isolation practices

36. 36 Rights & Responsibilities  Confidentiality/Privacy  Informed Consent  Advance Directives  Pain management  Communication – interpreter/translator

37. 37 Record of Care  Dating/timing/authentication  Post procedure note  All orders in medical record – including protocols  Verbal orders/telephone orders  Complete and accurate medical record  Medical record audit

38. 38 National Patient Safety Goals NPSG.01.01.01: Use at least 2 patient identifiers when providing care, treatment, and services  Use of 2 patient identifiers in office setting  Forms in Medical record  Food tray delivery  Pre-labeling of containers for blood or specimens

39. 39 National Patient Safety Goals NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification  Qualified individuals  Good process to observe

40. 40 National Patient Safety Goals NPSG.02.03.01: Report critical results of test and diagnostic procedures on a timely basis.  Written procedure  Staff knowledge of organizational requirement  Use of data to evaluate timeliness of reporting

41. 41 National Patient Safety Goals NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedure settings  Bowls on sterile field  Anesthesia meds especially Diprovan  Pre-labeled syringes

42. 42 National Patient Safety Goals NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.  Written policy addressing required lab test  Staff knowledge of policy and approved protocols  Patient education  Education for prescribers/staff

43. 43 National Patient Safety Goals NPSG.03.06.01: Maintain and communicate accurate patient medication information.  List of a patient medication upon admission  Comparison of home meds to those ordered in hospital  Written information upon discharge

44. 44 National Patient Safety Goals NPSG.06.01.01: Improve the safety of clinical alarm systems By now:  Established alarm safety as priority  Identified most important alarm signals By January 1, 2016  Policies & procedures in place  Educated staff & LIPs

45. 45 National Patient Safety Goals NPSG.07.01.01: Comply with CDC or WHO hand hygiene guidelines  Failure to set goals for improving hand hygiene compliance  Lack of confidence in hand hygiene data

46. 46 National Patient Safety Goals NPSG.07.03.01: Implement EBP to prevent healthcare associated infections due to MDRO  Periodic risk assessments  Educate staff & LIPs at hire and annually  Patient/family education  Monitor MDROs in organization

47. 47 National Patient Safety Goals NPSG.07.04.01: Implement EBP to prevent central line associated bloodstream, infections  Catheter checklist & standardized protocol for CL insertion  Standardize all processes related to CL management  Periodic risk assessment

48. 48 National Patient Safety Goals NPSG.07.04.01: cont’d  Educate staff & LIPs at hire and annually  Patient/family education  Monitor CL infections- surveillance on all central lines

49. 49 National Patient Safety Goals NPSG.07.05.01: Implement EBP for preventing surgical site infections  Periodic risk assessment  Educate staff & LIPs at hire and annually  Patient/family education  Implement EBP  Monitor compliance with policies  Measure infection rates

50. 50 National Patient Safety Goals NPSG.07.06.01: Implement EBP to prevent indwelling catheter associated urinary tract infections  Insert catheters based on EB guidelines  Manage catheters based on EB guidelines  Monitor compliance with organization policy-measure effectiveness of program

51. 51 National Patient Safety Goals NPSG.15.01.01: Identify patients at risk for suicide  Applies to any patient in general hospital with a primary diagnosis or primary complaint of an emotional or behavioral disorder  Appropriate follow-up required in response to assessment-address patient’s immediate safety needs

52. 52 National Patient Safety Goals UP.01.01.01: Conduct a preprocedure verification process  Verify correct procedure, patient, site  Verify all items required for procedure available  Match items to patient

53. 53 National Patient Safety Goals UP.01.02.01: Mark the procedure site.  Site marked by procedurealist  Method of marking standardized  Written process for patients who refuse or marking is impossible

54. 54 National Patient Safety Goals UP.01.03.01: Timeout is performed before the procedure Challenges:  Failure to complete or document timeout  Failure of entire team to pause and participate in timeout  Timeout conducted too early- not immediately before procedure

55. 55 References  Joint Commission (2016). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2016  Centers for Medicare and Medicaid Services, Department of Health and Human Services. (Rev. 151, 11-20-15) State Operations Manual, Appendix A, Survey protocol, regulations and interpretive guidelines for hospitals, retrieved from http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som1 07ap_a_hospitals.pdf accessed 2/18/16http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som1 07ap_a_hospitals.pdf

56. 56 Thank you jatkins@mckennaconsulting.com McKenna Consulting Post Office Box 3187 Charleston, WV 25332 304-988-1047