Both The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) require hospitals to arm patients and families with specific instructions about how to register complaints. These expectations have likely increased the volume of complaints processed over the last year. But, even more importantly, subtle changes in the content of complaints may pose a challenge for hospitals in 2010, particularly if the impact of these complaints is underestimated.

In recent years, increased media attention on “Never Events” and the prevalence of information on the Internet have made patients and families more informed and more keenly focused on quality of clinical care. Simple complaints of rude behavior and cold food have been replaced with reports of unmet pain needs, poor quality of care, and delays in service. These precise, care-related complaints and grievances can have regulatory implications beyond monitoring of patient satisfaction.

Processing complaints and grievances within the required timeframes
(7 days) can be challenging as volumes increase. CMS Patient Rights standards require that hospitals present to all patients who submit a grievance a response that includes the minimum items outlined in the standard. The items include:

• Written notice of hospital’s decision
• Name of the hospital contact person
• Steps taken on behalf of the patient to investigate the grievance
• Results of grievance process
• Date of completion

Of course, not all grievances can be resolved within a 7-day timeframe. In those cases, patients who have submitted grievances should receive acknowledgment of the grievance and an indication of what follow-up to expect. A second letter should outline what was done on behalf of the patient to resolve the grievance.

Failure to resolve grievances in a timely manner can result in findings during a CMS review. Furthermore, when specific complaints from informed patients and families reveal gaps in nursing care, medication errors, poor infection prevention or hints of patient rights violations, CMS and the states are compelled to investigate the validity of those complaints. Thus, an increasing number of hospitals are receiving CMS complaint surveys directly related to complaints from patients and families. When surveyors can substantiate these complaints based on more detailed information provided from families, the number of condition- and standard-level violations increases, bringing more hospitals close to Immediate Jeopardy and even Medicare Termination. (For more information about how patient complaints can lead to Immediate Jeopardy citations, check out this recent article from Medicaid Compliance News.)

Visits by CMS and state surveyors to investigate simple complaints are nothing new, of course. The current danger lies in hospitals’ temptation to dismiss these visits as “routine.” As more information funnels from patients and families to the surveyors, complaints become easier to substantiate. What’s more, healthcare reform and the increased demand for higher quality healthcare are expected to result in better funding for CMS and states, specifically to monitor the quality of care provided to Medicare recipients. Such a scenario would almost surely result in more in-depth and more frequent surveys.

Organizations that fail to fully address complaints when they can be quickly mitigated will likely place themselves at greater risk for findings during CMS survey. It is anticipated that hospitals will see a rise in Immediate Jeopardy citations and Medicare Termination this year. The bottom line? Take complaints seriously in 2010!

The California Department of Public Health recently announced the latest in the series of hospital administrative penalties issued under Senate Bill SB1301. Among the latest were hospitals that were fined for a variety of patient care related issues including failure to complete appropriate sponge and instrument counts and gaps in assessment and actions to rescue patients following medication and other errors.

In 2009, the amount of the fines rose from $25,000 per incident to $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation.  Once an initial complaint is investigated, hospitals can expect regular and routine follow-up, increasing the chance of finding additional violations, and larger fines.

The California Department of Public health posts on their website the reports from hospitals that received administrative penalties.  What is interesting is that issues that led to Immediate Jeopardy situations differ only in degree from common errors that occur across the country. Hospitals should take note to make sure that they have taken appropriate measures to meet the Centers for Medicare and Medicaid Services (CMS) standards to steer clear of these kind of violations.

Proactive activity aimed at assessing a hospital’s vulnerability to these kinds of violations is the best prevention. For organization finding themselves at odds following a patient’s death should prepare themselves to deal with events that could lead to this kind of consequences.

To read more about one hospital that weathered the storm, go to “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing. ”

So you heard that the survey process was unchanged for 2010. Not so fast.

The Joint Commission’s (TJC) 2010 Survey Guide subtlety outlines a survey process that holds some surprises for the new year. The latest surprise includes a new challenge for hospitals, the requirement to develop an agenda with surveyors minutes before the survey begins.

Survey agendas vary greatly based on the number and complement of surveyors and services offered by the organization. This fact remains unchanged. What is new is the challenge to come up with a survey agenda within the first hours of survey. While this new approach allows hospitals greater flexibility in setting their agendas, the side effect may be greater chaos on the first morning of survey if they do not plan ahead.

The 2010 Survey Guide includes a Survey Activity List that outlines the sessions routinely positioned in most surveys. This list will be used by the surveyor complement to develop an agenda during the survey’s opening sessions. Hospitals will continue to receive information about the number of survey days and their surveyor complement during the pre-survey planning call with their account representatives. But now, they will have to communicate the survey agenda to staff in real time.

Stemming the Chaos
To avoid a scramble on the day of survey, hospitals may wish to outline a draft agenda to serve as a discussion document for surveyors upon their arrival. While changes may need to be made in real time to accommodate survey areas that have limited hours (like clinics), some sessions can be pre-positioned to align with the hospital’s normal routine.

Anticipating the needs of the physicians involved in the credentialing process and pre-positioning their interviews around surgical schedules or office hours can be effective in assuring their availability for the session. Hospitals with four- or five-day surveys will have the greatest flexibility in drafting agendas that can be vetted by multiple groups. Smaller organizations with less survey days may wish to create sample agendas that propose ideal sessions for a M-W survey or a W-F survey.

Taking a few minutes to address preferences and “blackout” times for survey activities in anticipation of the unannounced survey can assist in avoiding additional surprises. Rolling the dice and waiting until the morning of survey to discover the survey agenda may create more stress than necessary. Hospitals need to consider their options in managing this new aspect for surveys in 2010.

Need more?

Contact Ruth Elzer at (513) 241-0142 x 114 to discuss this latest change and receive a SAMPLE survey agenda for 2010 from which to customize your own survey plan.

Hallelujah! After reading Pam Belluck’s New York Times article on preventing hospital-acquired surgical site infections, I couldn’t help but cheer. The study published recently in the New England Journal of Medicine that focused on skin preparation brings us closer to answering a decades-old question: “Which product do we use to prep the skin before surgery?”

The seminal document, “Guideline for the Prevention of Surgical Site Infections,” published in 1999, noted the advantages of using chlorhexidine gluconate over iodophors (e.g., povidone-iodine or betadine) or alcohol-containing products. The guideline also noted that there had been no controlled studies to support recommending one skin preparation product over the others, so it was left to individual surgeons, OR teams and ICPs (Infection Control Preventionists) to implement whatever they thought best.

In the 2008, The Society for Healthcare Epidemiology of America (SHEA) published an updated guideline, “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals.” But, in this guideline, the issue of skin preparation remained unresolved, referring back to the 1999 guideline. Still no answers! What’s an ICP to do?

Then, in 2005, when the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals to report two Surgical Care Improvement Project measures (antimicrobial prophylaxis provided within 1 hour before incision and discontinuation of antimicrobial prophylaxis within 24 hours after surgery), hopes were raised once again. Perhaps the catalyst needed to provide the answer was to somehow “reward for results.” But, again, we needed the science to support the practice before including such a measure in a “pay for performance” program.

Enter Dr. Darouiche, et al., and their landmark study, which concluded, “preoperative cleansing of the patient’s skin with chlorhexidine–alcohol is superior to cleansing with povidone–iodine for preventing surgical-site infection after clean-contaminated surgery.” Many thanks to everyone involved in this monumental effort. Marcia Patrick, who was quoted in the New York Times article, got it exactly right. This is going to be a huge help, not just to hospital ICPs, but to the patients, for whom these infections will be prevented. Now, if we can just adopt this practice into our everyday work!

Though frustrating and sad, history shows it often takes 20 years—a generation—to assimilate evidence-based practices in healthcare. Perhaps the next step is to include a skin preparation quality measure in the Surgical Care Improvement Project to facilitate the rapid adoption of this infection prevention strategy. After all, we tend pay attention to what’s important to the people at the top of the hospital chain and those who pay the bills. And as humans, we tend to do those things that are fun and rewarding. We’ve waited over a decade for the answer. We shouldn’t wait another two decades to implement this important infection prevention strategy for patients undergoing surgical procedures. As Dr. Wenzel said, “Everybody wins: patients, hospitals and payors.” But, this is only true if we follow through.

So your hospital has just received a notice of Immediate Jeopardy. Now what?

Actual termination from Medicare is relatively rare, but as surveys by the Centers for Medicare and Medicaid Services (CMS) have become more thorough, an increasing number of hospitals are being forced to deal with findings of Immediate Jeopardy and subsequent termination procedures. Responding to termination procedures is inevitably stressful and confusing. To help you navigate the process, here are a couple of basic tips on what to expect and how to respond to prevent Immediate Jeopardy findings from turning into Medicare termination.

Act quickly.
The most serious of regulatory deficiencies will result in 23-day Termination Procedures. This means that the hospital will have 23 days from the final day of survey to prove that it has come into compliance with CMS Conditions of Participation. Hospitals should be equipped to react within the timeline set by CMS, while leaving extra time for the realities that accompany the process. For example, CMS estimates that hospitals will be notified of Immediate Jeopardy and the related non-compliance by Day 2. In reality, this information could arrive as late as Day 10. So, clinical and quality leaders should be prepared to act quickly, aiming to resolve the Immediate Jeopardy by Day 19, at the latest. This leaves a four-day grace period, in case of complications.

Create plans you can complete.
One way to ensure a quicker response is to develop simple, reasonable action plans. Create plans that address deficiencies quickly and that can be validated. Wide-reaching strategies for addressing problems on a large scale are wonderful, but often take significant time and effort to execute. Since the action plan has to show how the organization has become compliant by the date the plan is submitted, it is better to aim for smaller, achievable solutions, than grand plans that look great on paper but have a low probability of succeeding.

Respond to CMS, not The Joint Commission.
While the expectations of The Joint Commission (TJC) and CMS overlap to some extent, it is important to understand the differences in the way that these organizations approach compliance. TJC supports progress toward bigger patient safety goals, while CMS expects 100% compliance with basic practices, 100% of the time. So when responding to Immediate Jeopardy, action plans and verbal responses during survey should reflect the CMS perspective on quality. For example, hospitals should craft action plans that ensure full compliance with the minimum standards. Such plans are much more likely to be followed, allowing hospitals to pass their first follow-up surveys, and avoid the necessity of re-survey.

Once is enough.
If your hospital is facing termination, the last thing you want to do is lengthen the recovery process by requiring multiple re-surveys. After an action plan is submitted, your hospital will undergo a follow-up survey to verify that Immediate Jeopardy no longer exists. If the hospital doesn’t pass, it is highly unlikely that the 23-day timeframe will permit a second survey. So, it’s important to pass the first time. Also remember that the longer the hospital goes without resolving Immediate Jeopardy, the greater the likelihood that the story will hit the press.

For more information on responding to Immediate Jeopardy and avoiding Medicare termination, download “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Healthcare-associated infections (HAIs) represent a growing concern within the healthcare community. Nurse Managers are on the frontlines of the battle against HAIs and need to understand and interpret NPSG 7 to help their hospitals prevent infections and facilitate compliance with these requirements.

In 2009, three new requirements were added to NPSG 7. These three requirements are to be fully implemented by January 1, 2010.

• Implement evidence-based practices to prevent healthcare-associated infections due to multi-drug resistant organisms (MDROs) in acute care.
• Implement best practices or evidence-based guidelines to prevent central line-associated blood stream infections (CLABSIs). This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter lines
• Implement best practices for preventing surgical site infections (SSIs).

For each of these new requirements, there are three actions that Nurse Managers can take to facilitate compliance and – even better – protect patients.

MDROs

1. Educate your staff about MDRO colonization and infection. Ask the Infection Preventionist in your organization to attend your staff meeting and talk to your staff about the difference between colonization and infection, as well as the critical measures they must take to prevent transmission. This will help your staff better educate patients and families about MDROs.
2. Know your MDRO prevalence data. How often are MDROs present on your unit? What are the common sites of infection or colonization?
3. Observe patient care practices, especially hand hygiene and isolation practices. Make it a habit to round on your unit, giving feedback – good or bad – to your staff members about their practices. Let your staff know you are watching. Remember, people do what you inspect, not what you expect.

CLABSIs

1. Know your policies regarding central line insertion and care. Periodically quiz your staff members on their knowledge, perhaps rewarding correct answers with a piece of candy or gum.
2. Spot-check your patients with central lines to see if policies and procedures are being consistently carried out. Are hubs and ports being disinfected before being accessed? Are non-tunneled central line dressings transparent? Are these being changed and site care performed with a chlorhexidine-based antiseptic every 5-7 days (more frequently if the dressing is soiled, loose or damp) and gauze dressings changed every 2 days (more frequently if the dressing is soiled, loose or damp)?

Check every patient with a central line DAILY to evaluate whether the line can be discontinued. If the line is not essential, get it out.

SSIs

1. For hair removal, make it easy to find and use the right equipment (clippers) and impossible to find or use the wrong equipment (razors). Have a designated storage/charging area for the clippers and the disposable blades.
2. Although pre-operative bathing with chlorhexidine-containing products is an unresolved issue in the guidelines for surgical site infection prevention, when physician orders call for the use of a pre-operative bath or shower, make sure you have the correct products on hand.
3. Give prophylactic antibiotics on time. Pre-operative antibiotics should be administered within 60 minutes of incision (not within 60 minutes of going to the pre-op area). 120 minutes are allowed for vancomycin and fluoroquinolones.

The evidence-based science for preventing healthcare-associated infections is there. The challenge for nurses is efficient and consistent implementation of best practices. Nurse Managers play a key role in establishing a unit-based culture of zero tolerance for healthcare-associated infections. These simple strategies will go a long way in preventing infections and protecting patients.

You’ve studied the new standards, updated policies, and conducted tracers to monitor compliance. What else can you do to strengthen your hospital in preparation for more rigorous regulatory surveys? Communicate with your board! The board should serve as a resource for the hospital and provide oversight, not just for financial performance, but for quality as well.

Currently, the Centers for Medicare and Medicaid Services (CMS) require hospitals to have a governing body (the board) that is legally responsible for the conduct of the hospital as an institution. The board of a hospital is required to hire the CEO, establish a competent medical staff, and oversee key aspects of the organization, such as the strategic plan and budget. However, it’s the governing body’s role in oversight of quality care that is most commonly cited during a complaint survey.

Rather than taking an active role in ensuring patient safety, most boards feel forced into a “rubber stamp” approach to quality oversight. This is often due to a combination of factors, including confusion about how the board oversees quality and lack of adequate knowledge about patient safety. But, clinical and quality leaders can support the board in fulfilling their responsibilities. Follow these guidelines to ensure that the board is an effective resource for your hospital.

Provide your board with an orientation. While not explicitly mentioned in the standard, board orientation has become an expectation for both CMS and The Joint Commission. Board members should receive an orientation to the hospital’s quality program, as well as opportunities for additional education, if needed. Orientation also provides a chance for quality directors to learn more about the needs and preferences of the board. What kinds of people make up the board? What are their professional backgrounds? What kinds of report formats would be best to convey information to them in a meaningful way?

Make quality information universally understandable. Hospital boards generally consist of people from a wide variety of professional backgrounds. For example, think of someone in your town who owns a furniture company. She is interested in providing health care to her employees, and as a result receives a seat on the board of the local hospital. While she may have some knowledge of basic quality control, she does not know very much about the hospital’s quality standards. Therefore, the hospital must inform this board member about quality care in a way that makes sense to her. Reports should be written for a lay (non-healthcare) audience and emphasize meaningful information over data.

Outline and document specific expectations for board members. In order for the board to effectively oversee quality (or operations in general), members must be engaged, interested, and willing to ask questions. Let your board know that you expect members to challenge old ideas, and encourage inquiry when appropriate.

Hold the board accountable for quality oversight. Boards receive quality reports for two reasons, to gain information and to direct action. Be clear when you want the board to take action on an identified issue. State your recommendations, then allow the board the opportunity to act. Merely approving a report is not meaningful action when there are problems. Once expectations have been established, follow up in subsequent meetings.

Maintain transparency. Keeping the board informed is extremely important, particularly if your hospital is facing adverse survey results like Immediate Jeopardy. This is the time when the board can provide the greatest assistance. A properly informed board can be the hospital’s greatest asset when it comes to communicating with the community and mitigating the impact of negative survey results. On the other hand, leaving the board in the dark about poor survey results can be disastrous, not only for reversing the findings, but in the loss of trust of the board members and the community they represent. For more information and the story of one hospital that learned this lesson the hard way, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

The idea of a hospital near-death experience might sound a bit strange. What would cause a hospital to “die,” and how could it “come back to life?”

For one hospital, near-death came in the form of Medicare termination. “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing,” the new whitepaper from Compass Clinical Consulting, tells the story of Haywood Regional Medical Center, examining some of the factors that brought this organization to the brink of collapse and the swift action that allowed it to thrive again.

Since October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) have held hospitals responsible for preventing hospital-acquired conditions (HACs). Some hospitals have focused on detecting conditions that are present on admission. Others have addressed the complex issues surrounding prevention of injury. But, given the competition for resources during tight economic times, many hospitals are unable to provide adequate resources to achieve their goals in both areas.

When more information about the impact of HACs becomes known, the degree and intensity of focus placed on preventing these conditions may change. Until then, hospitals will continue to do what they can to address the risks associated with HACs and introduce performance improvement efforts to reduce their impact.

Increasing the awareness of HACs and their impact on patients and the hospital is an important step toward focusing on HAC risk reduction. Presenting needed information on HACs in a creative way can set it apart from “routine” education. As Halloween approaches, consider adopting a “Haunted Ward” for in-service education.

Haunting a “ward” – either a classroom, out-of-use patient room, or other set-up – encourages staff to learn serious lessons in a fun setting. In a mock patient setting, dummies can be set up for failure to provide a scavenger hunt for risks factors for HACs. Consider the following “tricks” for targeting HACs.

Foreign Object Retained After Surgery

• Abdominal x-ray on the viewer with an obvious instrument
• Time-out documentation filled in incorrectly, surgical counts incomplete

Air Embolism

• Open ports on CVCs or PICC lines, or large air bubbles in IV tubing

Blood Incompatibility

• Blue blood hung on an IV pole that does not match a blood bracelet
• Unit past “administer by” time
• Blood slip does not include one of the two required signatures
• Patient vital sign record shows temp of 102

Stage III and IV Pressure Ulcers

• “Admission” mannequin shows red area on coccyx
• Band-Aid over red areas on heels
• Absence of pressure relief mattress
• Patient incontinent with pumpkin orange urine

Falls and Trauma

• Fractures
• Mannequin positioned with one leg shorter than the other
• Intracranial Injuries
• Mannequin shows unequal pupils and notes showing neurological assessment
• Burns
• Red area immediately in contact with heating pad
• Electric Shock
• Mannequin/skeleton soaking in a therapy tub with an electrical appliance in hand (radio, hair dryer)

Catheter-Associated Urinary Tract Infection (UTI)

• Foley bag positioned with dependent loops

Vascular Catheter-Associated Infection

• “Creepy” fluid under clear bandage at insertion site
• Label date exceeds policy for change frequency
• Catheter inserted in groin
• Poorly secured/protected catheter and tubing

Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Mannequin with a knee immobilizer using CPM machine as a foot stool instead of intended use

No educational approach can guarantee results, but entertaining illustrations can help to communicate key messages about important topics like HACs. Using a light-hearted but thorough approach, like a “Haunted Ward,” can bring home important lessons in a way that is fun and memorable.

By Ruth Elzer, RN, MS

Keeping up with the changing implications of The Joint Commission’s standards continues to be a challenge for many hospitals. Just when hospitals settle on tracer tools and checklists, word comes that The Joint Commission’s surveyors have developed a new “twist” on how they determine compliance on certain standards.

Keeping tracer teams up to date on the latest interpretations and survey methods is an ongoing challenge. Checklists can assist in addressing the static standards that have changed little since the early 1980s. But, the evolution of other standards and increasing pressure from the Centers for Medicare and Medicaid Services (CMS) will force tracer teams to be more knowledgeable and skilled to protect their hospitals from unexpected survey results.

Limitations of Checklists
If you don’t update your checklists every few months, you may be vulnerable. Some elements regarding fire equipment checks and security procedures may remain unchanged, but other standards interpretations change, and expectations become clearer over time. Out-of-date checklists often fail to address all of the requirements needed to comply with newer or changed standards.

Checklists are valuable tools. They provide a source for objective evaluation of specific items and assist in assuring reliability among observers. However, checklists should be reserved for evaluating standards and expectations that fit the following characteristics:

• Items listed can be clearly defined in terms of expectations (yes/no, present/absent, in place or not)
• Expectations leave limited room (or no room) for interpretation by the data collectors
• Items listed have been stable over a period of time and are not likely to vary much in the future
• Expectations can be evaluated though a clear cause and effect (if antibiotic was ordered, was it given within one hour of incision)

Individuals best suited for tracer teams that utilize checklists are those who are rules-driven and unlikely to deviate from the established checklist or give someone “the benefit of the doubt” in scoring compliance. These individuals can often be found outside of the traditional roles recruited for tracer teams (e.g., medical records, engineering, or IT).

Tracer Team Competency
To monitor compliance with new interpretations of old standards, new or evolving standards, and old standards applied to new or unique settings, you need tracer teams that understand the standards, rather than just following checklists. Evaluating compliance in these areas requires higher levels of familiarity and competency, since it introduces an element of subjectivity. This is where consistent communication of concepts underlying tracer activities becomes critical to success. Consider the following.

• What concept or principle is at work behind a “rule” or procedure in the hospital, and how does it relate to a regulatory standard? For instance, “no storage within 18 inches of the ceiling,” is not a regulatory standard. But, it is enforced by some hospitals to simplify compliance with the rule, “no storage within 18 inches of sprinkler heads.”
• What minimum expectations have been set during orientation or in policy? Determining compliance by comparing “what I would do” vs. what was done will result in wide variety of compliant, and non-compliant practices.
• What standards apply to this patient’s situation? Not all standards apply equally to all patients. Establishing which standards apply in which cases is often the greatest challenge for inexperienced tracer teams.
• How should the standard apply in this situation? Often, what people identify as “standards” are really expectations that apply to the most common situations. For example, corridor clearance can be less than 8 feet in some cases. Knowing the expectations and the rules becomes important to assure that non-compliance is not inappropriately assigned by tracer teams.

Educating Tracer Teams
Educating tracer teams may not initially seem necessary, since every manager “should know” how to be compliant. However, this assumption is seldom correct. Establishing a baseline set of expectations and skills for tracer team members can mean the difference between a tracer team that occasionally stumbles on killer survey targets and teams that regularly identify and mitigate regulatory issues.

Recruiting and retaining tracer team members with a variety of skills also increases the scope and effectiveness of your tracer teams. Consider establishing one team of people to evaluate compliance through checklists and another comprised of people with more advanced tracer skills. This strategy is one way to ensure that tracer teams are utilized efficiently.

Keeping the skills of tracer teams up to date can be difficult, given the multiple demands on their time. Updating teams on the latest changes in the standards and survey process requires additional time from both the accreditation coordinator and the team members. Consider education options that make the most of educators’ and tracer teams’ time. For example, audio-conferences or individualized training for tracer teams can update skills efficiently and at a relatively low cost to hospitals.

By Ruth Elzer, RN, MS

The recent article from Health Leaders entitled, “12 More Hospitals Fined For Putting Patients In Immediate Jeopardy” illustrates only one aspect of the costs of poor survey results. The fines being levied in California and other states only add to the costs associated with addressing Immediate Jeopardy, and in some cases, Medicare termination. While some hospitals will continue to believe, “this will never happen” to them or that CMS “can’t do anything ‘real’” to them, more and more hospitals are finding themselves in Immediate Jeopardy with short timeframes for compliance.

Efforts by quality leaders and CMS continue to track quality outcomes through core measures and QIO activities, but they also monitor ‘never events’ and blips in quality that can lead to more attention by state survey agencies and others. Pending health care reform is likely to continue the wave of transparency, requiring hospitals to share both good and bad outcomes. This will make more hospitals vulnerable to unexpected visits by regulators, unexpected fines, and potentially devastating violation reports. While prevention may be prudent and advisable, hospital leaders must also possess an immediate game plan for dealing with poor survey results that leads to a quick return to compliance to avoid further scrutiny by others.

By Ruth Elzer, RN, MS

The news from the Joint Commission’s Hospital Executive Briefings is always a mixed bag of information. This year is no different. Hospitals surveyed as part of a healthcare system, though, should brace themselves for a big change.

Ann Scott Blouin, Executive Vice President for Accreditation and Certification Operations at the Joint Commission, announced yesterday that hospitals currently undergoing the system survey option will experience changes in their survey processes.

Currently, hospitals surveyed as a part of a healthcare system begin their surveys with an orientation and opening conference that surveys standards that apply to all sites within the system. The surveys of individual hospitals within the system then follow in subsequent weeks using common surveys, when possible. This process provides some “advanced warning” to hospitals in the system, allowing them to anticipate surveyor arrival and be prepared for surveyor “preferences.”

However, by July 15, 2010, the Joint Commission will retool the system survey in the following key areas:

• Surveying the shared services and functions together, much like in the past
• Immediately conducting concurrent surveys in each of the hospitals within the system
• Providing the assistance of a field operations representative from The Joint Commission to assist with the survey. The field operations representatives are also the individuals who commonly provide input into the evaluation of surveyor performance. The degree to which these representatives will be “watching” the surveyors is unknown.

These significant changes in the approach to system surveys will likely cause hospitals to reconsider the system option. The Joint Commission will contact health systems in the coming months, urging them to make decisions about how their component organizations will be surveyed.

Systems and individual hospitals should consider several key points when making their decisions about the system survey option.

• CMS and The Joint Commission will align to provide one accreditation decision for each Medicare entity (one Medicare number=one accreditation decision). In systems with only one Medicare number, this may raise the risk to the entire system when one hospital’s performance lags behind that of the others.
• Concurrent surveys will likely multiply, rather than add to the number of individuals needed to “host” and manage the survey process. System quality representatives will be spread thin during a visit and have less ability to share information between hospitals.
• Concurrent surveys will eliminate the advantage that system surveys previously held in using the results of the first survey to improve results of subsequent surveys.

These factors, in addition to the cost associated with the system survey option, should be thoroughly investigated before hospitals agree to continued survey as a part of their health systems.

By Ruth Elzer, RN, MS

Even the best, most well-reasoned policies will not be followed if they are not communicated effectively to clinicians. Therefore, once the policy is ready, it is important to consider the best way to communicate the information at the bedside.

Whenever possible, avoid sending out a copy of the policy. Communicating changes in this fashion decreases the likelihood that the information will be read, and essential messages for patient safety will likely get lost.

When designing educational opportunities for communicating changes in policy, consider these additional tips.

• It is perfectly permissible to communicate expectations that rise above policy. Telling staff to assess pain every 4 hours makes compliance with a policy that requires assessment every 8 hours more manageable. Quality monitoring of both the minimum and the goal interval can let you know when a higher goal is going to work in the clinical care setting.
• For revised policies, only communicate the changes in the policy. Grammatical changes and references to names of equipment make little difference to caregivers. Stick to changes in the essential messaging categories outlined above.
• Use creative ways to communicate changes. “Potty pages,” posters, and quiz games are effective methods of communicating information without requiring scheduled classroom time.
• Utilize quality data to know which aspects of the policy or procedure need to be added to the education. Education on the choices for pain scales may not be needed if quality data show compliance in this area. Covering only the essential components, such as frequency and content of pain assessment, focuses your message and decreases the time it takes to disseminate it.
• Utilize unit champions for education. Clinicians often “hear” the message better from a peer in the trenches than an educator who has never used the policy in practice. When the education is done, the unit champion can become both the advocate and the “secret shopper” for compliance monitoring.

While writing comprehensive and realistic policies is important to closing the gap between policy and practice, communication is absolutely essential. When caregivers understand policies they are more likely to follow them. Finding ways to efficiently highlight the essential messages ensures that clinicians receive the information they need in a way that supports understanding and compliance.

By Ruth Elzer, RN, MS

To close the gap between policy and practice, the first step is to write a well-crafted policy that actually reflects the elements of care at the bedside.

Writing policy calls for more than knowledge of the policy content – it requires an understanding of how to communicate the information most effectively. The goals of an effective policy are different from the goals of the education associated with communicating the policy. Written policies should:

• Establish the minimum expectations surrounding a particular activity or action;
• Outline the responsibilities of the individuals involved; and,
• Set minimum rules for documentation or communication (as applicable).

Bearing in mind that policies communicate concepts, while procedures are a set of steps, consider the following tips.

• Procedures should be logically communicated, indicating what should be first, second, and third. Consider creating a flowchart of the process prior to converting it to policy format.
• Before writing, determine essential messages, such as regulatory elements, what to do, safety aspects, and important documentation elements.
• Write policies from both the regulatory end, where regulations inform changes, and the bedside, where practice drives change.
• Modifications should reflect a change in message or clarification of a component of the message.
• Establish actions and “rules” to comply with regulatory requirements in the context of your organization. Avoid the use of regulatory language, as it seldom means much at the bedside.
• Do not set expectations that cannot be met in a live patient setting, as policies and procedures should set only minimum expectations for care. For example, a policy might require that patients are asked about bowel movements at least once per day, but the flowchart for the policy actually leads caregivers to ask once per shift. This practice would assure that the daily expectations are met, even if the midnight shift was unable to ask a sleeping patient. Policies written in this way will be technically compliant, but they could also confuse a new nurse.
• Be cautious when copying policies from other organizations or policy templates. They often contain references to parallel processes not in place in your organization. Change references to other hospitals and procedures that do not apply at your organization.
• Ask a “non-healthcare” person to review the final version of the policy for clarity. Does it pass the “essential messaging” test?
• What am I expected to do and not do?
• What comes first, second, third?
• What should I watch our for?
• Assessment guidelines, side effects, warning signs
• What do I do if . . . ?
• When to call the physician or administration
• What do I document?
• Documentation guidelines
• Where can I go for more information?
• References

Once the policy has been finalized, it must be communicated to clinicians. Whether or not a policy is followed can have as much to do with the way it is communicated as the policy itself. Stay tuned for Part III of this series, “Communicating the Essential Messages.”

By Ruth Elzer, RN, MS

One of the alarming trends in survey findings since 2004 is the apparent disconnect between policy and practice. At the bedside, well-thought-out policies are used by large numbers of clinicians who may not understand their subtleties, potentially resulting in unpredictable and sometimes deadly results.

Since The Joint Commission moved to the tracer methodology, forcing surveyors out of the board room and to the bedside, the gap between written policies and their implementation has widened. Often, the actions dictated by educators, managers, and compliance experts are not demonstrated during survey, resulting in Requirements for Improvement from The Joint Commission, and deficiencies from CMS.

The majority of hospital policies and procedures come under the authority of key stakeholders, such as educators, managers, and quality staff. They are then approved by leaders and medical staff, who depend on the stakeholders to assure that the policies are both compliant and practical for frontline care.

Too often, the first test of the practical elements of care comes when the policy is tested in real life settings with real life patients. Only then do clinicians discover that the policy lacks detail, refers to mechanisms or equipment not in place in the organization, or calls for a skill not known to the individual assigned. This is when policies can become deadly to patients.

This three-part blog series will look at the dangerous gap between policy and practice and give tips for writing and communicating policies to ensure understanding and compliance. Stay tuned for Part II of this series, “Writing Effective Policies.”

By Ruth Elzer, RN, MS

Hospitals across the country continue to struggle with the issue of how to dispose of medication patches in a manner that is both safe for patients and families and convenient for caregivers.

Advocacy campaigns, including SMARxT Disposal* have attempted to enlighten caregivers and the public about the potential impact that discarded drugs can have on the environment. The White House’s Office of National Drug Control Policy has also issued general guidelines on the disposal of prescription drugs for consumers and professionals. Yet, regulatory agencies have few regulations applicable to hospitals regarding the disposal of medication patches.

Meanwhile, emerging information suggests that some medication patches are being misused and even abused. Lingering and unpredictable levels of medications are still contained in medication patches at the time of scheduled removal, and they can represent a risk to patients or caregivers if not disposed of properly. In addition, medication patches containing pain control substances hold a potential for abuse, adding further importance to the issue of properly securing medication patches upon removal.

Some hospitals have implemented home-like policies, such as disposal of patches in trash receptacles. Others have implemented policies for disposal of patches in medical sharps bins, which are later incinerated. This strategy holds unknown risks for individuals involved in the disposal process. Flushing patches down the toilet – another disposal option – sends medications into the municipal waste system with little-known effects.

In short, there is no certain best practice that applies to hospitals.

To provide some clarity, the following table has been compiled to assist organizations in establishing a policy that meets manufacturer’s recommendations for the most common patches used in hospitals. Please follow the “Source/More Info” links for further information. If your server disables links, visit www.hospital-accreditation.com, to explore this table further.

As with all medications, it is recommended that all used patches be kept out of the reach of children and pets.

Establishing Policy
To establish a policy regarding disposal of medication patches in your organization, consider the following steps:

• Evaluate which medication patches are commonly used in your organization.
• Review diversion reports for any risks associated with medication patches.
• Review the manufacturer’s recommendations for each medication patch used in the organization.
• Consider any local requirements for municipal disposal of medications.
• Review current practice with frontline caregivers to determine options for compliance and gain insight into common use.

Finally, pilot test the new policy to assure that sufficient safeguards have been taken to protect patients, their families, and other caregivers from the effects of discarded patches.

For information regarding disposal of medications in general, click here.
To see the publication from the Office of Drug Control Policy, click here.

*SMARxT Disposal is a public awareness campaign that targets medication consumers to provide guidance on proper disposal of unused and or expired prescription and over-the-counter medications. SMARxT Disposal also raises awareness about the potential environmental impacts from improperly disposed medications. SMARxT Disposal is a unique public-private partnership between the U.S. Fish and Wildlife Service, the American Pharmacists Association, and the Pharmaceutical Research and Manufacturers of America.

By Kate Fenner, RN, PhD

The July edition of “The Joint Commission Perspectives” contained an ominous signal for hospital executives facing survey and accreditation decisions in the coming months. The publication lists examples of items that can be reviewed by the Joint Commission’s Central Office. Of particular concern is the mention of situations in which the “surveyor has identified leadership changes over the past 12 to 18 months.”

The implicit threat is that surveyors will be able to subjectively evaluate the motivations leading to leadership changes at hospitals. Specifically concerning is the notation of what the Joint Commission has deemed “negative change,” when new leadership is tasked with finding cost reductions without sufficient attention to patient safety issues. In the hands of a subjective surveyor, a change in nursing or other clinical leadership might be interpreted as not supportive of safety, regardless of the realities of fiscal constraints.

Leaders will have to pay increased attention to documentation of organizational initiatives, with a particular focus on inclusion of patient safety rationale and/or evaluation in change processes. It seems this is just another gift from TJC to the average CEO or COO.

By Ruth Elzer, RN, MS

A Cautionary Tale

A real survey may be the first opportunity to discover that fire exit and directional signs do not correctly identify fire exit routes. This is particularly common following renovations of different areas that may have impacted fire egress routes. Instructing staff on the “rules” surrounding fire egress is important to assure not only that they understand how to evacuate patient safely, but also that they understand that it is not permissible to store items in the egress corridors. Instructing staff on how to tell the difference between an exit corridor and a cross corridor (which may be used for storage) is an area that many organizations overlook.

Lessons learned

This picture illustrates one aspect of improving tracer rounds. Ask teams to trace in areas with which they are unfamiliar, and ask them to follow signs to a fire exit. Doing this as the final step of the tracer is most effective, in that it ideally starts at a patient’s bedside and continues until the individual is outside. Tracing down the hallway to a fire door is only one part of the exercise. Following the stairwell down to the street allows for the identification of obstructions in the fire exit stairwell (which would result in Immediate Jeopardy), and tests whether the exit to the street is free of obstruction and snow. Conducting functional tracers like these is especially important when Interim Life Safety Procedures are initially put in place. Plans on paper do not always match those in real life, and tracer teams should be prepared to conduct tracers as new projects become active.

By Ruth Elzer, RN, MS

Ready-made labels are a time-saving device that clinicians have depended on for years. Whether used to denote when IV tubing will expire or direct when to throw out the green gelatin in the refrigerator, labels communicate information between caregivers. The requirements for the appropriate use of labels have been stepped up since the introduction of the National Patient Safety Goals (NPSGs), but hospitals are discovering that the requirements do not end there.

Labeling requirements outlined in NPSG.03.04.01 are precise, establishing a structured process for labeling items when they are added to the sterile field. Common violations of this standard include:

• Medications drawn up in a syringe are either not labeled or include an incomplete label with only the name of the medication listed.
• Medications and solutions used during minor or bedside procedures are not managed in a manner similar to the process in the OR.
• Failing to keep used vials and containers until after the procedure, particularly with bedside procedures.

Since many organizations have improved compliance with this NPSG, surveyors have turned to other labeling issues that can be surveyed under MM.05.01.09. This extends the surveyor’s reach from the OR, where staff are ready for questions, to the bedside, where staff may not be prepared. The highest risks seem to include:

• Medications (such as insulin), that are prepared in advance, perhaps following a “double check” and then placed, unlabeled, in the patient’s medication drawer until given.
• Failing to label medications that are to be administered by someone else.
• Incomplete information on antibiotic bags.

Many organizations use pre-made labels that contain only a portion of the information that clinicians should record as part of the process. Label manufacturers responded to the NPSG by producing labels, syringes, and other devices to make compliance easier. Having access to convenient labels is only one part of the solution for assuring compliance within the facility.

Complete labels, complete compliance.
Pre-printed labels provide some information, but there are occasions when labels must be created on the spot. To measure compliance, make sure your tracer teams check for the following:

• Medication name, strength, and amount, if not already present on the container. This includes listing the name and concentration of the diluent, particularly for IV medications. This is important for labels in common use in the OR that only contain the name of the medication but require the clinician to write in the concentration.
• Date prepared, applicable expiration times, and admixtures for any medications mixed outside the pharmacy (includes oxytocin mixed in the OR by anesthesiologists).
• Ensure that solutions, including “saline” are labeled with the appropriate concentration. Be cautious of solutions that may be made in more than one concentration, particularly antibiotics.
• When labels are used, include any information not already written on the container, and assure the label does not obstruct the container label.
• Score noncompliant any syringes or containers found to be empty. No pre-labeling of syringes is permitted. All manufacturer pre-labeled syringes should be discarded.
• Initials of the individual preparing the medication are also recommended.

Tracer teams should not limit tracers to the procedural suites (OR, ED, cath lab). Off-shift procedures done at the bedside are the source of common errors, as are procedures done in outpatient areas.

Next steps
Conduct a “treasure hunt” of all areas where procedures are performed, and look for any pre-labeled syringes, unlabeled pre-drawn syringes (yes, those syringes nurses are drawing out of a common IV bag), and labeling materials. Assure that sterile pens and labels are available to procedure personnel. Select each type of label available and post in a local area an example of compliant (and perhaps noncompliant) labels to illustrate expectations. Track and trend compliance both by location and circumstance to discover weaknesses in type of procedures or activities, and categories of caregivers. Assure that compliance data is shared with all applicable staff including the OR, cath lab, procedural areas, and applicable outpatient locations.

By Ruth Elzer, RN, MS

The Joint Commission (TJC) continues to work with the Centers for Medicare and Medicaid Services (CMS)  to complete an acceptable deeming application for its hospital program. The Medicare Improvements for Patients and Providers Act for 2008 (MIPPA) revoked the Joint Commission’s statutory deeming status for its hospital program, mandating a reapplication process before its term of approval expires July 15, 2010. The changes in the Joint Commission standards and survey process over the last year—including those in January and again in March—are part of that effort.  The next phase of that process is upon us, and it’s your turn to be heard.

CMS announced today that it will accept comments from the field about the Joint Commission’s deemed status application. In today’s Federal Register, CMS calls for “public comment on whether the Joint Commission’s requirements meet or exceed the Medicare conditions for participation for hospitals.”

The comment period opens today and will close on July 27, 2009 at 5 pm. Hospitals will have the opportunity to comment on their experiences with the Joint Commission survey process and factors that may impact the deeming process with CMS. To provide comment, individuals and organizations should respond according to the instructions written in the notice, using the file code of CMS-2302-PN. In short, hospitals have the option of providing comments via one of four ways:

• Electronically by going to www.regulations.gov and selecting More Search options and follow the direction under the Find and Take Action tab.
• By regular mail using the Baltimore address listed in the notice
• By express or overnight mail to the Baltimore address listed in the notice
• By hand or courier, using either a Washington, DC or Baltimore, MD address posted in the notice.

The notices describes the criteria to be considered in evaluating the Joint Commission’s process for deemed status consideration. The major factors to be considered include reviewing the accrediting organization’s:

• Requirements for accreditation
• Survey procedures
• Resources for conducting required surveys
• Capacity to furnish information for use in enforcement activities
• Monitoring procedures for provider entities found not in compliance with the conditions or requirements, and,
• The ability to provide CMS with the necessary data for validation.

Through comments received in these specific categories, CMS will evaluate the effectiveness of Joint Commission’s methods in demonstrating that all applicable Medicare conditions are met or exceeded. While many people might share the frustrations of trying to attain the rigid requirements of National Patient Safety Goals, remember that these requirements rise above the CoPs and are not an essential component of CMS’ oversight of the Joint Commission. Here are some suggestions for preparing your comments for CMS:

1. Requirements for accreditation-This area probably will receive the largest number of comments. The question is whether the Joint Commission’s standards meet or exceed CMS Conditions of Participation. Any hospital that has undergone a validation survey can share their experiences of how well TJC surveyors identified deficiencies compared to the follow-up survey by the state. Many known gaps in the standards were remedied in the January and March standards release from the Joint Commission, but some still remain. (See “A JAYCO Tap: Privileging by Proxy.”)
2. Survey procedures- Hospitals should comment on experiences during survey, evaluating the differences between the conduct of TJC and state surveyors and related survey procedures. Inconsistencies between TJC surveyors have been a common theme of dissatisfaction shared by hospitals.
3. Resources for conducting required surveys- This deals with the Joint Commission’s ability to continue to conduct surveys, both expected “triennial” surveys, and those required by events, such as sentinel event surveys. Factors to be considered include the surveyor cadre, financial resources of the Joint Commission, and technical support.
4. Capacity to furnish information for use in enforcement activities- This commonly refers to information shared between TJC and CMS representatives at the state and regional level for the purpose of enforcement actions.
5. Monitoring procedures for provider entities found not in compliance with the conditions or requirements- This criterion sparked the change in ESC responses over the last year. All less-than-compliant findings require follow-up, consistent with CMS procedures. However, the 45/60 day follow-up procedures are unique to the Joint Commission and may spark some comments.
6. The ability to provide CMS with the necessary data for validation- This refers to information shared with CMS and the states for the purpose of validation surveys, including the dates of survey and the results of survey.

This comment period represents an opportunity for hospitals to share their thoughts on the deemed status application and suggest improvements prior to its approval in 2010. Similarly, CMS is seeking comments on the deemed status application for the Joint Commission’s Critical Access Hospital program and the American Association for Accreditation of Ambulatory Surgery Facilities survey process.  The links to the instructions for comments are listed below.

To link to the Federal Register notice for hospitals, click here.
To link to the Federal Register notice for Critical Access Hospitals, click here.
To link to the Federal Register notice for American Association for Accreditation of Ambulatory Surgery Facilities, click here.

By Amanda Brown, RN, BSN, MSM, CIC

The economic impact on hospitals continues to play out across the country. The latest area of focus seems to be the resources provided to manage infection control programs. Even as the H1N1 pandemic looms, half of the IC professionals responding to a recent survey reported reductions in overall budgets for infection prevention.

Nearly half of the respondents to the 2009 Association of Professionals in Infection Control & Epidemiology (APIC) Economic Survey reported that State laws requiring public reporting of healthcare associated infections (HAIs) make it harder to focus on preventing infections. 

This is a public health threat with acute care implications.

The APIC Economic survey gathered responses from nearly 2000 members to summarize the implications of economic cuts on infection prevention and response. Lagging technology and cuts in educational budgets were cited as common denominators across the country.

The most immediate troubling piece is that as surveillance and prompt action are needed to stem the spread of the H1N1 virus, resources for prompt detection and prevention of spread of disease are being cut.  The combination of limited data mining systems to detect illness and less-than-adequate infection surveillance programs contribute to a poorly prepared hospital, leaving the surrounding community less protected.

Balancing cost savings and community protection

While organizations may need to tighten budgets to survive the economic crisis, they need to do so in a way that protects the safety of patients and the community.

Building capabilities aimed at using data effectively instead of creating data is key to a more efficient infection control program. Surveillance should stop being about monitoring cases, cultures and reports, and focus more on practical use of the information derived from the data.

Monitoring isolation practices during an outbreak and coaching staff on effective measures will impact patients more immediately than hours in the classroom speaking about potential modes of transmission.  The defeat of a pandemic will not lie in the data derived from its victims, rather, from applying lessons learned from the past, tempered with current information about the local spread.

There was much publicity when the Centers for Medicare and Medicaid (CMS) placed wrong-site surgery on the list of “Never Events” for which Medicare would not pay hospitals. In publishing the “Never Events” list, CMS said that the federal government would no longer pay hospitals when the wrong surgical procedure was performed. Few people, including hospitals, argued with the idea that hospitals should not be paid for doing the wrong surgical procedure. By denying payment to hospitals, CMS decided that hospital leadership needed to ensure that proper procedures were followed to prevent these wrong surgeries.

What the public may be surprised to know is that as recently as the first half of 2008 (prior to implementation of the “Never List”), twenty percent of Joint Commission surveyed hospitals were cited for failing to have a proper “time out’, part of the Universal Protocol, the process designed to prevent wrong-site surgery.  To properly implement this patient safeguard, all members of the surgical team (surgeons, nurses, anesthesiologists) must stop what they are doing and participate in the “time out”.

Recently, CMS clarified its intentions for non-payment for services related to wrong-site surgery. Additional information released in Transmittal 1755 on June 12, 2009 stated that surgeons and other practitioners, including anesthesiologists, will not be paid for professional services associated with wrong-site surgery because “Medicare will also not cover hospitalization and other services related to these non-covered procedures.“  These include:

·                     All services provided in the operating room when an error occurs are considered related and therefore not covered.

·                     All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment.

·                     All related services provided during the same hospitalization in which the error occurred are not covered.

While hospitals have realized the potential impact of wrong-site surgery on their payment, physicians such as anesthesiologists and radiologists, may not be aware that payment for their services will also be denied.  It may be logical to deny payment to anesthesiologists who should be part of the “time out” procedures, but it is harder to build a logic that justifies denying payment to physicians who were not involved in the surgical mishap and are subsequently brought in to “rescue” the patient. Isn’t this punishing the innocent as well as the guilty?

Nevertheless, the intent of this announcement is a good thing: to provide additional incentives to gain compliance with patient safety procedures to prevent wrong-site surgery. Non-committed participation by all members of the surgical team is unacceptable. Attempts to influence behavior by reasoning and trumpeting the cause of patient safety have not seemed to be enough to adopt new behaviors. It will be interesting to see whether the addition of this financial incentive improves the adoption of this patient safety procedure. If it isn’t enough, the next steps are likely to be more draconian. 

To read the Full Transmittal.

By Ruth Elzer, RN, MS

Earn cash for Joint Commission Compliance?

Well, not in the way that you think.

EARN CASH is a mnemonic device that outlines expectations for patient education in applicable patients. The expectations for the specific elements of patient education have gradually increased over the years and have now been combined under a single standard, PC.02.03.01.

The EARN CASH  mnemonic was designed to remind clinical staff of the elements that need to be addressed in patient education documentation, as applicable to the patient’s individual plan of care. The mnemonic reads as follows:

E- Equipment being used in the hospital and medical equipment anticipated for home use
A- Assessment of pain and pain management techniques, including the use of an appropriate pain scale
R- Rehabilitation techniques, such as crutch walking, and activities of daily living
N- Nutrition, including prescribed diets

C- Care plan, such as expected time line of hospital stay and discharge planning
A- All medications, including topical and respiratory medications
S- Safety, which may relate to fall prevention, cal bell use or participation in the safety program, including the National Patient Safety goals
H- Health and hygiene, including oral hygiene for applicable patients

Compliance with PC.02.03.01 is not solely dependent on meeting the expectations of EARN CASH. The process is the implementation aspect of the education standard. The first several EPs of the standard outline expectations for the learning needs assessment, completed on admission, which include the following elements:

• Cultural and religious beliefs
• Emotional barriers
• Desire and motivation to learn
• Physical and cognitive limitations
• Barriers to communication

The final EP of the standard is a “C” standard necessitating an MOS that requires that the hospital evaluate the patient’s understanding of the education and training provided.

What is the best approach?

While timely and complete patient education is a requirement, the Joint Commission allows for great latitude in how the education is documented. The right solution for each organization is going to be based on the options available, habits of various disciplines and the nature of care provided. The important thing to remember is that a single solution may not be the right answer. A combination of approaches that differs according to the care provided (inpatient vs. Outpatient) may hold the most complaint solution. When determining the solution that is right for you, consider the pros and cons. This tool lays out some general approach categories and their positive and negative aspects.

Next steps:

Choosing the best way to document patient education will largely be dependent on the options open to each patient care area. Regardless of the choice you make, the EARN CASH mnemonic can be helpful in assuring compliance.

Consider using it in one of the following ways:

• Use it to create categories on a multidisciplinary flowsheet for education documentation.
• Work with IT to integrate education into patient activities in each category. For example, when oral hygiene is documented, an educational screens pops up to record that activity as well.
• Use it for educational posters to remind staff to document key aspects of patient education. Prepare a different poster for each unit with examples serving as a case study of a common patients seen.
• Use the EARN CASH  mnemonic as a quality collection tool for proactively measuring compliance with PC.02.03.01.

Need more?

If you are struggling to understand the expectations for this topic or other areas, call for a free phone consultation. Call Ruth Elzer at 513-241-0142

By Ruth Elzer, RN, MS

“I bet you’ve seen it all,” is a comment frequently heard during mock surveys. Indeed, recent consultation with several Compass Clinical Consulting clients concluded with the discovery of radioactive food products being prepared and consumed in the nuclear medicine department. Further investigation and polling of others concluded that this could be happening in your organization.

Nuclear tracers have long been used to trace and diagnose a variety of conditions of various body systems. Gastric emptying studies, commonly used to diagnose gastric emptying dysfunction, have a variety of applications including diagnosis of diabetic gastroparesis and other slow gastric emptying diseases. This study consists of a test meal composed of food inoculated with a radionucleatide tracer that is eaten and then tracked using nuclear diagnostic equipment. Common test meals include scrambled eggs, egg salad, or prepared oatmeal. Where and by whom that meal is prepared varies greatly.

An informal phone survey of Compass Clinical Consulting clients revealed wide variation in the mechanisms in place to assure appropriate safety for these patients and their caregivers. Some departments were found to be preparing eggs for inoculation and consumption in the hot lab; others received prepared, inoculated eggs from a radiopharmaceutical warehouse. While most had appropriate policies and procedures in place for conducting the study, gaps in compliance were seen in the policies governing the preparation of the test meal, storage of food products outside of the kitchen, and care of the patient following the study (including management of contaminated emesis).

From a regulatory perspective, the most common tracer points for this procedure that would come into play would include:

• Storage and preparation of the Technetium for inoculation of the test meal
• Preparation of the food component of the test meal (in compliance with the FDA Food Code)
• Policies, procedures, and protocols for administering the test and contrast agent.
• Post-test care of the patient and relevant precautions.

In the 2008 publication Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine, recommendations for patients undergoing the procedure are outlined. A survey tool aligned with its recommendations is available from Compass Clinical Consulting.

Where do I Start?
Discovering whether your organization is currently meeting national norms as they relate to gastric emptying studies and similar situations is the first step in coming into compliance. If you discover a need to address this practice, consider the following steps:

• Establish a multidisciplinary group that includes nursing, radiology/nuclear medicine staff, and dietary professionals.
• Establish procedures for each of the major steps outlined above, incorporating relevant standards and guidelines. Refer to the Compass tool for ideas.
• Revisit patient educational information to outline steps for patients and their family.
• Assure that competency assessment mechanisms have been put in place for individuals as it relates to their role in each test.

For further information:

• Obtain Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine.
• Consult your supplier for relevant MSDS sheets on Technetium 99M.
• Review the 2005 Food Code. Information about eggs and egg product storage, and preparation can be found in Chapter 3.

Medication administration for most hospitalized patients is a fairly routine process. So why is this seemingly simple task becoming a hot spot for CMS and Department of Health surveys?

Here’s Why

§482.23(c)(1) Outlined expectations for medication administration, include:

• That there are policies and procedures approved by the Medical Staff to determine who is authorized to administer medications, and that the policies are followed;
• That entries on the medication administration records conform to the practitioner’s order, that the order is current, and that drug and dosage are correct and administered as ordered (5 rights);
• That patients are addressed by name and/or their identities are checked;
• That the nurse remains with the patient until medication is taken;
• That drugs are administered within 30 minutes of the scheduled time for administration; and
• That QA/PI activities regularly check to see if the administration of drugs is monitored.

Additional expectations include the need to notify the physician when medications are omitted, held, or delayed, since they have not been administered as ordered. Note that medication administration expectations apply to all types of medications, including respiratory treatments and inhalers.

The Good News

The good news is that CMS has accepted the position statement from the American Association of Respiratory Care, which asserts that respiratory medications may be given within 60 minutes on either side of the scheduled administration time.

The Not So Good News

However, CMS and state surveyors have repeatedly categorized missed and late treatments as medication administration errors and have written citations if they are not captured as medication errors in the QA/PI program. Tracking and trending of all medication errors are expected to be routine elements of every hospital’s QA/PI program.

Another common misinterpretation lies in understanding the CMS expectations for timely medication administration. The CMS interpretive guidelines have historically set the expectations that medication be administered 30 minutes before or after the scheduled time. This permits a one-hour window for administration. Over the years, this “one-hour window” had been misinterpreted to mean one hour before and after the scheduled time, leaving a two-hour window that has proven unacceptable to state surveyors.

What to Do?

Determining your risk for this type of CMS deficiency and addressing the gaps in compliance are the first steps to avoiding this finding during survey. To evaluate your readiness, consider the following actions:

• Conduct observational and chart review studies to determine if medications are given 30 minutes before or after the scheduled administration time.
• Utilize reporting features of automated dispensing devices to compare the time medications were removed from the device as compared to the time the medication was documented as given.
• Evaluate the timeliness of respiratory therapy treatments. Identify if late or missed treatments are being captured in the QA/PI program for action and improvement.
• Assess staff knowledge of the requirement for timely medication administration and periodically reeducate staff members who administer medications.
• Track and trend medication errors related to timeliness issues to identify opportunities for improvement. Consider an FMEA to root out barriers to timely medication administration.

And Don’t Forget

Remember that CMS requires timely medication administration relative to the scheduled administration time. Check your policy to see if it permits staff to change scheduled administration times for patient-centered reasons, such as:

• To align medication administration times with patient’s home routines
• To permit the administration of large volume antibiotics (such as Vancomycin) at recommended infusion rates.
• To prevent drug-drug or drug-food interactions.
• To satisfy a patient request.

Questions?

If you have any questions about this subject or another regulatory or accreditation hot spot, call me, Ruth Elzer at 513.241.0142, or email me @relzer@compassgroupinc.com

Using a consistent approach to hand-off communication throughout the organization continues to be a resistant National Patient Safety Goal. One of the more popular methods for meeting the requirement is SBAR, a standardized technique developed by Kaiser Permanente. SBAR (Situation – Background – Assessment – Recommendation) is ideal for framing critical discussions, particularly those involving serious changes in patient condition. However, many organizations struggle with how to use the tool for routine communications during shift changes, hand-offs between departments, and hand-off involving non-professionals, such as technologists or assistants.

DATA (Demographics, Assessment, Treatment, Action Plan), developed by nurses at Compass Group, offers flexibility for physicians, nurses, or support persons needing to hand off routine information during transitions in care. A program involving the use of DATA for routine communications and either DATA or SBAR for critical care discussions can offer a quick resolution to maintain compliance.

The Simplicity of DATA

DATA was designed with simplicity and flexibility in mind. Each element can be expanded or pared down for use in a variety of clinical settings or situations. The content of the hand-off will differ by patient type and population, but the essential format and function remain constant. DATA is designed to be easily remembered by staff at all levels, from transporters to physicians. Here is a quick view of its elements:

Demographics

• Patient’s name, DOB, location, and other relevant demographics
• History of current illness and significant past history
• Allergies (if new)

Assessment

• Pertinent normal and abnormal findings related to reason for hospitalization
• Abnormal assessment findings pertinent to current care
• Significant recent lab or test results (using read-back for any critical test results)
• Pain or discomfort, including any need for reassessment following recent intervention
• Resuscitation status if other than full code

Treatment

• Surgeries or procedures anticipated
• Invasive lines and therapies
• Scheduled diagnostic testing

Action

• Immediate plan for the next care cycle (pain management, ambulation, or antibiotic therapy)
• Discharge plan or anticipated discharge/transfer date
• “To do” list for the next care cycle or beyond, as appropriate
• Physician plan for care over next 24-48 hours (if known)

Free Tools from Compass Group

Click on the links to receive any of the following free tools:

• DATA: A Compass Group Solution to Hand-off Communication
• Shift Hand-off DATA Tool – A shortened version of the DATA tool for routine hand-offs during nursing shift reports
• A free policy outlining the use of DATA and SBAR in clinical settings

The 2009 Compass Clinical Consulting Forum schedule is now available online. The Compass Clinical Consulting Forum is a series of 48 audio- and web-based education sessions conducted by Compass Group’s accreditation and regulatory experts.

Topics range from the Joint Commission survey process and standards, to the latest on CMS Conditions of Participation. Sessions are customized for specific audiences, supporting managers and educators, quality managers, and those responsible for CMS Compliance.

Because the sessions are conducted by phone (with web access being optional), organizations can place an unlimited number of individuals in the room to access this important resource.

View the 2009 Compass Clinical Consulting Forum Schedule.