Essentials of Joint Commission Readiness

1
Essentials of Joint Commission Readiness

• Dale Brown, RN, MSN
• Stephen Dorman, MD
• Day 2

2
Patient Centered Communication
3
PC. 02.01.21

• The hospital effectively communicates with
  patients when providing care, treatment, and
  services.
• EP 1- (A)The hospital identifies the patients
  oral and written communication needs, including
  the patients preferred language for discussing
  health care.
• EP 2-(A) The hospital communicates with the
  patient during the provision of care, treatment,
  and services in a manner that meets the patients
  oral and written communication needs.

4
RI. 01.01.01

• The hospital respects, protects, and promotes
  patient rights.
• EP 5-(C) the hospital respects the patients
  right to and need for effective communication

5
RI. 01.01.03

• The hospital respects the patients right to
  receive information in a manner he or she
  understands.
• EP 2-The hospital provides language interpreting
  and translation services.
• (HR. 01.02.01, EP 1)
• EP 3-The hospital provides information to the
  patient who has vision, speech, hearing, or
  cognitive impairments in a manner that meets the
  patients needs.

6
Medication Management
7
MM.01.01.03

• The organization safely manages high-alert and
  hazardous medications.

8
MM.01.01.03

• 5-A The hospital reports abuses and losses of
  controlled substances to the individual
  responsible for the pharmacy department or
  service and to the chief executive officer, in
  accordance with law and regulation.

9
MM.03.01.01

• The organization safely stores medications.
• Secure no unsupervised, unauthorized individuals
  may access medications.

10
MM.03.01.01

• 3-A The hospital stores controlled (scheduled)
  medications in a locked, secured area to prevent
  diversion, in accordance with law and regulation.
  Scheduled medications include those listed in
  Schedules IIV of the Comprehensive Drug Abuse
  Prevention and Control Act of 1970.

11
MM.03.01.01

• 19-A The hospital has a pharmacy directed by a
  registered pharmacist or a supervised drug
  storage area, in accordance with law and
  regulation.

12
MM.05.01.07

• The organization safely prepares medication.

13
MM.05.01.07

• 5-DI,A Medications are prepared and administered
  in accordance with the orders of a licensed
  independent practitioner responsible for the
  patient's care, and in accordance with law and
  regulation.

14
MM.05.01.07

• 6-DI,A In-house preparation of
  radiopharmaceuticals is done by, or under the
  direct supervision of, an appropriately trained
  registered pharmacist or doctor of medicine or
  osteopathy.
• Note Direct defined by CMS as on the same
  campus.

15
MM.07.01.03

• The organization responds to actual or potential
  adverse drug events, significant adverse drug
  reactions, and medication errors.

16
MM.07.01.03

• 6-DI,A Medication administration errors, adverse
  drug reactions, and medication incompatibilities
  are immediately reported to the attending
  physician, and, as determined by the hospital, to
  the organization-wide performance improvement
  program.

17
CMS Changes for 2013
18
CMS Changes

• 1. Removal of requirement for special education
  for blood and medication administration.
  (HR.01.02.01)
• 2. Mandate for CEO, nurse leaders and medical
  staff leaders to address problems identified by
  infection control (LD.01.02.01).
• 3. A podiatrist may serve as a medical staff
  leader including president (LD.01.05.01).

19
CMS Changes

• 4. Permission to use standing orders (without a
  requirement for an order) if
• Based on best practice guidelines
• Approved by the medical staff, nursing and
  pharmacy
• For a defined patient population
• No choices in the set.
• Maintain required to sign, date and time at some
  point. (MM.04.01.01)

20
Restraint

• 5. Permission to use orders for care, treatment
  of services for outpatients from any licensed
  provider as allowed by laws and regulation
  providing there is a supporting hospital policy.
  (MM.05.01.07)
• 6. New reporting process for death in restraints.
  Not required for death in wrist restraints if
  the death is not related to the restraint.

21
CMS Changes

• 7. All verbal orders must be authenticated within
  law and regulation. All time requirements have
  been removed but it is clear that unauthenticated
  orders at 30 days would constitute a delinquent
  record.
• 8. Authentications may be performed on behalf of
  partner physicians.

22
CMS Changes

• 9 Single governing body
• 10. ONE medical staff per CCN.
• 11. Nursing care plans may be included in
  interdisciplinary care plans.
• 12. Removed requirement for one person
  responsible for ambulatory and outpatient care.

23
Field ReviewRadiology Standards

• Stephen M. Dorman, M.D.

24
EC.02.01.01

• The hospital manages safety and security risks.

25
EC.02.01.01

• EP 14
• For hospitals that provide magnetic resonance
  imaging (MRI) services The hospital manages
  safety risks in the MRI environment associated
  with the following
• - Patients who may experience claustrophobia,
  anxiety, or emotional distress

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EC.02.01.01

• EP 14
• Patients who may require urgent or emergent
  medical care
• - Metallic implants and devices
• - Ferrous objects entering the MRI environment

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EC.02.01.01

• EP 16
• For hospitals that provide magnetic resonance
  imaging (MRI) services The hospital manages
  safety risks by doing the following
• - Restricting access of everyone not trained
  screened by staff to an area that immediately
  precedes the entrance to the MRI scanner room

28
EC.02.01.01

• EP 16
• - Making sure that this area is controlled by and
  under the direct supervision MRI trained staff
• - Posting signage at the entrance to the MRI
  scanner room that conveys that the magnet is
  always on

29
EC.02.02.01

• The hospital manages risks related to hazardous
  materials and waste.

30
EC.02.02.01

• EP 17
• For hospitals that provide computed tomography
  (CT), positron emission tomography (PET), or
  nuclear medicine (NM) services The hospital
  monitors radiation exposure levels for all staff
  and licensed independent practitioners who
  routinely work in CT, PET, and NM areas.

31
EC.02.02.01

• EP 17
• Note This is typically done through the use of
  exposure meters, such as personal dosimetry
  badges.

32
EC.02.04.01

• The hospital manages medical equipment risks.

33
EC.02.04.01

• EP 7
• The hospital identifies activities and
  frequencies to maintain the image quality of the
  diagnostic images produced. The content and
  frequency of these activities are in accordance
  with state regulatory requirements,
  manufacturers guidelines, and the
  recommendations of a medical physicist.

34
EC.02.04.03

• The hospital inspects, tests, and maintains
  medical equipment.

35
EC.02.04.03

• EP 15
• The hospital maintains the image quality of the
  diagnostic images produced.
• (See also EC.02.04.01, EP 7)

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EC.02.04.03

• EP 17
• For hospitals that provide computed tomography
  (CT) services When utilizing standard adult
  brain, adult abdomen, and pediatric brain
  protocols, a qualified medical physicist measures
  the actual radiation dose produced by each
  diagnostic CT imaging system at least annually
  and verifies that the radiation dose displayed on
  the system is within 20 percent of the actual
  amount of radiation dose delivered. The dates of
  these verifications are documented.

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EC.02.04.03

• Note This element of performance is applicable
  only for systems capable of calculating and
  displaying radiation doses.

38
EC.02.04.03

• EP 19
• For hospitals that provide computed tomography
  (CT) services If the hospital does not utilize
  standard adult brain, adult abdomen, or pediatric
  brain protocols, the hospital uses a qualified
  medical physicist to measure the actual radiation
  dose produced by each diagnostic CT imaging
  system at least annually and verify that the
  radiation dose displayed on the system is within
  20 percent of the actual amount of radiation dose
  delivered for the three most common CT protocols
  used by the hospital. The dates of these
  verifications are documented.

39
EC.02.04.03

• Note This element of performance is applicable
  only for systems capable of calculating and
  displaying radiation doses

40
EC.02.04.03

• EP 20
• For hospitals that provide computed tomography
  (CT) services At least annually, a medical
  physicist conducts a performance evaluation of
  all CT imaging equipment. The evaluation results,
  along with recommendations for correcting any
  problems identified, are documented. The
  evaluations include the use of phantoms to assess
  the following imaging metrics

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EC.02.04.03

• EP 20
• - Image uniformity
• - Slice thickness accuracy
• - Slice position accuracy
• - High-contrast resolution
• - Low-contrast resolution
• - Geometric or distance accuracy
• - CT number accuracy and uniformity
• - Artifact evaluation

42
EC.02.04.03

• EP 21
• For hospitals that provide magnetic resonance
  imaging (MRI) services At least annually, a
  medical physicist or MRI scientist conducts a
  performance evaluation of all MRI imaging
  equipment. The evaluation results, along with
  recommendations for correcting any problems
  identified, are documented. The evaluations
  include the use of phantoms to assess the
  following imaging metrics

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EC.02.04.03

• EP 21
• - Image uniformity
• - Slice thickness accuracy
• - Slice position accuracy
• - High-contrast resolution
• - Low-contrast resolution (or contrast-to-noise
  ratio)
• - Geometric or distance accuracy
• - Magnetic field homogeneity (for MRI)
• - Artifact evaluation

44
EC.02.04.03

• EP 22
• For hospitals that provide positron emission
  tomography (PET) or nuclear medicine (NM)
  services At least annually, a medical physicist
  conducts a performance evaluation of all imaging
  equipment. The evaluation results, along with
  recommendations for correcting any problems
  identified, are documented. The evaluations
  include the use of phantoms to assess the
  following imaging metrics

45
EC.02.04.03

• EP 22
• - Image uniformity
• - Extrinsic or system uniformity
• - Intrinsic or system spatial resolution
• - Low-contrast resolution
• - Sensitivity
• - Energy resolution
• - Count-rate performance
• - Artifact evaluation

46
EC.02.06.05

• The hospital manages its environment during
  demolition, renovation, or new construction to
  reduce risk to those in the organization.

47
EC.02.06.05

• EP 4
• For hospitals that provide computed tomography
  (CT), positron emission tomography (PET), or
  nuclear medicine (NM) services The hospital
  conducts a shielding integrity survey of rooms
  where ionizing radiation will be emitted or
  radioactive materials will be used or stored (for
  example, scan rooms, injection rooms, hot lab).

48
EC.02.06.05

• EP 4
• Note For additional guidance on structural
  shielding design, see National Council on
  Radiation Protection and Measurements Report No.
  147 (NCRP-147).

49
HR.01.02.05

• The hospital verifies staff qualifications.

50
HR.01.02.05

• EP 19
• For hospitals that provide computed tomography
  (CT) services The hospital verifies and
  documents that a radiologic technologist who
  performs CT exams has the following
  qualifications

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HR.01.02.05

• EP 19
• - Registered by the American Registry of
  Radiologic Technologists (ARRT)
• - Certified by the ARRT in radiography and/or
  computed tomography
• - Trained and experienced in operating CT
  equipment

52
HR.01.02.05

• EP 20
• For hospitals that provide computed tomography
  (CT) services Diagnostic medical physicists that
  support CT services are board certified in
  diagnostic radiological physics or radiological
  physics by the American Board of Radiology, the
  American Board of Medical Physics, or an
  equivalent source. If the diagnostic medical
  physicist is not board certified, then he or she
  has completed the following

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HR.01.02.05

• EP 20
• - A graduate degree in medical physics,
  radiologic physics, physics, or another relevant
  physical science or engineering discipline

54
HR.01.02.05

• EP 20
• - Formal coursework in the biological sciences
  with at least one course in biology or radiation
  biology, and one course in anatomy, physiology,
  or a similar topic related to the practice of
  medical physics
• - Three years of documented experience in a
  clinical CT environment

55
HR.01.05.03

• Staff participate in ongoing education and
  training.

56
HR.01.05.03

• EP 14
• For hospitals that provide computed tomography
  (CT) services The hospital verifies and
  documents that radiologic technologists who
  perform CT examinations participate in ongoing
  education. Ongoing education must include annual
  training on radiation dose reduction awareness
  and techniques following As Low As Reasonably
  Achievable (ALARA), Image Gently, and Image
  Wisely concepts.

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HR.01.05.03

• EP 25
• Staff providing magnetic resonance imaging (MRI)
  services participate in education and training on
  safe practices in the MRI environment including
  the following

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HR.01.05.03

• EP 25
• - Patient screening criteria for ferrous-based
  items
• - Proper patient positioning activities to avoid
  burns
• - Equipment and supplies that have been
  determined to be safe for use in MRI areas
• - MRI safety response procedures for patients who
  require urgent or emergent medical care
• - MRI equipment emergency shutdown procedures

59
LD.04.04.01 (new standard)

• The hospital uses clinical practice guidelines
  when providing the following diagnostic imaging
  services computed tomography, magnetic resonance
• imaging, positron emission tomography, and
  nuclear medicine.
• For Hospitals that use CT, MRI, PET and NM

60
LD.04.04.01

• EP 1
• The hospital uses evidence-based guidelines and
  considers the patients age and previous imaging
  exams when deciding on the most appropriate type
  of imaging exam.

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LD.04.04.01

• EP 2
• The hospital establishes imaging protocols based
  on current standards of practice, which address
  key criteria including, clinical indication,
  patient age, patient positioning, scan times,
  radiation dose limits, and contrast
  administration.
• See (PI.01.01.01, EP 46)

62
LD.04.04.01

• EP 3
• Imaging protocols are kept current and adjusted
  with input from an interpreting radiologist,
  medical physicist, and chief imaging
  technologist. Imaging protocols are adjusted
  based on individual patient needs and on changes
  to standards of practice.

63
MM.06.01.01

• The hospital safely administers medications.

64
MM.06.01.01

• EP 13
• Before administering a radioactive isotope, staff
  verify that the dose to be administered is within
  20 of the prescribed dose, or, if the dose is
  prescribed as a range, staff verify that the dose
  to be administered is within the prescribed
  range.

65
PC.01.02.15

• The hospital provides for diagnostic testing.

66
PC.01.02.15

• EP 5
• The hospital documents in the patients record
  the radiation dose on every study produced during
  a CT examination.
• Note 1 This element of performance is applicable
  only for systems capable of calculating and
  displaying radiation doses.

67
PC.01.02.15

• EP 5
• Note 2 This element of performance does not
  apply to systems used for therapeutic radiation
  treatment planning or delivery, or for
  calculating attenuation coefficients for nuclear
  medicine studies.

68
PC.01.02.15

• EP 6
• For hospitals that provide computed tomography
  (CT) services The interpretive report of a
  diagnostic CT study includes the radiation dose.
  The dose is either recorded in the patient's
  interpretive report or included on the protocol
  page, which is then attached to the interpretive
  report. (used to apply only to California).

69
PC.01.02.15

• EP 7
• For hospitals that provide computed tomography
  (CT) services The hospital electronically sends
  each CT study and protocol page that lists the
  radiation dose and related technical factors to
  the hospitals electronic picture archiving and
  communications system (PACS).

70
PC.01.02.15

• EP 7
• Note This element of performance is only
  applicable for systems capable of calculating and
  displaying radiation doses.

71
PC.01.02.15

• EP 10
• For hospitals that provide computed tomography
  (CT), magnetic resonance imaging (MRI), positron
  emission tomography (PET), or nuclear medicine
  (NM) services Prior to conducting a diagnostic
  imaging study, the hospital verifies the
  following

72
PC.01.02.15

• EP 10
• Correct patient
• - Correct imaging site
• - Correct patient positioning
• - For CT only Correct imaging protocol
• - For CT only Correct scanner parameters

73
PC.01.02.15

• EP 11
• For hospitals that provide computed tomography
  (CT), magnetic resonance imaging (MRI), positron
  emission tomography (PET), or nuclear medicine
  (NM) services The hospital makes certain that
  imaging studies are based on an order from a
  licensed independent practitioner or other
  qualified practitioner in accordance with law and
  regulation.

74
PI.01.01.01

• The hospital collects data to monitor its
  performance.

75
PI.01.01.01

• EP 46
• For hospitals that provide computed tomography
  (CT) services The hospital collects data on
  incidents where radiation dose limits identified
  in imaging protocols have been exceeded.

76
PI.01.01.01

• EP 47
• For hospitals that provide magnetic resonance
  imaging (MRI) services The hospital collects
  data on patient burns that occur during MRI exams.

77
PI.01.01.01

• EP 48
• For hospitals that provide magnetic resonance
  imaging (MRI) services The hospital collects
  data on the following
• - Incidents when ferrous-based items entered the
  MRI scanner room
• - Injuries resulting from the presence of
  ferrous-based items in the MRI scanner room

78
PI.02.01.01

• The hospital compiles and analyzes data.

79
PI.02.01.01

• EP 6
• For hospitals that provide computed tomography
  (CT) services The hospital analyzes data on CT
  radiation doses and compares it with external
  benchmarks, when available.

80
Medical Staff OPPE and FPPE

• The Joint Commissions New Approach to Assessing
  Physician Performance

81
The Standard MS.05.01.01 CLINICAL

• The organized medical staff has a leadership role
  in organization performance improvement
  activities to improve quality of care, treatment,
  and services and patient safety.
• Relevant information developed from the following
  processes is integrated into performance
  improvement initiatives and consistent with
  organization preservation of confidentiality
  and privilege of information.

82
The Standard MS.05.01.01

• 1 The organized medical staff provides
  leadership for measuring, assessing, and
  improving processes that primarily depend on the
  activities of one or more licensed independent
  practitioners, and other practitioners
  credentialed and privileged through the medical
  staff process. (See also PI.03.01.01, EPs 1-4)

83
The Standard MS.05.01.01

• 2 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Medical assessment and treatment of
  patients. (See also PI.03.01.01, EPs 1-4)

84
The Standard MS.05.01.01

• 3 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Use of information about adverse
  privileging decisions for any practitioner
  privileged through the medical staff process.

85
The Standard MS.05.01.01

• 4 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Use of medications

86
The Standard MS.05.01.01

• 5 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Use of blood and blood components

87
The Standard MS.05.01.01

• 6 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Operative and other procedure(s)
• Judgment (decision making)
• Clinical and Technical Skills

88
The Standard MS.05.01.01

• 7 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Appropriateness of clinical practice
  patterns.
• Utilization Review (LOS, Avoidable days, denials)

89
The Standard MS.05.01.01

• 8 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following Significant departures from
  established patterns of clinical practice.
• All other departments Pathology, radiology,
  anesthesiology, ER

90
The Standard MS.05.01.01

• 9 The medical staff is actively involved in the
  measurement, assessment, and improvement of the
  following The use of developed criteria for
  autopsies. (CMS REQUIREMENT)

91
The Standard MS.05.01.01

• 10 Information used as part of the performance
  improvement mechanisms, measurement, or
  assessment includes the following Sentinel event
  data.

92
The Standard MS.05.01.01

• 11 Information used as part of the performance
  improvement mechanisms, measurement, or
  assessment includes the following Patient safety
  data.

93
The Standard MS.05.01.03 CITIZENSHIP

• 1 The organized medical staff participates in
  the following activities Education of patients
  and families.

94
The Standard MS.05.01.03 CITIZENSHIP

• 2 The organized medical staff participates in
  the following activities Coordination of care,
  treatment, and services with other practitioners
  and hospital personnel, as relevant to the care,
  treatment, and services of an individual patient.

95
The Standard MS.05.01.03 CITIZENSHIP

• 3 The organized medical staff participates in
  the following activities Accurate, timely, and
  legible completion of patients medical records.

96
The Standard MS.05.01.03 CITIZENSHIP

• 4 The organized medical staff participates in
  the following activities Review of findings of
  the assessment process that are relevant to an
  individuals performance. The organized medical
  staff is responsible for determining the use of
  this information in the ongoing evaluations of a
  practitioners competence.

97
The Standard MS.05.01.03 CITIZENSHIP

• 5 The organized medical staff participates in
  the following activities Communication of
  findings, conclusions, recommendations, and
  actions to improve performance to appropriate
  staff members and the governing body.

98
The Standard MS.08.01.03

• Ongoing professional practice evaluation
  information is factored into the decision to
  maintain existing privilege(s), to revise
  existing privilege(s), or to revoke an existing
  privilege prior to or at the time of renewal.

99
The Standard MS.08.01.03

• 1 The process for the ongoing professional
  practice evaluation includes the following There
  is a clearly defined process in place that
  facilitates the evaluation of each practitioners
  professional practice. (D means there must be a
  policy)

100
The Standard MS.08.01.03

• 2 The process for the ongoing professional
  practice evaluation includes the following The
  type of data to be collected is determined by
  individual departments and approved by the
  organized medical staff. (Performance measures
  must be defined for CMS in a Medical Staff Plan).

101
The Standard MS.08.01.03

• 3 The process for the ongoing professional
  practice evaluation includes the following
  Information resulting from the ongoing
  professional practice evaluation is used to
  determine whether to continue, limit, or revoke
  any existing privilege(s).

102
FOCUSED REVIEW

• While it was a good thing to evaluate providers
  after they had already been working 6 months, it
  was apparent that there was real risk in the
  unknown.
• Peer Recommendations could not be trusted.
• Harm could come to patients soon after practice
  began.

103
FOCUSED REVIEW

• There were analogous standards in the Human
  Resources chapter for an initial assessment of
  competency before hospital staff could carry out
  job responsibilities independently.

104
FOCUSED REVIEW

• It was clear that something was needed on the
  front end.
• Next it was determined that in classic peer
  review, cases simply fell off and issues were
  never closed or casually investigated. There was
  no accountability for closure of many significant
  issues.

105
FOCUSED REVIEW

• The purpose
• Initial assessment competence of all new
  physicians or new privileges regardless of
  experience.
• Conduct intensive, planned and focused
  investigations when adverse events occurred
  (trigger events).
• Conduct intensive, planned and focused
  investigations when ongoing performance
  measurement indicated undesirable performance.

106
Focused Review New Privileges

• Goal To be conducted as rapidly as possible.
• Volume of review defined by the medical staff
  and departments.
• Individual plans should be developed to allow the
  medical staff to know when the review has
  concluded.
• Each provider may warrant a tailored plan.
• Some departments are completely uniform.

107
Focused Review New Privileges

• Should be conducted in a time frame that is too
  short for rate based performance measurement
  data collection would not be statistically
  significant for short term.
• Evaluation of privilege must be realistic chart
  review versus direct observation.
• All requirements defined in a plan.
• TOP Medical Staff Standard RFI in 2009.

108
The Standard MS.08.01.01

• The organized medical staff defines the
  circumstances requiring monitoring and evaluation
  of a practitioners professional performance.
• - Initial Appointment (new privileges)
• - New mid-cycle privilege
• - Trigger events
• - Variant data

109
The Standard MS.08.01.01

• The focused evaluation process is defined by the
  organized medical staff. The time period of the
  evaluation can be extended, and/or a different
  type of evaluation process assigned. Information
  for focused professional practice evaluation may
  include chart review, monitoring clinical
  practice patterns, simulation, proctoring,
  external peer review, and discussion with other
  individuals involved in the care of each patient
  (e.g., consulting physicians, assistants at
  surgery, nursing or administrative personnel).

110
The Standard MS.08.01.01

• Relevant information resulting from the focused
  evaluation process is integrated into performance
  improvement activities, consistent with the
  organizations policies and procedures that are
  intended to preserve confidentiality and
  privilege of information.

111
The Standard MS.08.01.01

• 1 A period of focused professional practice
  evaluation is implemented for all initially
  requested privileges.

112
The Standard MS.08.01.01

• 2 The organized medical staff develops criteria
  to be used for evaluating the performance of
  practitioners when issues affecting the provision
  of safe, high quality patient care are
  identified. (D means Plan)

113
The Standard MS.08.01.01

• 3 The performance monitoring process is clearly
  defined and includes each of the following
  elements
• - Criteria for conducting performance monitoring
• - Method for establishing a monitoring plan
  specific to the requested privilege
• - Method for determining the duration of
  performance monitoring
• - Circumstances under which monitoring by an
  external source is required

114
The Standard MS.08.01.01

• 4 Focused professional practice evaluation is
  consistently implemented in accordance with the
  criteria and requirements defined by the
  organized medical staff.

115
The Standard MS.08.01.01

• 5 The triggers that indicate the need for
  performance monitoring are clearly defined.
• Note Triggers can be single incidents or
  evidence of a clinical practice trend.

116
The Standard MS.08.01.01

• 6 The decision to assign a period of performance
  monitoring to further assess current competence
  is based on the evaluation of a practitioners
  current clinical competence, practice behavior,
  and ability to perform the requested privilege.
• Note Other existing privileges in good standing
  should not be affected by this decision.

117
The Standard MS.08.01.01

• 7 Criteria are developed that determine the type
  of monitoring to be conducted. (D means this has
  to be in the plan).

118
The Standard MS.08.01.01

• 8 The measures employed to resolve performance
  issues are clearly defined. (D means it must be
  in the plan).

119
The Standard MS.08.01.01

• 9 The measures employed to resolve performance
  issues are consistently implemented.

120
Scoring

• All of the medical staff standards on these
  issues are A meaning 100 compliance is
  required
• Focused Review 16 of hospitals cited
• Ongoing Review 15 of hospitals cited
• Problems with no or low volume providers
• Changes to privileges based on data

121
Restraints
122
PC.03.05.03

• The organization uses restraint or seclusion
  safely.

123
PC. 03.05.03Elements of Performance

• 1-DI, A The hospital implements restraint or
  seclusion using safe techniques identified by the
  hospitals policies and procedures in accordance
  with law and regulation.
• 2-M, C The use of restraint and seclusion is in
  accordance with a written modification to the
  patient's plan of care.

124
PC. 03.05.05

• The organization initiates restraint or seclusion
  based on an individual order.

125
PC. 03.05.05Elements of Performance

• 3-A The attending physician is consulted as soon
  as possible (immediately), in accordance with
  hospital policy, if he or she did not order the
  restraint or seclusion.

126
PC. 03.05.05

• 4-M, C Unless state law is more restrictive,
  orders for the use of restraint or seclusion used
  for the management of violent or self-destructive
  behavior that jeopardizes the immediate physical
  safety of the patient, staff, or others may be
  renewed within the following limits
• 4 hours for adults 18 years of age or older
• 2 hours for children and adolescents 9 to 17
  years of age
• 1 hour for children under 9 years of age

127
PC. 03. 05. 05 Elements of Performance

• 5-DI, A Unless state law is more restrictive,
  every 24 hours, a physician or other authorized
  licensed independent practitioner primarily
  responsible for the patients ongoing care sees
  and evaluates the patient before writing a new
  order for restraint or seclusion used for the
  management of violent or self-destructive
  behavior that jeopardizes the immediate physical
  safety of the patient, staff, or others in
  accordance with hospital policy and law and
  regulation.

128
PC. 03.05.05Elements of Performance

• 6-DI, A Orders for restraint used to protect the
  physical safety of the nonviolent or
  non-self-destructive patient are renewed in
  accordance with hospital policy.

129
PC. 03.05.07

• The organization monitors patients who are
  restrained or secluded.

130
PC. 03.05.07

• 1-DI, A Physicians or other licensed independent
  practitioners or staff who have been trained in
  accordance with 42 CFR 482.13(f) monitor the
  condition of patients in restraint or seclusion.
  (See PC.03.05.17, EP 3)

131
PC. 03.05.09

• The organization has written policies and
  procedures that guide the use of restraint or
  seclusion.

132
PC. 03.05.09Elements of Performance

• 1-D, A The hospitals policies and procedures
  regarding restraint or seclusion include the
  following
• Physician and other authorized licensed
  independent practitioner training requirements
• Staff training requirements
• The determination of who has authority to order
  restraint and seclusion

133
PC. 03.05.09Elements of Performance

• 1-D, A The hospitals policies and procedures
  regarding restraint or seclusion include the
  following
• The determination of who has authority to
  discontinue the use of restraint or seclusion
• The determination of who can initiate restraint
  or seclusion
• The circumstances under which restraint or
  seclusion is discontinued.
• The requirement that restraint or seclusion is
  discontinued as soon as is safely possible

134
PC. 03.05.09Elements of Performance

• The hospitals policies and procedures regarding
  restraint or seclusion include the following
• A definition of restraint in accordance with 42
  CFR 482.13(e)(1)(i)(A-C)
• A definition of seclusion in accordance with 42
  CFR 482.13(e)(1)(ii)
• A definition or description of what constitutes
  the use of medications as a restraint in
  accordance with 42 CFR 482.13(e)(1)(i)(B)

135
PC. 03.05.09Elements of Performance

• The hospitals policies and procedures regarding
  restraint or seclusion include the following
• A determination of who can assess and monitor
  patients in restraint or seclusion
• Time frames for assessing and monitoring patients
  in restraint or seclusion

136
PC. 03.05.09Elements of Performance

• 2-DI,A Physicians and other licensed independent
  practitioners authorized to order restraint or
  seclusion (through hospital policy in accordance
  with law and regulation) have a working knowledge
  of the hospital policy regarding the use of
  restraint and seclusion.

137
PC. 03.05.11

• The organization evaluates and reevaluates the
  patient who is restrained or secluded.

138
PC. 03.05.11Elements of Performance

• 1-D, A A physician or other licensed independent
  practitioner responsible for the care of the
  patient evaluates the patient in-person within
  one hour of the initiation of restraint or
  seclusion used for the management of violent or
  self-destructive behavior that jeopardizes the
  physical safety of the patient, staff, or others.
  A registered nurse or a physician assistant may
  conduct the in-person evaluation within one hour
  of the initiation of restraint or seclusion this
  individual is trained in accordance with the
  requirements at PC.03.05.17, EP 3.

139
PC. 03.05.11Elements of Performance

• 2-DI, A When the in-person evaluation (performed
  within one hour of the initiation of restraint or
  seclusion) is done by a trained registered nurse
  or trained physician assistant, he or she
  consults with the attending physician or other
  licensed independent practitioner responsible for
  the care of the patient as soon as possible after
  the evaluation, as determined by hospital policy.

140
PC. 03.05.11Elements of Performance

• 3-DI, A The in-person evaluation, conducted
  within one hour of the initiation of restraint or
  seclusion for the management of violent or
  self-destructive behavior that jeopardizes the
  physical safety of the patient staff or others,
  includes the following
• An evaluation of the patient's immediate
  situation
• The patient's reaction to the intervention
• The patient's medical and behavioral condition
• The need to continue or terminate the restraint
  or seclusion

141
PC.03.05.13

• The organization continually monitors patients
  who are simultaneously restrained and secluded.

142
PC. 03.05.13

• 1-DI, A The patient who is simultaneously
  restrained and secluded is continually monitored
  by trained staff either in-person or through the
  use of both video and audio equipment that is in
  close proximity to the patient.

143
PC. 03.05.15

• The organization documents the use of restraint
  or seclusion.

144
PC. 03.05.15Elements of Performance

• 1-M, C Documentation of restraint and seclusion
  in the medical record includes the following
• Any in-person medical and behavioral evaluation
  for restraint or seclusion used to manage violent
  or self-destructive behavior
• A description of the patients behavior and the
  intervention used
• Any alternatives or other less restrictive
  interventions attempted

145
PC. 03.05.15Elements of Performance

• 1-M, C Documentation of restraint and seclusion
  in the medical record includes the following
• The patients condition or symptom(s) that
  warranted the use of the restraint or seclusion
• The patients response to the intervention(s)
  used, including the rationale for use of the
  intervention
• Individual patient assessments and reassessments
• The intervals for monitoring

146
PC. 03.05.15Elements of Performance

• 1-M,C Documentation of restraint and seclusion
  in the medical record includes the following
• Revisions to the plan of care
• The patients behavior and staff concerns
  regarding safety risks to the patient, staff, and
  others that necessitated the use of restraint or
  seclusion
• Injuries to the patient

147
PC. 03.05.15Elements of Performance

• 1-M, C Documentation of restraint and seclusion
  in the medical record includes the following
• Death associated with the use of restraint or
  seclusion
• The identity of the physician or other licensed
  independent practitioner who ordered the
  restraint or seclusion
• Orders for restraint or seclusion
• Notification of the use of restraint or seclusion
  to the attending physician
• Consultations

148
PC. 03.05.17

• The organization trains staff to safely implement
  the use of restraint or seclusion.

149
PC. 03.05.17Elements of Performance

• 2-M, C The hospital trains staff on the use of
  restraint and seclusion, and assesses their
  competence, at the following intervals
• At orientation
• Before participating in the use of restraint and
  seclusion
• On a periodic basis thereafter

150
PC. 03.05.17Elements of Performance

• 3-M, C Based on the population served, staff
  education, training, and demonstrated knowledge
  focus on the following
• Safe application and use of all types of
  restraint or seclusion used in the hospital,
  including training in how to recognize and
  respond to signs of physical and psychological
  distress (for example, positional asphyxia)
• Clinical identification of specific behavioral
  changes that indicate that restraint or seclusion
  is no longer necessary

151
PC. 03.05.17Elements of Performance

• 3-M, C Based on the population served, staff
  education, training, and demonstrated knowledge
  focus on the following
• Monitoring the physical and psychological
  well-being of the patient who is restrained or
  secluded, including but not limited to
  respiratory and circulatory status, skin
  integrity, vital signs, and any special
  requirements specified by hospital policy
  associated with the in-person evaluation
  conducted within one hour of initiation of
  restraint or seclusion

152
PC. 03.05.17Elements of Performance

• 3-M, C Based on the population served, staff
  education, training, and demonstrated knowledge
  focus on the following
• Use of first aid techniques and certification in
  the use of cardiopulmonary resuscitation,
  including required periodic recertification

153
PC. 03.05.17Elements of Performance

• 4-A Individuals providing staff training in
  restraint or seclusion have education, training,
  and experience in the techniques used to address
  patient behaviors that necessitate the use of
  restraint or seclusion.

154
PC.03.05.17Elements of Performance

• 5-M, D, C The hospital documents in staff
  records that restraint and seclusion training and
  demonstration of competence were completed.

155
CMS Restraint Changes
156
Reporting Restraint-Related Deaths

• Restraint-Related Deaths Replaces the
  requirement that hospitals report deaths related
  to soft, 2- point restraints, with a requirement
  that hospitals maintain a log (or other system)
  that will be made available to CMS if requested.

157
Reporting Restraint-Related Deaths

• Log The Log is internal to the hospital and the
  name of the practitioner responsible for the care
  of the patient may be used in the log in lieu of
  the name of
• the attending physician if the patient was
• under the care of a non-MD practitioner.
  

158
Reporting Restraint Deaths

• Section 482.13 is amended by a) revising
  paragraphs (g)(1) through (3) and b) adding
  paragraph (g)(4). The revisions and addition read
  as follows With the exception of deaths
  described under paragraph (g)(2) of this section
  the hospital must report the following
  information to CMS by telephone, fax or
  electronically as determined by CMs no later
  than the close of next business day

159
CMS Restraint Changes

• (g) (i) Each death that occurs while a patient is
  in restraint or seclusion
• (g) (ii) Each death that occurs within 24 hours
  after that patient has been removed from restrain
  or seclusion

160
Reporting Restraint-Related Deaths

• (g) (iii) Each death known to the hospital that
  occurs within 1 week after restraint or seclusion
  where it is reasonable to assume that use of
  restraint or placement in seclusion contributed
  directly or indirectly to the patients death,
  regardless of the type (s) of restraint used on
  the patient during this time.

161
Reporting Restraint-Related Deaths

• (2) When no seclusion has been used and when the
  only restraints used on the patient tare those
  applied exclusively to the patients wrist(s),
  and which are composed solely of soft, non-rigid,
  cloth-like materials, the hospital staff must
  record in an internal log or other system, the
  following information

162
Internal Restraint Log Components

• (i) Any death that occurs while a patient is in
  restraints
• (ii) Any death that occurs within 24 hours after
  a patient has been removed from such restraints.

163
Internal Restraint Log Components

• (3) The staff must document in the patients
  medical record the date and time the death was
• Reported to CMS for deaths described in (g) (1)
  of this section or other systems for deaths
  described in paragraph (g) (2) of this section.
• For deaths described in paragraph (g) 2 of this
  section entries into the internal log or other
  system must be documented as follows

164
Internal Restraint Log Components

• (ii) The information must be made available in
  either written or electronic form to CMS
  immediately upon request.

165
Internal Restraint Log Components

• (i) Each entry must be made not later than 7 days
  after the date of death of the patient.
• (ii) Each entry must document the patients name,
  date of birth , date of death, name of attending
  physician or other LIP who is responsible for
  the care of the patient , medical record number
  and primary diagnosis(es)

166
Patient Flow Standards
167
LD 04.03.11

• The hospital manages the flow of patients
  throughout the hospital.

168
LD.04.03.11

• EP 1
• The hospital has processes that support the flow
  of patients throughout the hospital.
• EP 2
• The hospital plans for the care of admitted
  patients who are in temporary bed locations, such
  as the post-anesthesia care unit or the emergency
  department.
• EP 3
• The hospital plans for care to patients placed
  in overflow locations.

169
LD. 04.03. 11

• EP 4
• Criteria guide decisions to initiate ambulance
  diversion.
• EP 5
• The hospital measures and sets goals the
  components of the patient flow process including
• The available supply of beds
• The throughput of areas where patients receive
  care, treatment, and services ( such as inpatient
  units, laboratory, operating rooms, telemetry,
  radiology and PACU.

170
LD. 04.03.11

• EP. 5 (Continued)
• The safety of areas where patients receive care,
  treatment and services
• The efficiency of the non-clinical services that
  support patient care and treatment (such as
  housekeeping and transportation).
• Access to support services (such as case
  management and social work)

171
LD. 04.03.11

• EP 6
• Effective January 1, 2014
• The hospital measures and sets goals for
  mitigating and managing the boarding of patients
  who come through the emergency department.
• Note Boarding is the practice of holding
  patients in the emergency department or a
  temporary location after the decision to admit or
  transfer has been made. The hospital should set
  its goals with attention to patient acuity and
  best practice it is recommended that boarding
  timeframes not exceed 4 hours in the interest of
  patient safety and quality of care.

172
LD. 04.03.011

• EP 6 (Cross-referenced standard)
• NPSG. 15.01.01., EPs 1 2, PC.01.01.01 EPs 4
  9
• PC. 01.02.03, EP 3, PC. 02.01.19, EP 1 2
• NPSG. 15.01.01 EP 1
• Conduct a risk assessment that identifies
  specific patient characteristics and
  environmental features that may increase or
  decrease the risk for suicide.

173
LD. 04.03.11

• NPSG. 15.01.01. EP 2
• Address the patients immediate safety needs and
  most appropriate setting for treatment.
• PC.01.01.01
• The hospital accepts the patient in the care,
  treatment, and services based on its ability to
  meet the patients needs.

174
LD. 04.03.11

• PC. 01.01.01
• EP 4 Hospitals that do not primarily provide
  psychiatric or substance abuse services have a
  written plan that defines the care, treatment and
  services or the referral process for patients who
  are emotionally ill or suffer the effects of
  alcoholism or substance abuse

175
LD. 04.03.11

• PC. 01. 01. 01
• EP 24 If a patient is boarded while awaiting
  for emotional illness and/or the effects of
  alcoholism or substance abuse, the hospital does
  the following
• Provides for a location for the patient that is
  safe, monitored, and clear of items that the
  patient could use to harm himself or herself or
  others.
• Provides orientation and training to any clinical
  and non-clinical staff caring for such patients
  in effective and safe care, treatment, and
  services.
• Conducts assessments, and reassessments, and
  provides care consistent with the patients
  identified needs.

176
LD. 04.03.11

• PC. 01.02.03 EP 3
• Each patient is reassessed as necessary based on
  his or her plan for care or changes in his or her
  condition.
• Note Reassessments may also be based on the
  patient's diagnosis desire for care, treatment,
  and services response to previous care,
  treatment, and services and/or his or her
  setting requirements.

177
LD.04.03.11

• PC. 02.01.19 EP 1
• The hospital has a process for recognizing and
  responding as soon as a patients condition
  appears to be worsening.
• PC. 02.01.19 EP 2
• The hospital develops written criteria describing
  early warning signs of a change or deterioration
  in a patients condition and when to seek further
  assistance.

178
LD. 04.03.11

• EP 7
• The individuals who manage patient flow processes
  review measurement results to determine that
  goals were achieved.
• Cross-referenced standard NR. 02.02.01 EP 4
• The nurse executive, registered nurses, and other
  designated nursing staff write Nursing standards
  of patient care, treatment, and services.

179
LD. 04.03.11

• EP 8
• Leaders take action when patient flow goals are
  not achieved.
• Cross-referenced standard PI. 03.01.01, EP 4
• The hospital takes action when it does not
  achieve or sustain planned improvements.

180
LD. 04.03.11

• Note for EP 8.
• At a minimum, leaders included medical staff and
  governing body, the chief executive officer and
  other senior managers, the chief nurse executive,
  clinical leaders, staff members in leadership
  positions within the organization.

181
LD. 04.03.11

• EP 9
• Effective January 1, 2014
• When the hospital determines that it has a
  population at risk for boarding due to behavioral
  health emergencies, hospital leaders communicate
  with behavioral health providers and/or
  authorities serving the community to foster
  coordination of care for this population
• Cross-referenced standards LD. 03.04.01 EPs 3
  6

182
LD. 04.03.11

• LD. 03. 04. 01
• EP 3
• Communication is designed to meet the needs of
  internal and external users.
• EP 6
• When changes in the environment occur, the
  hospital communicates those changes effectively

183
Leadership
184
LD.04.03.09

• Care, treatment, and services provided through
  contractual agreement are provided safely and
  effectively.

185
LD.04.03.09

• 1-A Clinical leaders and medical staff have an
  opportunity to provide advice about the sources
  of clinical services to be provided through
  contractual agreement.
• 2-D,A The hospital describes, in writing, the
  nature and scope of services provided through
  contractual agreements.

186
LD.04.03.09

• 3-D,A Designated leaders approve contractual
  agreements.

187
LD.04.03.09

• 4-A Leaders monitor contracted services by
  establishing expectations for the performance of
  the contracted services.
• 5-D,ALeaders monitor contracted services by
  communicating the expectations in writing to the
  provider of the contracted services.
• Note A written description of the expectations
  can be provided either as part of the written
  agreement or in addition to it.

188
LD.04.03.09

• 6-A Leaders monitor contracted services by
  evaluating these services in relation to the
  hospital's expectations

189
LD.04.03.09

• 7-A Leaders take steps to improve contracted
  services that do not meet expectations.
• Note Examples of improvement efforts to
  consider include the following
• - Increase monitoring of the contracted
  services.
• - Provide consultation or training to the
  contractor.
• - Renegotiate the contract terms.
• - Apply defined penalties.
• - Terminate the contract.

190
LD.04.03.09

• 8-DI,A When contractual agreements are
  renegotiated or terminated, the hospital
  maintains the continuity of patient care.
• 10-D,A Reference and contract laboratory
  services meet the federal regulations for
  clinical laboratories and maintain evidence of
  the same.

191
Contract Principles
TJC does not require organizations to manually
verify each contract employee file. If the
contracting entity is Joint Commission accredited
there is no requirement to request the
information on the employee Full hospital
orientation is not required Orientation to key
areas such as emergency preparedness, infection
control, safety, and security is critical.
192
Contract Principles

• If specified in the contract, the contracting
  organization can rely on the contract staff
  provider to complete annual in-service training,
  many topics of which are the same as those
  required by the customer (such as, infection
  control, population-specific health care,
  cultural diversity, proper lifting techniques,
  and so forth).

193
Contract Principles

• Contracts must be in writing.
• The organization must define the expectations
  of the contract, including human resource
  expectation.
• The contract should specify that the
  contracted organization will provide only staff
  who are qualified in relation to their education,
  training, licensure, and competence as defined by
  the contracting organization.

194
Contract Principles

• The contracted organization has the
  responsibility to verify orientation, performance
  evaluations, health status, background checks,
  and any applicable references.

195
Contract Principles

• The contract should include the following
• Define within the contract the required
  qualifications for the contracted staff
• Review the personnel practices of the
  contracted organization to assess compliance with
  its own and Joint Commission requirements (for
  example, who will complete competence
  assessments)

196
Contract Principles

• If the contracted organizations practices are
  acceptable, the organization can accept those
  practices for the provided contracted personnel.
• If the contracted organizations practices are
  not acceptable, the organization can define in
  the contract the specific requirements or perform
  the requirements itself.

197
Human Resources
198
Competence Assessment Activity

• Competence Assessment
• 10-12 Personnel Records
• Contract Personnel based on list provided
• Agency Staff
• Bring Hospital Orientation curriculum
• Education Requirements (see handout)
• Make sure department manager of requested
  employee is present for the activity.

199
2013 Education Requirements

• Arranged by Chapter in Joint Commission Manual
• Annually means every 12 months, different than
  yearly
• Ongoing is surveyed as every 3 years or so
• At orientation-is before being independent

200
HR.01.02.01

• The hospital defines staff qualifications
• Job Descriptions

201
HR. 01.02.05

• 7-DI, A Before providing care, treatment, and
  services, the hospital confirms that
  non-employees who are brought into the hospital
  by a licensed independent practitioner to provide
  care, treatment, or services have the same
  qualifications and competencies required of
  employed individuals perfor