The Mihalik Blog

Joint Commission Update Part III

This is the final installment of Michael Alcenius’ Joint Commission Update.  I’ll be back next week. 

Gary

I walked away with from the Joint Commission Hospital Executive Briefings in

Garden Grove, California with an appreciation of the significant restructuring of the emergency management standards in the Environment of Care chapter.  Most of the modifications are based on lessons learned from disasters that have impacted health care since 2001 (e.g., 9/11; Katrina).  The new standards, effective January 1, 2008, emphasize a scalable approach to managing response and organizational self-sustainability for at least 96 hours.

As a foundation, it is important to understand three definitions relative to events that impact an organization’s ability to provide care:

·        Emergency

o       Infrastructure remains intact

o       Able to support care/services

o       No deaths directly related to the event

·        Disaster

o       Infrastructure damaged

o       Able to support care/services

o       Few deaths directly related to the event

·        Catastrophe

o       Infrastructure damaged

o       Not able to support care/services

o       Many deaths possible

In addition, the new structure addresses six important areas of emergency management

·        Communication

·        Resources and assets

·        Safety and Security

·        Staff roles and responsibilities

·        Utility management

·        Clinical and support activities

A synopsis of the revised standards follows.   

EC.4.11 Planning

·        Hazard Vulnerability Analysis (HVA)

·        For each emergency identified in HVA, define:

o       Mitigation activities

o       Preparedness activities

o       Response strategies

o       Recovery strategies

·        Document assets and resources needed during emergencies

·        Objectives, scope, performance, effectiveness of planning is evaluated at least annually

EC.4.12 Written Plan

·        Emergency Operations Plan (EOP)

o       Establishes incident command structure

o       Identifies staff reporting structure

o       Identifies organizational capabilities

o       Establishes response efforts when organization cannot be supported by community for at least 96 hours

o       Identifies alternate sites of care for evacuation if necessary

EC.4.13 Communications

·        Plan for ongoing communication

·        Communication with other organizations in area

·        Communications with patients and third parties such as FBI, Health Department

EC.4.14 Strategies for Managing Resources/Assets

·        Plan for obtaining supplies at onset of emergency

·        Plan for replenishing

·        Managing staff resources

·        Managing staff and family support needs

·        Sharing of resources with other organizations

·        Evacuation

·        Transporting patient and resources during evacuation

·        Transporting patient information

EC.4.15 Strategies for Managing Safety and Security

·        Controlling egress and exit

·        Controlling movement within facility

·        Controlling traffic

EC.4.16 Staff Roles and Responsibilities

·        Define roles

·        Train staff for roles

·        Communication to LIPs about role

·        Identification of care providers and other personnel

EC.4.17 Managing Utilities

·        Identify alternative means for providing

o       Electricity

o       Water

o       Fuel

o       Ventilation/Heat

o       Medical gas/vacuum

EC.4.18 Managing Clinical and Support Activities

·        Personal hygiene and sanitation

·        Mental health

·        Mortuary services

·        Documenting and tracking clinical information

EC.4.20 Exercising the Plan

·        Define scope of exercises

o       Number and types – twice annually in response to actual emergency or planned exercise, one must include influx of actual or simulated patients

o       At least one escalated to evaluate performance when community cannot support

o       At least one community-wide exercise/year if organization has a role in community structure

o       Realistic addressing emergencies identified in HVA

o       Monitor performance and identify opportunities for improvement

o       Monitor the six crucial areas

§         Communication

§         Resources

§         Safety and Security

§         Staff roles and responsibilities

§         Utility systems

§         Clinical and support activities

·        Critique

o       Multidisciplinary process

o     EOP modified in response

Information Exchange

Last week I taught two NCQA education programs.  One on Physician and Hospital Quality and the other on Quality Plus Challenges and Solutions. 

The participants in these programs were similar to what I have experienced in NCQA programs over the last couple of years.  They were looking for answers. 

When I first started teaching NCQA programs ten years ago, the interest was largely in understanding what was required.  It seems that, now, understanding what is required is only a transit point for getting some concrete advice on how to implement systems and processes that are compliant with the standards. 

This need is one which is rarely satisfied at an NCQA conference.  But, honestly, I don’t think it’s NCQA’s role (nor their strong suit) to tell organizations how to meet the intent of the standards.  This is a distinction that I learned many years ago as Associate Director in the Joint Commission’s Department of Standards.  When doing standards interpretation, the goal was to help organizations understand what the standard meant and what it required but not specifically how to meet it. 

Clearly there’s a gray zone between these areas.  With rare exceptions, the people who work in standard-setting organizations are not really involved in health care delivery or health care management any longer—even if they once were.  Systems change.  Software evolves.  The folks who work for NCQA, the Joint Commission, and other standard-setting organizations apply their clinical and managerial experience at a meta level.  This creates an understandable tension with individuals who work for organizations trying to comply with the standards—a micro level, so to speak. 

Which brings me back to what I was thinking when I started writing this column.  At both programs, some really good advice on how to meet the intent of the standards came from the audience. 

Would harnessing that experience and making it available be of interest? 

This blog, or an extension of it, could be turned into a moderated forum where individuals could post questions and get advice from others in the field who have faced similar challenges.  Along the way I would add my perspective on the questions asked and the advice given.  Perhaps this format would span the divide between understanding the standards and knowing what to do to meet them.

I look forward to your thoughts on this topic.  If you think it’s a good idea, or a bad idea, or if you have any thoughts at all, please click on the “Comments” button at the bottom of this page and let me know.  If there’s an interest in doing this I’ll do my best to put the systems in place to meet the need. 

Joint Commission Update Part II

My previous blog entry outlined highlights relating to administrative updates at Joint Commission gleaned during my recent attendance at the annual Executive Briefings.  This entry will address some of the modifications and additions to National Patient Safety Goals and standards for 2008.  Next time I'll convey significant changes to the structure and standards found in the Environment of Care chapter of the Accreditation Manual for Hospitals.  Feel free to ask questions and I'll be happy to offer insight. 

National Patient Safety Goals 2008 for Hospitals

·        1A – 2 patient identifiers

·        1B – Time out prior to surgery

·        2A – Read back for verbal orders

·        2B – Prohibited abbreviations (list hasn’t changed)

·        2C – Measuring and improving time of reporting critical test results

·        2E – Standardized approach to hand off communication

·        3C – List of look alike, sound alike medications (list is at www.jointcommission.org)

·        3D – Labeling of medication containers on and off sterile field

·        3E – NEW – Reduce likelihood of harm associated with the use of anticoagulation therapy

o       Define the program

o       Unit dose and pre-mixed parenterals

o       Dispense Warfarin based on established monitoring procedures

o       Use protocols

o       Baseline and current INR monitoring for Warfarin

o       Notify dietary

o       Use programmable infusion pumps for continuous IV Heparin

o       Policy for  baseline and ongoing testing for management of Heparin therapy

o       Anticoagulant education to staff and patients

o       Evaluate anticoagulant safety practices

·        7A – Hand Hygiene

·        7B – Manage death or permanent loss of function associated with health care-associated infection as a sentinel event

·        8A – Medication Reconciliation

·        8B – Communicate the list to the next provider of care and to the patient upon discharge

·        9B – Implement fall reduction program and evaluate effectiveness

·        13A – Define and communicate means for patients to report concerns about patient safety

·        15A – Identify patients at risk for suicide

·        16A – NEW – Select a method for staff to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to worsen – Rapid Response Team

o       Select method

o       Develop criteria

o       Empower staff, patients, families

o       Educate requesters and responders

o       Measure utility and effectiveness

o       Measure arrest and mortality rates

Phase in milestones for new goals (3E and 16A)

·        3 months – assign responsibility

·        6 months – work plan in place

·        9 months – pilot testing underway

·        12 months – fully implemented

Universal Protocol

·        1 – Pre-op verification process

·        2 – Site marking

·        3 – Time out immediately before procedure (NPSG 1B)

Standards Changes for 2008

·        Accreditation Participation Requirement 17 (APR 17)

o       Changes to verbiage makes it clear that medical staff and employees must be educated about reporting concerns relating to safety or quality of care to Joint Commission without retaliation.

·        LD.3.110  Asystolic Recovery/Organ Procurement

o       Hospital must document efforts to reach an agreement with OPO

o       Donation policy reflects justification for not providing asystolic recovery

·        LD.3.50  Oversight of Contracted Services

o       Assure same level of care delivered regardless of relationship

o       Requires monitoring for safety and quality

o       Credentialing and privileging

·        PC.2.10 Timeframes for Histories and Physicals

o       Organization defines in writing timeframes for conducting initial assessments

o       H&P completed no more than 30 days prior or within 24 hours after inpatient admission

o       H&P completed within 30 days prior to inpatient admission must have an update stating any changes in patient’s condition within 24 hours after inpatient admission or prior to surgery

o       These changes bring the standard in line with CMS Final Rule effective 1/27/07

Next Installment:  The new Emergency Management Standards for 2007!

Michael Alcenius, CPHQ

Director - Quality and Risk Management

Lovelace Westside Hospital

Albuquerque, New Mexico

2008: Up Close and Personal

Well, NCQA’s 2008 standards have been with us for a while now.  I’ve gone through them to really figure out the big differences between 2007 and 2008. 

As promised, the changes are minimal—if you’re an MCO!

If you’re a PPO—watch out!  These standards represent a major change.  The change is understandable.  With an ever increasing proportion of members in PPOs, it makes sense to combine HMO, PPO, and POS plans into a single accreditation process.  If not, the shrinking part of the pie, HMOs, would be subject to the most rigorous standards. 

A survey of the 2008 Health Plan standards indicates that the scoring algorithms for the following elements were changed to require that all factors be present for a score of 100%:

§         QI 1A: Quality Improvement Program Structure

§         UM 6B: Procedures for Onsite Facility Reviews

§         CR 1A: Practitioner Credentialing Guidelines

§         RR 1A: Rights and Responsibilities Statement

§         RR 4A: Subscriber Information

§         RR 7B: Communicating with Prospective Members

If you’re not a PPO, the only other significant changes relate to the following few standards:

§         QI 4B now specifies the practitioners who must be included in PCP availability analyses.  These are:

s         General Practitioners

s         Internists

s         Family Practitioners

s         Pediatricians.

§         QI 6A has added the “Quality of Practitioner Office Site” to the required complaint categories.  The previous categories remain, which are:

s         Quality of care

s         Access

s         Attitude and service

s         Billing and financial issues.

§         CR 6, Practitioner Office Site Quality, is no longer limited to PCPs and high-volume behavioral health practitioners.  On the other hand, a site visit is only required if there is a member complaint.  Here’s the detail.

§         CR 6A now requires that individual standards and thresholds be set for the factors listed below.  Previously, separate scoring was only required for the site as a whole and treatment record keeping.  Five different thresholds are now required, one for each of the following:

s         Physical accessibility

s         Physical appearance

s         Adequacy of waiting and examining room space

s         Availability of appointments

s         Adequacy of treatment record keeping

§         CR 6B requires that site visits be conducted when a member complaint is received about any of the five factors listed above.  A full site visit is required, addressing all factors, not a focused one that addresses the topic of the complaint.  After the site visit, appropriate actions are required, as appropriate to the findings, including:

§         Instituting actions to improve offices that do not meet thresholds

§         Evaluating effectiveness of the actions at least every six months, until deficient offices meet the thresholds

§         Monitoring member complaints for all practitioner sites at least every six months

§         Documenting follow-up visits for offices that had subsequent deficiencies

§         A member complaint related to any of the five criteria in CR 6A triggers a full site visit

§         CR 10B was clarified to confirm that both physician and non-physician suspensions must be reported to appropriate monitoring authorities.

I’ll keep you updated on other changes as they occur.