The Joint Commission Medication Management Standards Update 2016 CHS Pharmacy Education Series ProCE, Inc. www.ProCE.com 1 2016 Pharmacy Education Series March 16, 2016 Th J i tC i i M di ti M t St d dUdt 2016 The JointCommission Medication Management Standards Update 2016 Featured Speaker: Jeannell M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCP Principal Consultant, Medication Management and Safety Joint Commission Resources/Joint Commission International 1 Submission of an online evaluation is the only way to obtain CE credit Online Evaluation, Self-Assessment and CE Credit Submission of an online evaluation is the only way to obtain CE credit for this webinar Go to www.ProCE.com/CHSRx Webinar attendees will also receive an email with a direct link to the web page Print your CE statement of completion online – Credit for live or enduring only Deadline: April 15, 2016 ( l bl h ) 2 CPE Monitor (applicable to pharmacists) – CE information automatically uploaded to NABP/CPE Monitor within 1 to 2 weeks of the completion of the self‐assessment and evaluation Event Code Code will be provided at the end of today’s activity
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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 1
2016 Pharmacy Education Series
March 16, 2016Th J i t C i i M di ti M t St d d U d t 2016The Joint Commission Medication Management Standards Update 2016
Featured Speaker:Jeannell M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCPPrincipal Consultant, Medication Management and SafetyJoint Commission Resources/Joint Commission International
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Submission of an online evaluation is the only way to obtain CE credit
Online Evaluation, Self-Assessmentand CE Credit
Submission of an online evaluation is the only way to obtain CE credit for this webinar
Go to www.ProCE.com/CHSRx Webinar attendees will also receive an email with a direct link to the
web page Print your CE statement of completion online
– Credit for live or enduring only
Deadline: April 15, 2016( l bl h )
2
CPE Monitor (applicable to pharmacists)– CE information automatically uploaded to NABP/CPE Monitor within 1 to 2
weeks of the completion of the self‐assessment and evaluation
Event Code
Code will be provided at the end of today’s activity
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 2
How to Ask a Question
Locate menu bar on your computer desktop Click No!
Click orange arrow button
Menu box will open
Type question into question box
Click Send
Do not close menu box
– This will disconnect you from the Webcast
Please submit questions throughout presentation
Enter question
Click Send
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Accessing PDF Handout
Click the hyperlink that is located directly above the No!located directly above the question box
Do not close menu box
– This will disconnect you
from the Webcast
Close other applications Clickhyperlinkhyperlink
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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 3
2016 Pharmacy Education SeriesMarch 16, 2016
The Joint Commission Medication Management Standards Update 2016
Featured Speaker:Jeannell M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCPPrincipal Consultant, Medication Management and SafetyJoint Commission Resources/Joint Commission International
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It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. All of today’s presenters have no relevant commercial and/or financial relationships to disclose.
Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.
CE Activity Information & Accreditation
ProCE, Inc. (Pharmacist CE)
– 2.0 contact hours
Funding:This activity is self‐funded through CHSPSC
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This activity is self funded through CHSPSC.
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
– Identify at least one key issue found on survey relating to the top four challenging medication management standardsmanagement standards
– List recommendations to assess and address opportunities to improve safety with the use of electronic medical records and computerized prescribing applications
– List recommendations for evaluating a medication ili ti ’ ff ti
• EP 11: after review, all concerns, issues, or questions are clarified with the individual prescriber before dispensing
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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 14
Auto-Verification: What is TJC position?
• Auto-verification is a process that is part of the functionality of some EMR vendors that yallows, depending on how it is set up by client, to allow access to medications without a pharmacist review
• Use of auto-verification in some settings where pharmacist review has been required
stewardship completed- expect to see in 2016, to be
surveyed January, 2017
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Disclaimer
These slides are current as of February 28, 2016. The Joint Commission reserves the right to change the content of the information as appropriatecontent of the information, as appropriate.
These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or Joint Commission Resources.
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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 25
Questions
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2016 MEDICATION MANAGEMENT UPDATE
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MANAGEMENT UPDATE
Tackling Our Problems ToProblems To
Resolve Them
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
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Program Objectives• Identify the most problematic Medication Management
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Medication Management standards in 2015 for our associated facilities
• Outline areas of focus and issues to be addressed for each of those identified problematic standardseach of those identified problematic standards
• Discuss actions to resolve the issues and enhance compliance to the identified problematic standards
Most Problematic MM Standards - 2015
The majority of our MM RFIs were cited at:
• MM.03.01.01- relates to safe storage of
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medications in compliance with law, regulation and manufacturer’s guidelines (EPs 2-8 & 18)
• MM.04.01.01- relates to clear, complete and accurate medication orders to enhance communication between all participants in the medication management process (EP 1 3 6 9 13 d 15)(EPs 1, 3, 6-9, 13 and 15)
• MM.05.01.01- relates to the pharmacist’s review of the appropriateness of medication orders for medications that are to be dispensed in the hospital (EPs 1, 8, 13)
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
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Historical Perspective
2013 2014 2015
• Over the past 3 year accreditation cycle all
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2013 2014 2015
MM.03.01.01
20 29 17
MM.04.01.01
36 29 41
MM 05 01 01
accreditation cycle, all three of these standards have been problematic for our facilities
• While there has been dramatic improvement in
MM.05.01.01
1 22 8the outcomes for MM.03.01.01 and MM.05.01.01,but that is not true for MM.04.01.01
MM.03.01.01 – Areas of Focus• Special storage conditions
• Medications in warming cabinets
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• Refrigerated medications
• Monitoring conditions 24/7
• Temperature logs with temperatures out of acceptable range without recorded actions
S f• Securing medications from unauthorized access• Locking storage areas v. continuous supervision
• Disposal of controlled substances
• Securing prescription pads
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 28
MM.03.01.01 - Areas of Focus
• Expired medications
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• Dating multidose containers upon opening
• Expired medications that remain accessible for administration
• IV bags removed from overwraps or stored in warmers without revised expiration dates
Improving MM.03.01.01 Outcomes• Ensure your written policy on medication storage
addresses all elements of storage
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g• Locking v. constant supervision• Who may access the locked areas • The circumstances under which they may have access
• Educate staff to revise expiration dates of medications stored in a warming cabinet- follow the manufacturer’s guidelines!Review refrigerator temperature logs and provide• Review refrigerator temperature logs and provide refresher training when out of range temperatures are recorded without appropriate actions being documented
• Ensure that Crash Carts are visible at all times, especially if stored in occupied ED rooms
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 29
MM.04.01.01 – Areas of Focus• Incomplete medication orders
• Order lacks any of the parameters required by policy (i e route of administration frequency of dosing etc )
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(i.e. route of administration, frequency of dosing, etc.)• Order includes prohibited abbreviations• Weight-based dosing required but not done• Not clarified with prescriber prior to
medication being dispensed
• Blanket Resume Orders• Medication orders not found in the patient record• Undocumented verbal orders• Missing protocols
• Orders lack selection criteria to guide administration• Involves preprinted order sets as well as orders
generated by an individual provider• Not clarified with prescriber prior to medication being
dispensed
• Titration and Sedation ordersL k ifi it i f tit ti (i iti l d/• Lack specific criteria for titration (initial and/or incremental doses, clinical parameters)
• Lack sedation goal and/or dosing parameters• Not clarified with prescriber prior to medication being
dispensed
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 30
Improving MM.04.01.01 Outcomes
• Educate and re-educate all clinical staff involved in the medication management process on all requirements of
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a complete order
• Review preprinted order sets to ensure only complete, accurate orders are included
• Monitor the clarification process to ensure incomplete, inaccurate orders are clarified with the prescriber prior to dispensing the medication
• Monitor troublesome types of orders (titration, sedation) to ensure criteria for use are included and followed• Provide feedback to prescribers (OPPE?) and those who
administer medications on the monitoring results you obtain
MM.05.01.01 – Areas of Focus• Pharmacist’s review of orders
• Orders faxed from physician’s office and implemented ith t h i t’ i
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without pharmacist’s review• PACU orders not transmitted for
pharmacist’s review• Preprinted order sets and protocols
• Clarifying orders• Incomplete, inaccurate orders not
clarified before dispensing• All issues not clarified with prescriber
before dispensing• Confusion over nursing v. pharmacy role in clarification
process
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 31
Improving MM.05.01.01 Outcomes
• Educate and re-educate all clinical staff involved in the medication management process on the need for
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medication management process on the need for pharmacist’s review of orders
• Review preprinted order sets and protocols with a critical eye to determine any potential unresolved therapeutic duplication issues
• Work with clinicians who administer medications to promote understanding of the clarification processpromote understanding of the clarification process • Orders should be written correctly from the beginning
• Ideally, nursing can clarify at the time of issuance
• But, remember the final responsibility for clarification rests with the dispensing pharmacist
Resolve these issues…
To ensure a successful survey outcome!
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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
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U d t C tU d t C t PhPhUpdate on Current Update on Current Pharmacy Pharmacy Initiatives and StrategiesInitiatives and Strategies
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Jerry H. Reed, MS, RPh, FASCP, FASHP
Corporate Director, Pharmacy Operations
Community Health Systems
The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series
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A Checklist for Safe Use of Medication Samples
Proactively identify your organization’s approach to medication samples. If you decide to allow the use of medication samples, determine the following:
l For which types of patients? l On a trial basis or for chronic use? l Which medications? l Will you accept controlled substance medication samples?
Define control over medication samples. l Identify a secure location, with authorized access only. l Determine who will receive samples. l Determine who will log in samples. l Determine who will maintain the sample location, remove and properly dispose of
expired medications, and oversee recalled medications. l Review state laws to determine who is authorized to dispense sample medications
to the patient.
Review the list of allowed medication samples for compliance with the following:
l Look-alike, sound-alike medication process, if appropriate l High-alert or hazardous medication process, if appropriate l Applicability for weight-based dosing in pediatric patients
Include the following in the decision to provide a patient with a sample medication:
l Document in the patient’s medical record. l Properly label the sample. l Take steps to ensure no contraindications, interactions, duplications, or
patient-specific variables that might affect prescribing (check with the pharmacist). l Log dispensing in sample medication log book. l Provide information to the patient about the medication and its proper use. l Consider providing the patient with a prescription for subsequent refills, with
instructions.
Consider formalizing medication sample decisions for your practice site with a policy.
l Educate staff and pharmaceutical representatives on these policy decisions.