Critical Access Hospital Medication Management and ...

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Building Leaders – Transforming Hospitals – Improving Care

Critical Access Hospital

Medication Management

and

Infection Control

A Deep Dive

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• Turnaround

Strategy

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Carolyn St. Charles, RN, BSN, MBA

Regional Chief Clinical Officer Carolyn began her healthcare career as a staff nurse in Intensive Care. She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years. In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the lead consultant for development of Community Health Needs

Assessments and conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Carolyn also provides assistance in developing strategies for continuous survey readiness and developing plans of correction.

Clinical Consulting


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UPCOMING EVENTS

June 15th Webinar The Right Candidate -- But Not on Paper Hosted by: Peter Godspeed, VP of Executive Search http://bit.ly/1Ww4OKU June 21th Webinar Leveraging Technology To Ensure Staff Productivity And Quality Hosted by: Mark Westman, Corporate VP Revenue Cycle for Iasis Health and Derek Morkel, CEO GAFFEY Health http://bit.ly/1SV0By5


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Instructions for Today’s Webinar

• You may type a question in the text box if you have a question during the presentation

• We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail

• You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)

• The webinar will be recorded and the recording will be available on the HealthTechS3 web site

www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

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In the News

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A Deep Dive


C-0276: Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

C-0277: Procedures for reporting adverse drug reactions and errors in the administration of drugs.

C-0297: All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws.

Infection Control

C-0278 : A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

CAH CoPs: 10/9/15

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_w_cah.pdf

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Required Policies

• Responsibility for pharmacy services

• Storage of drugs and biologicals, including the location of storage areas, medication carts and dispensing machines

• Proper environmental conditions

• Security

• Handling drugs and biologicals

• Compounding

• Use of outside compounders

• Use of compounding pharmacies

• Dispensing drugs and biologicals

• Administration of drugs and biologicals

• Record keeping for the receipt and

disposition of all scheduled drugs

• Ensuring that outdated, mislabeled, or

otherwise unusable drugs are not used for

patient care

• Assessing adverse drug reactions and

medication administration errors

• Procedures for reporting adverse drug

reactions and errors in administration of

drugs

Question(s) Yes No Maybe

Policies have been reviewed for the most recent evidence-based practice?

All required policies are in place?

Policies have been reviewed by a physician and a mid-level within the last 12 months?

Policies have been approved by the governing board within the last 12 months?

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Responsibility for Pharmacy Services

The CAH must identify the qualifications for and designate an individual who has overall responsibility for the CAH’s pharmacy services, including development of the rules governing pharmacy services.

Question(s) YES NO MAYBE

Does the pharmacist job description include qualifications and overall responsibility? Note: If you don’t have a full-time pharmacist – you must still have a pharmacist designated with overall responsibility.

Has the pharmacist signed – their job description? Or if a contract pharmacist are qualifications – duties – specified in the contract?

She really is a pharmacist

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Proper Environmental Conditions

Where the manufacturer’s FDA-approved package insert specifies environmental conditions,

such as temperature, humidity, exposure to light, etc., for storage of drugs, the CAH is expected to follow the labeled conditions.

Absent the manufacturer’s labeled conditions, USP indicates that storage of drugs and biologicals be done according to USP/NF, or the food chemicals codex (FCC) monograph requirements.

CAHs must exercise caution in dispensing or using any drug or biological that is not labeled to indicate proper storage conditions or that may have been stored under inadequate conditions.

Question(s) YES NO MAYBE

Policies in place for appropriate storage of drugs?

Proper storage adhered to in ALL areas where drugs are stored (surgery, nursing units, medical imaging, respiratory therapy, outpatient departments)

Drugs are labeled with proper storage conditions?

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Security

The CAH must have policies and procedures that are consistent with State and Federal law to address who is authorized access to the pharmacy or drug storage area.


Are there policies and procedures in place for what staff can access (enter) pharmacy after hours?

Is there a log of after hours entry? Is it checked against those who are authorized to enter pharmacy?

Are staff who enter pharmacy after hours oriented? Who is responsible for orientation? Is orientation documented? How are new staff / supervisors oriented?

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Security

Drugs and biologicals must be stored in a secure manner to prevent unmonitored access by unauthorized individuals. Drugs and biologicals must not be stored in areas that are readily accessible to unauthorized persons.

• Medication carts, anesthesia carts, epidural carts and other non-automated medication carts containing drugs or biologicals (hereafter, all referred to as “carts”) must be secured

when not in use.

• If a cart containing drugs or biologicals is in use and unlocked, someone with authorized access to the drugs and biologicals in the cart must be close by and directly monitoring the cart. That person could be a nurse, a physician, or other individual who in accordance with State and Federal law and CAH policy is authorized access to the drugs and biologicals in the cart. That individual must monitor the cart and be aware of other people’s activities near the cart. He/she is responsible for the security of the drugs

and biologicals in the cart.


Are medication carts secured when not in use?

Are carts directly monitored when unlocked?

How is security of carts monitored?

Secure enough?

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Handling Drugs and Biologicals Except in emergencies or when not feasible (for example, when the product’s stability is short), only the pharmacy performs reconstituting, mixing, admixing or compounding.

NOT

All compounding of medications used or dispensed by the CAH must be performed consistent with accepted professional principles which are equivalent to or more stringent than those described in the compounding-related chapters in the USP/NF, which are recognized as authoritative standards regarding minimum standards of safe practice applicable to both sterile and non-sterile compounding. A CAH pharmacy must ………. be able to demonstrate how it assures that all sterile and non-sterile compounded preparations

dispensed and/or administered to the CAH’s patients are being compounded consistent with accepted professional standards to ensure safety.


Does pharmacy mix drugs when they are not on-site (not nursing)?

Does pharmacy reconstitute or mix drugs in advance for next shift if pharmacy is closed?

Are there policies in place for compounding consistent with accepted professional principles?

Do nursing staff who reconstitute or mix medications have evidence of competency?

Is the area used when nursing staff reconstitute or mix medications a clean area? And appropriate for mixing medications?

Coverage at night?

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Use of Outside Compounders

(Outsourcing Facilities)

In a January 2014 letter to purchasers of compounded medications (available at

http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm380596.htm ),

the Commissioner of the FDA encouraged the use of registered outsourcing facilities and noted that,“[a]s a purchaser of compounded drugs, you can play an important role in improving the quality of compounded drugs by requiring compounding pharmacies that supply drugs to your facility to register as outsourcing facilities. Once they register, you and

the patients you serve can be assured that FDA will inspect these facilities on a risk-based schedule, hold them to CGMP requirements, monitor the adverse event reports they are required to submit to the agency, and require appropriate labeling.”

Note that these registered outsourcing facilities are also popularly referred to as “503B pharmacies.” Question(s) Yes No Maybe

Do you use an outsourcing facility?

Is it registered with the FDA?

Do you have evidence of current registration?

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Use of Compounding Pharmacies

If a CAH obtains compounded medications from a compounding pharmacy rather than a manufacturer or a registered outsourcing facility, then the CAH must demonstrate how it assures that the compounded medications it receives under this arrangement have been prepared in accordance with accepted professional principles for compounded drugs as well as applicable State or Federal laws or regulations.

• Ensure that the CAH has access to quality assurance data verifying that the vendor is adhering to current USP <795> and <797> requirements, and can the CAH document that it obtains and reviews such data?

• Requiring the vendor to meet the requirements of Section 503A of the FDCA concerning pharmacy compounding of human drug products?

Note that these registered outsourcing facilities are also popularly referred to as “503A pharmacies.”


Do you have quality assurance data verifying compliance with USP 795 and 797?

Was the data reviewed and by whom?

Is the review documented?

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Dispensing drugs and biologicals

There must be sufficient numbers and types of personnel to provide accurate and timely

medication delivery

• Medications must be dispensed in a timely manner

• The CAH must have a system that ensures medication orders get to the pharmacy promptly

and medications are available for administration to patients when needed, including when the

pharmacy is not open

• Concerns, issues or questions pharmacy staff have about any medication order must be

clarified with the prescribing practitioner or another practitioner responsible for the care of the

patient before dispensing

• Policies and procedures must address who can access medications during after-hours


Do you have a policy defining “timeliness”?

Is there a policy for who can access pharmacy after-hours?

Are staff who enter pharmacy after-hours oriented? And documented?

Are there a limited number of medications accessible to staff entering pharmacy after-hours?

What have you done to limit access? Do you review access with P&T on a regular basis – including reason for access?

Are orders clarified before dispensing (and administration)?

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Record keeping for the receipt and

disposition of all scheduled drugs

Determine if the CAH has a system that tracks movement of all scheduled drugs from the point of

entry into the CAH to the point of departure either through administration to the patient, destruction of the drug, or return to the manufacturer.


Does your system provide documentation on scheduled drugs in a readily retrievable manner to facilitate reconciliation?

Do you have a system for tracking scheduled drugs administered by anesthesia?

Are there discrepancies? How often do they occur? Where do they occur? What is the reason for the discrepancy?

Do you have a process and system for recognizing (early) drug diversion?

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Ensuring that outdated, mislabeled, or otherwise unusable

drugs are not used for patient care

Must have pharmacy labeling, inspection and inventory management system that ensures that

outdated, mislabeled or otherwise unusable drugs and biologicals are not available for patient use – including drugs that are recalled

Maintain and implement policies and procedures that provide clear and consistent directions regarding how to determine beyond-use-date


Do you have a system for monitoring – how often? Who? What locations? (Don’t forget RT – Imaging)

Do you monitor drugs packaged as part of a kit?

Do you have a policy for “beyond-use-date”?

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Assessing Adverse Drug Reactions & Medication Errors

• CAH staff must report all drug (medication) administration errors and all adverse drug reactions

• If…….. they are not caught before they reach the patient, a “report” must be made to a practitioner responsible for the care of the patient

• If the error…….. has harmed or has reached the patient and could potentially cause harm, the report to a practitioner must be made immediately after the staff identify the adverse reaction or (potentially) harmful error……..

• If the impact of the error that reached a patient is unknown, the error must be reported to a practitioner immediately

• Documentation of the error or reaction, including notification to the practitioner, must be in the patient’s medical record

• Medication administration errors that have reached the patient but result in no harm and do

not have the potential to cause harm can be reported to a practitioner during usual working hours


Policies are in place on reporting?

Practitioners are notified immediately if harm or potential harm – or – if unknown?

Documentation is included in the medical record?

Documentation of errors without harm are reported to the practitioner?

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Institute for Healthcare Improvement – IHI

Strategies to reduce Medication Errors

• Provide Antidote and Recovery Strategy Information

• Label Drugs Specifically for Each Dose • Ensure That Allergy Information

Accompanies Patients

• Make Allergy Information Available in Multiple Locations

• Involve Patients in Administering Their Own Medications

• Provide Medication Reference Materials at the Point of Care

• Remove Discontinued Medications Immediately

• Use Pre-Made Dosing Charts • Eliminate or Reduce the Availability of

Multiple Medication Strengths • Separate Drugs That Look or Sound Alike • Have Patients Maintain Their Own

Medication Administration Record (MAR)

• Conduct Independent Double-Checks on the Unit

• Use Pre-Typed Medication Records, Orders, and Flowsheets

•

•

•

•

• Implement Pharmacy-Based Dosing • Use Expert Consultants to Guide

Interventions During ADEs • Minimize the Number of Medications

Available on Units

• Computerize Medication Administration Records

• Provide Medication and Food Interaction Information

• Provide Dose Calculation Aids on Drug Labels

• Involve Patients in Medication Checks

• Use One Tablet Size for Each Oral Medication

• Conduct Adverse Drug Event (ADE) Drills • Use Bar Codes to Identify Medications • Prepare Non-Standard Doses in

Pharmacy • Dispense Medications in Ready-to-Use

Single Doses • Limit Over-Ride Options on Computer

and Medical Device Safety Features • Pre-Compile Responses to Adverse Drug

Events

Other Sources ISMP - AHRQ

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Quality Assurance / Improvement

• To facilitate reporting, the CAH must educate staff on medication

administration errors and ADRs including the criteria for those errors

and ADRs that are to be reported for quality assurance/improvement

purposes, and how, to whom and when they should be reported

• CAH must assess the effectiveness of its internal reporting system

• Pharmacy services is expected to assess reports and issues – and to

take effective action to address identified issues


Data is collected for medication errors or adverse drug reaction, assessed for patterns and trends, and corrective actions developed?

Review of effectiveness of reporting system occurs at least annually?

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Policies and Procedures

• CAH must have written policies and procedures for the administration of all drugs

and biologicals that adhere to accepted standards of practice and Federal and

State laws.

• All drugs, biologicals, and intravenous medications must be administered by or

under the supervision of a registered nurse, a doctor of medicine or osteopathy, or,

where permitted by State law, a physician assistant, in accordance with written

and signed orders, accepted standards of practice, and Federal and State laws.


Policies and procedures have been reviewed and are current with evidence-based practice within the last 12 months?

Policies and procedures have been reviewed by a physician and a mid-level within the last 12 months?

Policies and procedures have been approved by the governing board within the last 12 months?

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Medication Orders

• Minimum content of medication orders

– Name of patient

– Age and weight of patient, to facilitate dose calculation when applicable

– Date and time of the order

– Drug name

– Exact strength or concentration, when applicable

– Dose, frequency, and route

– Dose calculation requirements, when applicable;

– Quantity and/or duration, when applicable\

– Specific instructions for use, when applicable

– Name of the prescriber


Policy current, within last 12 months, and includes all of the required elements?

Medication orders are audited for compliance with policy?

Incomplete medication orders are clarified with the provider before administration

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Verbal and Standing orders • For verbal orders, CAH policies must, at a minimum, address the following:

– Describe situations in which verbal orders may be used, as well as limitations or prohibitions on their use

– Provide a mechanism to establish the identity and authority of the practitioner issuing a verbal order

– List the elements required for inclusion in the verbal order process

– Establish protocols for clear and effective communication and verification of verbal orders. CMS expects nationally accepted read-back verification practice to be implemented for every verbal order

– Identify the categories of clinical staff who are authorized to receive and act upon a verbal

order

– Provide for prompt documentation in the medical record of the receipt of a verbal order

– In the case of both verbal and standing orders, a practitioner responsible for the care of the patient must authenticate the order in writing as soon as possible after the fact


Policy for verbal orders include all of the required elements including authentication?

Process for authenticating identify of practitioner?

Process to audit timeliness of provider authentication? (May be sooner than State requirement)

Process to audit / monitor frequency of verbal orders? Interventions to reduce verbal orders?

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Standing Orders

• CAH policies must, at a minimum, address the following:

– The process by which a standing order is developed; approved; monitored; evaluated and updated when needed

– For each standing order, which staff may initiate it and under what circumstances; (under no circumstances may a CAH use standing orders in a manner that requires any staff not authorized to write patient orders to make clinical decisions outside of their scope of practice in order to initiate such orders)

– The requirements for subsequent authentication by a practitioner responsible for the care of the patient

– In the case of both verbal and standing orders, a practitioner responsible for the care of the patient must authenticate the order in writing as soon as possible after the fact


Policy for standing orders include all of the required elements including when the order must be authenticated?

Standing orders are “specific” and not “general guidelines”?

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Self-Administration of Medications

• The CAH may choose to allow practitioners to write orders allowing patients to self-

administer CAH-issued drugs and biologicals or drugs the patent has brought from home into the CAH for use during their stay.

• IF the CAH permits this , it must develop polices and procedures for self-administration of drugs by patients or their informed caregivers.


Policy for self-administration of medications?

Policy and procedure for how medications brought from home are reviewed by pharmacy prior to administration?

Policy includes how patients and/or caregivers are evaluated if they are allowed to self-administer drugs?

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Training

• Policies and procedures must address the required components of the training and if the

training provided during CAH orientation imparts sufficient education or whether ongoing

in-services or continuing education will be required to demonstrate competence


Training on medication administration is included as part of orientation?

Method for competency has been determined?

Competency is determined prior to staff administering medications?

Competency is documented?

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Basic Safe Practices for Medication

Administration

• The CAH’s policies and procedures must reflect accepted standards of

practice that require the following be confirmed prior to each administration

of medication (often referred to as the “five rights” of medication

administration practice)


Policy and procedure is current?

Medication tracers include observation of staff administering medications?

Overdose?

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Timing of Medication Administration

• CAH policies and procedures must specifically address the timing of medication

administration, based on the nature of the medication and its clinical application, to ensure safe and timely administration. The policies and procedures must address at least the following:

– Medications not eligible for scheduled dosing times – Medications eligible for scheduled dosing times – Time-critical scheduled medications

– Non-time critical scheduled medications – Missed or late administration of medications

• Evaluation of medication administration timing policies

– CAHs must periodically evaluate their medication administration timing policies, including staff adherence to the policies, to determine whether they assure safe and effective

medication administration. Medication errors related to the timing of medication administration must be tracked and analyzed to determine their causes.


Policies are current and include all the required elements?

Evaluation of medication administration timing policies occurs at least annually?

Evaluation is shared with P&T or Quality Committee?

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Assessment/Monitoring of Patients

Receiving Medications

• Observing the effects medications have on the patient is part of the multi-faceted

medication administration process

• Patients must be carefully monitored to determine whether the medication results in the

therapeutically intended benefit, and to allow for early identification of adverse effects

and timely initiation of appropriate corrective action


There is documentation in the medical record of the effects of medication?

Documentation includes effectiveness of pain medication (before and after)?

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Medications and Blood Transfusions

Many of the medications included in the high-alert categories are administered intravenously. CAH policies and procedures for IV medications must address at least the following:

• Vascular Access Route

– Hospital policies and procedures must address which medications can be given intravenously via what type of access

• Other

– Tracing invasive lines and tubes prior to administration to ensure the medication is to be administered via the proper route (for example, peripheral catheter versus epidural catheter connections)

– Avoiding forcing connections when the equipment offers clear resistance

– Verifying proper programming of infusion devices (concentrations, flow rate, dose rate)

• Monitoring patients receiving IV medications

– Policies and procedures for IV medication administration must address appropriate IV medication monitoring requirements, including assessment of patients for risk factors that would influence the type and frequency of monitoring

Question(s)Yes Yes No Maybe

Policies are current and include all the required elements?

Invasive lines and tubes are traced prior to administration?

Policies and procedures address frequency of monitoring for patients receiving IV medications?

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Blood Administration

• In addition to the safe practices and other safety considerations that apply to all IV

medication administration, policies and procedures must address blood administration procedures that are consistent with accepted standards of transfusion practice, including but not limited to:

– Confirming the following prior to each blood transfusion

• the patient’s identity

• verification of the right blood product for the right patient

• The standard of practice calls for two qualified individuals, one of whom will be administering the transfusion, to perform the confirmation

• Requirements for patient monitoring, including frequency and documentation of monitoring

• How to identify, treat, and report any adverse reactions the patient may experience

during or related to transfusion.


Are all policies and procedures current?

Is blood transfusion documentation audited?

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Infection Control

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Start Here

1. Infection Control Plan

2. Infection Control Risk Assessment

3. Infection Control Priorities based on Risk Assessment

4. Plan to Address Priorities – Goals – what you want to accomplish

– Action Steps – What – Who – When

– Measurable Targets

5. Report at every IC Meeting

6. Modify plan / goals if needed

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Policies

Policies related to: A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel

*The hospital has infection control policies and procedures relevant to: construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control risk assessment(ICRA)to define the scope of the project and need for barrier measures

before a project gets underway.


*Can the Infection Control Officer(s)provide evidence that the hospital has developed general infection control policies and procedures that are based on nationally recognized guidelines and applicable state and federal law.

Were policies reviewed in the last 12 months by a physician and a mid-level?

Have the policies been approved by the governing board within the last 12 months?

*CMS Infection Control Surveyor Worksheet

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Designated Individual

The CAH is expected to have a designated individual who is qualified by education and/or

experience and who is responsible for the infection control program. This person must have education or experience in the principles and methods for infection prevention and control


*Has the hospital has designated one or more individual(s) as its Infection Control Officer(s)?

*Does the hospital have evidence that demonstrates the Infection Control Officer(s) is qualified and maintain(s) qualifications through education, training, experience or certification related to infection control consistent with hospital policy

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Special Challenges

Multi-Drug Resistant Organisms (MDROs)

• CAHs are encouraged to have mechanisms in place for the early identification of patients with targeted MDROs prevalent in their CAH and community, and for the prevention of transmission

• When ongoing transmission of targeted MDROs in the CAH is identified, the infection prevention and control program should use this event to identify potential breaches in infection control practices

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Multidrug Resistant Organisms


* The hospital has policies and procedures to minimize the risk of development and transmission of multidrug-resistant organisms (MDROs)within the hospital (applicable to all persons in the hospital).

*Systems are in place to designate patients known to be colonized or infected with a targeted MDRO and to notify receiving units and personnel prior to movement of such patients within the hospital.

*Systems are in place to designate patients known to be colonized or infected with a targeted MDRO and to notify receiving healthcare facilities and personnel prior to transfer of such patient between facilities

*The hospital can provide a list of target MDROs. Note: Hospitals should provide a list of MDROs that are targeted for infection control because they are epidemiologically important (e.g.,MRSA, VRE).

*The hospital can demonstrate the criteria used to determine epidemiologically important MDROs on their list.

*The hospital can provide justification for any epidemiologically important organisms not on their list and otherwise not targeted in their hospital.

*The hospital has an established system(s)to ensure prompt notification to the Infection Control Officer when a novel resistance pattern based on microbiology results is detected

*Patients identified as colonized or infected with target MDROs are placed on Contact Precautions.

Go away MDROs!

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Multidrug Resistant Organisms


*The hospital has written policies and procedures whose purpose is to improve antibiotic use (antibiotic stewardship).

*The hospital has designated leader (e.g., physician, pharmacist, etc.) responsible for program outcomes of antibiotic stewardship activities at the hospital.

* The hospital’s antibiotic stewardship policy and procedures requires practitioners to document in the medical record or during order entry an indication for all antibiotics, in addition to other required elements such as does and duration.

*The hospital has a formal procedure for all practitioners to review the appropriateness of any antibiotics prescribed after 48 hours from the initial orders (e.g., antibiotic time out).

*The hospital monitors antibiotic use (consumption) at the unit and/or hospital level

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Surveillance and Corrective Action

• The CAH must conduct surveillance on a facility-wide basis in order to identify infectious risks or

communicable disease problems at any particular location

• CAHs must have reliable sampling or other mechanisms in place to permit identifying and

monitoring infections and communicable diseases occurring throughout the CAH

• Surveillance must be documented including measures selected for monitoring and collection

and analysis methods

• Surveillance activities must be conducted in accordance with recognized infection control

surveillance practices, such as, for example, those utilized by the CDC’s National Healthcare

Safety Net (NHSN)

• The CAH must develop and implement appropriate infection control interventions to address

issues identified through its detection activities, and then monitor the effectiveness of interventions

through further data collection and analysis

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Surveillance and Corrective Action


*The Infection Control Officer can provide an updated list of diseases reportable to the local and/or state public health authorities.

*The Infection Control Officer can provide evidence that the hospital complies with the reportable diseases requirements of the local health authority.

Is there a method for identifying infectious risks - not just actual infections!

A plan for surveillance is in place and approved by the Infection Control Committee?

The surveillance plan is updated annually based on the annual risk assessment?

Surveillance includes both hospital acquired and community acquired infections? (Community acquired is not required but recommended.)

Surveillance data is collected by site and organism?

Surveillance data is analyzed for trends and patterns? Including “clusters” of infections?

Interventions are identified based on analysis?

Interventions are monitored for effectiveness?

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Sanitary Environment

• All areas of the CAH must be clean and sanitary ---- Including off-site locations

– Must include appropriate monitoring of housekeeping, maintenance (including repair, renovation and construction activities) and other activities to ensure that the CAH maintains a sanitary environment


Housekeeping policies and procedures are approved by IC Committee?

Housekeeping techniques are “assessed” – “observed”?

All cleaning products are approved by the IC committee before being put in to use?

Staff are trained on use of cleaning products before being used?

IC is notified PRIOR TO a repair or renovation / construction project?

Surgical Services processes are “observed” on a regular basis to identify any infection control issues including: cleaning, sterilizing, temperature, humidity, etc.?

Kitchen and food preparation processes are “observed” on a regular basis to identify any infection control issues including: dishwasher temps, use of 3-compartment sink, refrigerator temperatures, food storage?

Staff are observed cleaning equipment, stretchers, tables, beds in ALL departments?

Environmental / Infection Control rounds are conducted monthly in ALL depts. including outpatient?

Any issues or trends are identified and a plan of correction developed – including root cause?

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Mitigation of Risk

The CAH must have policies and procedures in place to

mitigate the risks that contribute to healthcare-associated

infections. They must incorporate infection control

techniques and standard precautions including, but not

limited to:

• Hand Hygiene

• Respiratory Hygiene/Cough Etiquette

• Use of Transmission-Based Precautions

• Use of personal protective equipment (PPE) for

healthcare personnel

• Safe work practices to prevent healthcare worker

exposure to bloodborne pathogens, such as safety

needles and safety engineered sharps devices

• Safe medication practices including but not limited to:

– Routine preparation of injectable medications takes

place in a designated clean medication area that is

not adjacent to areas where potentially contaminated

items are placed;

– Proper hand hygiene before handling medications

–Always disinfecting a rubber septum with alcohol prior

to piercing it;

–Always using aseptic technique when preparing and

administering injections;

–Never entering a vial with a used syringe or needle

–Never administering medications from the same

syringe to more than one patient, even if the needle is

changed;

– Recognizing that. after a syringe or needle has been

used to enter or connect to a patient’s IV it is

contaminated and must not be used on another

patient or to enter a medication vial;

–Never using medications labeled as single-dose or

single-use for more than one patient.

– If multi-dose vials are used for more than one patient,

they must not be kept or accessed in the immediate

patient treatment area.

–Never using bags or bottles of intravenous solution as

a common source of supply for more than one

patient

–Wearing a surgical mask when placing a catheter or

injecting material into the spinal canal or subdural

space

– Never using insulin pens and other medication

cartridges and syringes intended for single-patient-use

only for more than one person

• Other

–Never using the same fingerstick device for more than

one person

–Avoiding shred blood glucose meters if possible

– Policies to ensure that reusable patient care

equipment is cleaned and reprocessed appropriately

before use on another patient

© HTS3 2016 | Page 47

Mitigation of Risk


Are all policies in place?

Have staff been trained on appropriate procedures? And competency documented?

Is there a system for monitoring for effectiveness and compliance? (Infection Control Rounds – direct observation?)

Are you monitoring departments other than nursing? ( i.e. Respiratory, Imaging, Outpatient Departments)

Does monitoring include hand hygiene compliance? Is it accurate?

© HTS3 2016 | Page 48

Mitigation of Risk

• The CAH must train staff on infection control policies and practices pertinent to the staff’s responsibilities and activities

• The CAH is also expected to provide education to patients and their visiting family members/caregivers, when applicable, about precautions to take to prevent infections

• The CAH is expected to monitor compliance with all policies, procedures, protocols, and other

infection control program requirements


Is there an annual education program? Does it focus on areas of concern identified in the annual risk assessment?

Are new staff oriented BEFORE starting to work including contract staff and Travelers?

Are ALL staff trained including dietary – environmental services – imaging, etc.

Are patients and their families educated about precautions to take to prevent infections

Is a program for monitoring compliance in place? They really are teachers!

© HTS3 2016 | Page 49

Tools for Improvement

© HTS3 2016 | Page 50

Tools for Improvement

• Best Practices – APIC

– ISMP

– AHRQ

– IHI – QIO

– State (i.e. MERP)

• Patient Safety Rounds

• Tracers

• Failure Mode and Effects Analysis (FMEA)

© HTS3 2016 | Page 51

Tracer Methodology

The Joint Commission

The tracer methodology uses information from the organization to follow the experience of care, treatment or services for a number of patients through the organization’s entire health care delivery process.

– Individual tracer activity: These tracers are designed to “trace”

the care experiences that a patient had while at an organization. It is a way to analyze the organization’s system of providing care, treatment or services using actual patients as the framework for assessing standards compliance.

– System tracer activity: Includes an interactive session with a surveyor and relevant staff members in tracing one specific “system” or process within the organization, based on information from individual tracers. • The three topics evaluated by system tracers are data management,

infection control and medication management.

© HTS3 2016 | Page 52

Organize

Step 1: Select team • Pharmacist and/or

• Infection Control Preventionist

• RN caring for patient

• Others as appropriate for patient

• Physician – Hospitalist – if possible

Step 2: Select frequency

• Weekly

• Monthly

• Quarterly

Step 3: Develop calendar by date / department

© HTS3 2016 | Page 53

Identify Focus Areas


• High Volume – Obstetrics

– Orthopedic Surgery

– Swing Bed

• Low Volume / High Risk – Restraints (Chemical and

Physical)

– Chemotherapy

– Isolation

• Special Focus Areas – MDRO

– Pain Medication

– Antibiotic

• Special Populations – Pediatrics

– Special Care / Intensive Care Nursery

– Mental Health

• Departments – Respiratory Therapy

– Medical Imaging

– Surgery

© HTS3 2016 | Page 54

Identify Focus Areas

Infection Control

• Cleaning Processes – Housekeeping

– Surgery

– Ultrasound

– Dietary

– Equipment

• Isolation – Staff

– Family / Visitors

• Special Focus Areas – MDRO

• Waste Management – Department to Pick-Up

• Environment – Air Exchanges

– Temperature and Humidity

– Cleanliness

• AND patient tracers too

© HTS3 2016 | Page 55

Methodology

• Actual tracer methodology and

questions are dependent on your

focus

• Always do tracers concurrently if

possible

• Always involve staff – not just

managers

• Opportunity to identify system and

process issues – no gotchas’

© HTS3 2016 | Page 56

So many opportunities

So little time

• Start with an Assessment

• Identify Opportunities – Barriers - processes that need to be improved

• Identify Priorities – think patient safety first

• Develop a Plan including outcome measures

Beware------- Education is not the only answer!

• Think

© HTS3 2016 | Page 57

Continuous Survey Readiness

Everyone’s Job

© HTS3 2016 | Page 58

Questions?

© HTS3 2016 | Page 59

Contact Information

If you would like to schedule a mock survey or have questions, please contact:

Carolyn St.Charles

Regional Chief Clinical Officer

Email: [email protected] Phone: 360-584-9868

59

mailto:[email protected]

© HTS3 2016 | Page 60

THANK YOU!

Carolyn St. Charles, RN, BSN, MBA HealthTechS3

[email protected]


mailto:[email protected]

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