December 2017 Phc newsletter - Patton Healthcare Consulting · Phc newsletter News from Joint Commission and CMS Inside This Issue: Perspectives: ... maintain critical components

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SurveyReportEnhancements:ThismonthPerspectivesdiscussessomesignificantchangesthatwillbeoccurringinsurveyreportsfor2018. We have seen mock ups of some of thereportedchangesanditlookslikeanimprovementineaseofuse.Oneoftheplannedchangesweareparticularly fond of is the ability to download acopy of the report findings into Excel. Eachobservationforeachelementofperformancewillappearinauniquerow.Thatisthesameformatweuse for our Patton HCmock survey consultationreportsanditallowstheusertoassigncorrectiveactions,assignresponsiblepartiesandcompletiondates,andsortandcloseoutcompletedtasks.Staytuned, but this looks like an improvement in theabilitytomanagetheaccreditationprocess.2018 Prepublication Standards – DownloadNow!Thereisalsoanarticleonthechangesthatwillbeoccurring in the EC and LS chapters for 2018.Thereisalinktotheprepublicationstandardsandthiswill leadyoutoan87-pagedocument,whichdetailseverythingthatisnew,everythingthathasmoved, andeverything thathas changedorbeenrevised. For purposes of your preparation, thoseitems that have moved, but the requirement isidentical to the prior requirement, there is little

December 2017 Phc newsletter

News from Joint Commission and CMS

Perspectives: Inside This Issue:

ü Perspectives� SurveyReportEnhancements� 2018PrepublicationStandards� ScoringforHandHygieneLapses� LookingforHospitalstoMeetCMSDefinitionofaHospital

� NewDecisionRuleforPDAü ECNews

� ManagingSprinklerSystems� ChangesfortheBehavioralHealthOrganizations

ü AnotherVincristineAlertü SuicideRiskAlgorithmü CMSUpdatesü Readyfor2018?

� MedicationRelatedStandards� PainManagementStandards


PATTON HEALTHCARE CONSULTING NEWSLETTER – DECEMBER 2017

needfordiscussion.Therevisionsorchanges, forthe most part reflect changing references todifferentversionsof theNFPAmanuals.Youmayneed to verify that you have these new NFPAeditions. Some revisions are more substantive,such as the change to EC.02.03.03, EP 3, whichpreviously stated at least 50% of quarterly firedrills are unannounced, and in 2018 it just saysquarterly fire drills are unannounced. Similarly,EC.02.05.09,EP1hasasignificantchange.TheoldEP required the hospital to inspect, test andmaintaincriticalcomponentsofpipedmedicalgasandvacuumsystems.In2018,thisEPaddstotherequirement by including waste anesthetic gasdisposal and support gas systems on the“inventory.”Thenitgoesintoadditiondetailaboutalltheitemswhichmustbeontheinventory.Lastlythe EP now also establishes a certificationrequirement for the individual performing theinspection per the American Society of SanitaryEngineers,orASSE.StandardEC.02.05.09,EP5thatpreviously discussed piped medical gas systemshas moved to EP 11 and it has changedsubstantially.Theyhaveaddedconsiderabledetailtothelabelingrequirementsformedicalgaspipesand shut off valves. EC.02.06.05, is the standardthatdiscussesapreconstructionriskassessmenttoincludeimplementingactionsneededtominimizerisk during demolition, construction, andrenovation.Nowin2018EP3wasmodifiedtoadd“or general maintenance” to the list of work toevaluatehowtominimizeriskduringthatwork.Thereallyimportantlistofchangeshoweverisallofthosethatarenewfor2018.Youdon’twanttogetsurprisedonsurveyifyouareduein2018andevenifyouarenotdue,youdon’twanttohavetooshortatrackrecordincompliancewiththesenewrequirements.Wedidnoteatthebeginningof2017thatmanyorganizationswerecaughtoffguardbychangesTJCmade to thesechapters in late2016.Therearetwowaysyoucanorganizethisanalysis.Thefirstandperhapseasiestwayistosimplyprinttheentire87-pagedocumentandshareitwithyourfacilities leadership, asking them to providefeedbackonallthenewrequirementsandtomake

sure they are all up and running in the next fewweeks.However,wecanattestthatsortingthroughthe new, the revised, and themoved is indeed atediousassignment.A secondandperhapseasierway is to use the E-Edition for 2018, which isavailableonyourextranetandsetyourfiltertojustthoseitemsthatare“new.”Nowyoucanprintthatlimitedportionofeachchapteridentifyingjustthenewrequirements. In theprintdialoguebox, it isalso easy to save this to a PDF file that you canemailandsearch.We wanted to point out one of the newrequirements in EC.02.03.01, EP 12 because itrequirescliniciansto implementcertainpracticesrelative to fire safety in the operating room. Thenew EP establishes requirements for safe use offlammablegermicidesorantisepticsintheOR.TheJointCommissionlanguagebringsincontentfromtheCMSInterpretiveGuidelines,TagA-0951(lastupdatedinNov2015)intheirentirety.Inaddition,we noted an additional requirement thatflammable “solution soaked materials must beremovedfromtheoperatingroompriortodrapingand the use of surgical devices.” If you had notalready included this fire safety time out likeprocessinyouroperatingrooms,youwillwanttodosoassoonaspossible.ScoringBeginsAgainforHandHygieneLapses:The December Perspectives also discussed thatfailed hand hygiene observations will again bescoredin2018.Severalyearsago,TJChadmodifiedits process for evaluating the National PatientSafety Goal for hand hygiene, instead looking atgoalsetting,establishmentofaprocessandmakingimprovements.Well;scoringoftheNPSGwillstillfocusontheseissues,butnowIC.02.01.01,EP2iswhere they will instruct surveyors to score anyfailurestheyseeinproperhandhygiene.LookingforHospitalstoMeetCMSDefinitionofaHospital:Perspectives also announced the immediateimplementationofanewrequirementasaresultofthe CMS SC memo we discussed in the October



PattonHCnewsletterrelativetothedefinitionofahospital. The CMS memo was both detailed andconfusing in termsof how theywould assess theveracityofbeingahospital,butonedecisionthatcame out of it is that Joint Commission will notconduct an accreditation survey at a hospital iftherearelessthan2inpatientspresent.Thishasnoimpact on the vast majority of our readers, butsome smaller surgical specialty hospitals shouldtake note. The announcement indicates thisrequirementisonlybeingappliedtohospitals,nottocriticalaccesshospitals.NewDecisionRuleforPDA–BeAware:Thereisalsoanarticleonthe2018DecisionRulesfor Hospitals. We have previously discussed thisportionof theaccreditationmanualasoneof theleast readsectionsof theentiremanual,butveryimportant to the overall outcome of your surveyprocess. There is one important addition to thedecisionrules for2018withtheadditionofwhattheycallDA06.Thisisdenialofaccreditationanditwillbethesurveyoutcomewhenanorganizationhas been placed in preliminary denial ofaccreditationstatusontwosequentialsurveys. ManagingSprinklerSystems:The lead article in this month’s EC News is onmanaging sprinkler systems,EC.02.01.35.We seesprinkler issues being scored frequently inhospitals and Joint Commission indicates thisstandardwasscoredin14%ofsurveysinthefirsthalfof2017.ThefirstcomplianceproblemisEP4,a failuretokeepthesprinklerpipe free fromanyattachments, draping of cables, tubes or otherpipes.Theexpectationisthatnothingissuspendedor attached to the sprinkler pipe. Unfortunately,these pipes are above the ceiling and somewhatinvisibletodetection.Wheneitherstafforvendorsareinthehospitalworkingaboveyourceiling,youwanttoconductanabovetheceilinginspectionatthe completion to verify that they have not laidsomething on or tied off something to yoursprinkler pipe. In addition, you should have an

above the ceiling inspection process to detect ifanyonemadethiserrorinyearspast,sothatitcanbe corrected by eliminating the attachment. Thesecond problem with this standard is EP 5 thatrequiresundamaged,cleansprinklerheads.Thesegetcontaminatedovertimewithgrease,dust,hairand sometimes paint andmust be either cleanedprofessionally or replaced. Fortunately, these areeasilyvisibleanddirtyordamagedheadsshouldbelooked for during rounds. The next issue is theclassic 18-inch rule, EP 6. This is an issue thateveryone seems to be aware of, but problemscontinue to occur with compliance. Here theyprovide a helpful explanation of the so-called“library”rulethatallowsstorageabove18inchesaround the perimeter of the room with certainqualifications, of course. The last significantcomplianceissueisanewEP7thatwasaddedtothe 2017 standards requiring at least 6 sparesprinklerheadswithassociatedwrenchestobeonhandandstoredatlessthan100degreesF.Manyorganizationsmissed this new requirement earlyin2017,butmosthavenowcaughtup.The issueabout being stored below 100 degrees F isexplainedinthearticlestatingthattheOrings intheheadcandegradeisstoredabove100degrees.You do want to look at where these are beingstored since some shop areas may be un-air-conditioned.Changes for the Behavioral HealthOrganizations:ECNewsalsohasanarticleonsomeadditionstoEC.02.03.05 for behavioral healthcare programsthat brings inmany of the difficult requirementshospitals continue to strugglewith.This includesthe testingof firealarmequipment, inspectionoffireextinguishers,annualmaintenancetoportablefireextinguishers,andacontinuingproblemEPfordocumentingthename,date,inventoryofdevices,required frequency, results and NFPA referencesfor each of the required fire safety tests in theirdocumentation books. At the end of the articlethere is a useful checklist for self-assessingcompliancewith this standard that is potentially

EC News:



usefultobothbehavioralhealthorganizationsandhospitals.Lastmonth Joint Commission issued one of theirQuickSafetynewsletters, issue37oneliminatingvincristine administration errors. Vincristine is achemotherapy agent that is administeredintravenously, but is fatal if administeredintrathecally.Unfortunately,itissometimespartofatreatmentregimen,aportionofwhichshouldbeadministered intrathecally, however thevincristinemustneverbegivenintrathecally.JointCommissionhad issuedaSentinelEventAlertonthis same subject in 2005, and the Quick Safetynewsletter identifies Joint Commission, theInstitute for Safe Medication Practices, theOncology Nursing Society, the World HealthOrganization and the National ComprehensiveCancer Network all of whom are consistent inrecommending this drug be dispensed in aminibag,notasyringe.Thisrecommendedpracticeillustratesaconceptwehavediscussedpreviouslyin our Patton HC newsletter, namely, errorelimination rather than error reduction. Erroreliminationmeans engineering out the chance oferror, not just applyingwarning labels to reducethe chanceof error. ThisQuick Safetynewsletterreferencesaninternationalsurveywhichidentifiedthat31%ofreportinghospitalsarestilldispensingvincristineinasyringeinsteadofinaminibag.Oursuggestion is to verify with your pharmacy thatyour hospital has indeed engineered out thepotential for error made by the newest nurse,medical resident or pharmacist and alwaysdispensesthisproductinaminibag.Lastmonthwediscussed the latest requirementsforhospitalsprovidingcaretopatientswhomaybeat risk for suicide. These requirements wereextremely detailed and can be difficult torememberandanalyze.Flowchartsaresometimeshelpfulsowehavedevelopedaonepagediagram

thatdepictsthedecisionprocessandinterventionswe believe are required to help implement therequirementsinbehavioralhealth,emergencyandmedicalunitsettings.Theflowchartcanbefoundonthelastpageforyouruse. There were no CMS Survey and Certificationmemosfocusedonthehospital industrythispastmonth. InourearlierdiscussionaboutthenewECandLSrequirements we mentioned filtering to identifywhat’s “new” in your E-Edition search. We alsosuggest doing this as a final check that you haveprepared for all the prepublication standardspublishedthisyear,whichtakeeffectinJanuary,aswellas thenewEMrequirements,whichactuallytook effect in November. When you go into E-EditionnowyouwillseeaNovemberdatabaseanda January database. If you first click on theNovember database, and set your filter to “new,”youwillseethenewEMelementsofperformancewhichtookeffectinNovembertocoincidewiththeCMSchangesforemergencymanagement.Thiswillidentify16newelementsofperformanceacross6standards. Since many of the new requirementsidentify new content thatmust be added to youremergencyoperationsplan,youwanttomakesurethat each is addressed as required in your 2018updateifnotalreadymodified.Then return to the E-Edition and change thedatabase to the January 2018 standards edition.ThiswillidentifychangesintheEC,LD,LS,MM,MS,PI,PCandRCchapters.Again,wewouldencouragereaderstoprinttheseouttoverifytheyhavebeenaddressed. The EC and LS changes mandated byCMSwereaddressedearlierinthisnewsletter.TheLD,MS,PCandPIchangesaretheonesassociatedwith the new pain management standards. ThemedicationmanagementchangeswereinMMandEC and one minor change in RC just affecting

CMS Update:

Are you ready for 2018?

Another Vincristine Alert:

Suicide Risk Algorithm:



critical access hospitals. You can also use thefollowing checklist to verify you have addressedeach of the new requirements announced earlierthisyear. MedicationRelatedStandards:EC.02.05.03:EP 14: Have we developed a policy to provideemergency backup for essential medicationdispensingequipment?EP 15: Have we developed a policy to provideemergency backup for essential refrigeration formedications?MM.04.01.01:EP1:Havewedeveloped a policy on signed andheld orders that addresses the clearly definedcircumstances when a signed and held ordershouldbereleasedforuse?MM.08.01.01:EP16:Havewedevelopedapolicyforautomateddispensing cabinets that describes the types ofmedication over rides that will be reviewed forappropriateness?PainManagementStandards:LD.04.03.13:EP 1: Have we identified our pain managementleaderorleadershipteam?EP 2: Do we provide nonpharmacologic paintreatmentmodalities?EP 3: Did we provide our staff and LIPs witheducational resources and programs to improvepain assessment, management and safe use ofopioids?EP4:HaveweinformedstaffandLIP’sofavailableconsultation services for complex painmanagementneeds?EP 5: Have we identified opioid treatmentprogramsthatcanbeusedforpatientreferrals?EP6:Ifyourstatehasanopioidprescriptiondrugmonitoring program have we facilitated easyaccessforourphysiciansandpharmacists?

EP7:Hasleadershipprovidedclinicalstaffwiththeequipmentneededtomonitorpatientswhoareatriskforadverseoutcomesfromopioidtreatment?MS.05.01.01:EP18:Hasthemedicalstaffestablishedprotocolsand quality metrics for pain assessment andmanagementandhasaprocessbeenestablishedtoprovidedatatothemedicalstaffforanalysis?PC.01.02.07:EP1:Dowehavedefinedcriteriatoscreen,assessand reassess pain that is consistent with thepatient’sage,conditionandabilitytounderstand?(Note: This is a simplification of the priorrequirement to conduct a comprehensiveassessment)EP 2: Do we screen patients for pain during EDvisitsandadmission?EP3:Doweeithertreatpainorreferpatientsfortreatment?EP 4: Do we develop an evidence based paintreatment plan appropriate to the patient’scondition, past history and pain managementgoals?EP 5: Do we involve patients in the treatmentplanning process, developing realisticexpectations, objectives of treatment andprovidingeducation?EP6:Arewemonitoringthoseathighestrisk foradverseoutcomesrelatedtoopioidtreatment?EP7:Arewereassessingandrespondingtopainbyevaluating and documenting response andinterventions,includingprogresstowardachievinggoals,sideeffectsoftreatmentandriskfactorsforadverseevents?EP 8: Are we educating patients and families ondischarge plans relative to the pain plan of care,sideeffects,ADLinthehomethatmightincreaseordecrease pain and the safe use, storage anddisposalofopioids?PI.01.01.01:EP56:Havewesetupadatacollectionprocessonpain assessment,management, interventions andeffectiveness?



PI.02.01.01:EP18: IsourPI teamanalyzingcollecteddataonpainassessment,managementandabletoidentifyareasinneedofchange?EP19:Arewemonitoringthesafeuseofopioidsbytracking adverse events such as respiratorydepression, naloxone use, as well as dose anddurationofopioidprescriptions?

Consultant corner WehopeeveryonehadawonderfulThanksgiving!Don’tforgettocheckoutourBlogathttps://pattonhc.com/patton-healthcare-consulting-blog/.Enteryouremailaddresstoreceivenotificationsofnewpostsbyemailtostayup-to-date.Pleasevisitusathttps://pattonhc.com/patton-healthcare-consulting-newsletters/toviewallofourarchivedNewsletterpublications,assomeinformationistimesensitivetotheNewYear!Wewishallofyouahappy,healthy,safeholidayseasonandaverysuccessful2018!Thank you, Jennifer Cowel, RN, MHSA [email protected]

Kurt Patton, MS, RPh [email protected] John Rosing, MHA [email protected]

Mary Cesare-Murphy, PhD [email protected]



December 2017 Phc newsletter - Patton Healthcare Consulting · Phc newsletter News from Joint Commission and CMS Inside This Issue: Perspectives: ... maintain critical components

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