Feedback from Surveys: 1st Quarter 2010
Periodically, we provide our readers with feedback from Joint Commission surveys. During the first quarter of 2010, several of our clients have undergone their TJC surveys. Some common themes have emerged regarding "high scrutiny" areas. Some of these have been around for awhile; others are new in 2010. The following are common themes in our clients' surveys conducted between January and March 2010. These include both psychiatric hospitals and behavioral health organizations.
National Patient Safety Goals: The National Patient Safety Goals are as important as ever. Just because some of them have been moved into the standards doesn't mean they get less scrutiny.
Deemed Status Requirements:For psychiatric hospitals that use TJC accreditation for deemed status, there is strong emphasis on all the new deemed status requirements now incorporated into the standards.
Direct Impact vs. Indirect Impact Standards:Based on this model, all organizations have had a smaller number of Direct Impact RFIs and a longer list of Indirect Impact RFIs.
Medical Staff Chapter: Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation.
Psychiatric hospitals are now being cited for lack of compliance with the requirements for Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation. All of the hospital surveys this quarter probed for how the medical staff was carrying out these functions.
Tip: Many psychiatric hospitals currently have mechanisms for collecting data on physician performance. These typically include peer review, documentation requirements, patient satisfaction, and performance evaluations. These can be "packaged" to meet many of the requirements for FPPE and OPPE. Be sure that your medical staff rules and regulations or procedures actually reflect the language of FPPE and OPPE and that medical staff are conversant on these terms.
Leadership Chapter: Contracts
Contracts are getting more scrutiny than ever before under LD.04.03.09. The focus is on contracts for clinical services.This includes contracts with agencies as well as contracts with individual practitioners.
Tip: Be sure you have a mechanism in place to monitor the performance of the contract service. A simple way to do this is to create a checklist of the contract's deliverables and then rate how adequately they were met. You also need to rate the timeliness and responsiveness of the contractor. Many organizations also ask "Would you hire this contractor again?"
Record of Care Chapter
Dating and Timing of Entries
For deemed status hospitals, all entries in the medical record must not only be signed and dated but also timed. (See RC.01.01.01 EP 19). The focus during recent surveys has been on psychiatric evaluations, histories & physicals, orders, and lab reports.
Tip: Educate all physicians on the importance of including both date and time when they sign their entries. Monitor compliance and feed results back to the physicians and into the re-privileging process.
Authentication of Verbal and Telephone Orders
Nothing new here, except that several hospitals were asked for their internal compliance data for authentication of verbal and telephone orders. Others were asked if they have had formal PI initiatives to reduce the use of verbal orders.
Note: TJC does allow another practitioner to authenticate the verbal/telephone order for the ordering practitioner. This provision will expire in January, 2012. (See RC.02.03.07 EP 4.)
Provision of Care Chapter
The focus on treatment planning in behavioral health continues as strong as ever. Several organizations received RFIs for their treatment plan updates not describing progress toward the goals and objectives on the treatment plan. Tip: Make sure that your format for treatment plan updates includes a section where you address each objective on the treatment plan and describe the patient's progress or lack of progress as well as any new or revised interventions.
Nutrition screening, assessment and follow-up continue to be high scrutiny areas. In outpatient BH settings, several organizations were cited for not having clear criteria for when a nutritional screening should lead to a nutritional assessment. Tip: Having a few nutrition related questions in your health screening is not adequate for compliance. Both your health screening form and your policy should clearly outline the criteria for when the nutritional screening should lead to a referral for a full nutritional assessment.
Medication Management Chapter
High Risk High Alert Medications
The focus during recent surveys has been on evaluating nurses' understanding of the hospital's policy on these types of medications. Surveyors have typically asked the nurses how they prepare and administer insulin. Tip: Make sure your policy is clear and educate all nursing staff on the specific procedures for administering these medications. Also, see the article in our March newsletter on strategies for dealing with this topic.
Adverse Drug Reactions
Several organizations were cited for lack of a comprehensive process for collecting information on adverse drug reactions. Often, the organization's data shows very few ADRs and the surveyors conclude that there is under-reporting of these occurrences. Tip: Reinforce the importance of reporting any suspected or potential adverse drug reaction. Consider a telephone reporting line for ADRs. Many organizations have found that this improved reporting of ADRs.
Monitoring of Medication Refrigerator Temperatures in Outpatient Settings
Surveyors are consistently checking to see that the temperature of medication refrigerators is monitored daily, including weekends when the clinic is closed. The old "penny in the cup" method is considered inadequate. Tip: Get one of those electronic monitoring devices for all outpatient medication refrigerators.
Infection Prevention & Control Chapter
Infection Control Risk Assessment
Surveyors are looking for an annual risk assessment that identifies the hospital's specific risks for infections based on its location, population, and its surveillance data. See IC.01.03.01EP 1 - 5 and notice that EP 5 has a "D" for documentation so the risk assessment must be contained in a specific document. Tip: Be sure that the risk assessment is specific to your location and your population. Several organizations have been cited for their risk assessment being "too generic."
Stay tuned throughout the year and we'll continue to keep you posted on survey issues and trends!