Standards and National Patient Safety Goals: What s new for Critical Access Hospitals in 2012

Transcription

1 Standards and National Patient Safety Goals: What s new for Critical Access Hospitals in 2012 Susan Hill, RN, Critical Access Hospital Surveyor John Herringer, Associate Director, Standards Interpretation Group January 12, :00-2:30 CST

2 Agenda Welcome & Introductions Jeff Conway, Associate Director Newly approved National Patient Safety Goals that focus on: Medication reconciliation Catheter-associated urinary tract infections (CAUTI) Patient-provider communication standards Top standards compliance issues at Joint Commission accredited critical access hospitals Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) Additional resources & Q&A Slide 2 of 53

3 Standards and National Patient Safety Goals Susan Hill, RN, Critical Access Hospital Surveyor The Joint Commission Slide 3 of 53

4 SUSAN HILL, M.A., B.A., R.N. Biography Susan Hill is currently a resident of Arcadia, California. She received her Associate of Arts degree in Nursing at Pasadena City College, Pasadena, California; her Bachelor of Arts degree in Fine Arts from the University of Redlands, Redlands, California; and her Master of Arts degree in Human Resource Management from the University of Redlands, Redlands, California. In the past, Susan has held the position of Head Nurse in Labor and Delivery, CCU/ICU staff nurse, Nursing Educator, Quality Coordinator, DRG coordinator, and Management/Leadership trainer in both the acute and long term care settings. Susan has had experience in the following; critical care, infection control, quality assurance, quality improvement, performance improvement, education and training and corporate compliance. As the Vice President of Education and Development for a Long Term Care company, her responsibilities included development of an original QA program for that company, moved the program into CQI, and headed up the Performance Improvement effort in the company. With prospective payment for long term care, Susan spearheaded the process required to meet the PPS MDS assessment requirements. Susan is a member of professional organizations including the Organization of Healthcare Educators, Los Angeles, Sigma Theta Tau, Society for Quality and Improvement and has participated as Los Angeles ACLS and BCLS instructor for the American Heart Association. She has spoken to the National Organization for Directors of Staff Development, The Texas Long Term Care Volunteer Conference, the National Activities Professionals Conference, the Los Angeles Organization of Health care Educators and various HMO case managers from Cigna, Healthnet, and Blue Cross. In addition, Susan has presented pre-survey updates to organizations in preparation for survey. Ms. Hill has been a Joint Commission surveyor since 1997, and surveys the Standards in the Accreditation Manual for Hospital, Long Term Care, Subacute Care, Dementia and Assisted Living. She is also trained in the Integrated Survey Process for Hospital, Long Term Care and Home Care and Behavioral Health. Slide 4 of 53

5 Medication Reconciliation NPSG : Maintain and communicate accurate patient medication information. EP 1 Obtain information on the medications the patient is currently taking when he or she is admitted to the critical access hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. EP 2 Define the types of medication information to be collected in non-24 hour settings and different patient circumstances. Note 1: Examples of non-24 hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose. Slide 5 of 53

6 Medication Reconciliation NPSG Maintain and communicate accurate patient medication information EP 4: Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the critical access hospital or at the end of an outpatient encounter(for example; name, dose, route, frequency, and purpose). Slide 6 of 53

7 Medication Reconciliation NPSG : Maintain and communicate accurate patient medication information. EP 5: Explain the importance of managing medication information to the patient when he or she is discharged from the critical access hospital or at the end of an outpatient encounter. Keep in mind: PC : coordination of care, sharing information PC : providing patient education PC : providing information at discharge Slide 7 of 53

8 Catheter-Associated Urinary Tract Infections ( CAUTI) NPSG : Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections Not applicable to peds population Evidence based guidelines for CAUTI located at: um of Strategies to PreventHAIs.aspx cauti.html Slide 8 of 53

9 Catheter-Associated Urinary Tract Infections (CAUTI) NPSG : Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections. EP 2 Insert indwelling urinary catheters according to established evidence-based guidelines that address the following: Limiting use and duration to situations necessary for patient care Using aseptic techniques for site preparation, equipment, and supplies EP 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following: Securing catheters for unobstructed urine flow and drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples Slide 9 of 53

10 Catheter-Associated Urinary Tract Infections ( CAUTI) NPSG : Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections. EP 4: Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following: Selecting measures using evidence-based guidelines or best practices. Monitoring compliance with evidence-based guidelines or best practices. Evaluating the effectiveness of prevention efforts. Surveillance may be targeted to areas with high volume (as identified through risk assessment - (IC EP2) Slide 10 of 53

11 Patient Provider Communication Standards Counts toward accreditation decision starting July 1, 2012 Found in: HR EP 1 Provision of Care: PC EPs 1 & 2 Record of Care: RC EP 1 Rights and Responsibilities: RI EPs 28 & 29, RI EPs 2 & 3 Slide 11 of 53

12 Patient Provider Communication Standards Changes due to recent CoP update (for organizations using Joint Commission for deemed status) RI EPS 28 & 29 became effective July 1, These changes affect accreditation decisions. Slide 12 of 53

13 Patient Provider Communication Standards RC EP 1 - expands the policy requirement Note: For critical access hospitals that use Joint Commission accreditation for deemed status purposes: The critical access hospital s written policies address procedures regarding patient visitation rights, including any clinically necessary or reasonable restrictions or limitations. Slide 13 of 53

14 Patient Provider Communication Standards Addresses: (RC EP 1) Providing language services Can include: Critical access hospital employed language interpreters Contract interpreters Trained bilingual staff May be provided in person or via telephone or video Slide 14 of 53

15 Patient Provider Communication Standards Addresses: (HR EP 1) Qualifications for language interpreters Can be met through language proficiency assessment, education, training and experience. (RI EP 3 ) Identifying patient communication needs Includes need for personal devices such as hearing aids or glasses, language interpreters, communication boards, etc. Slide 15 of 53

16 Patient Provider Communication Standards RC EP 2 - Expands the informing patient requirement Note: For critical access hospitals that use Joint Commission accreditation for deemed status purposes: The critical access hospital informs the patient (or support person, where appropriate) of his or her visitation rights. Visitation rights include the right to receive the visitors designated by the patient, including, but not limited to, a spouse, a domestic partner, or a friend. Also included is the right to withdraw or deny such consent at any time. Slide 16 of 53

17 Patient Provider Communication Standards Addresses: Patient access to chosen support individual (RI EP 28) Allowed to be present with the patient for emotional support during course of stay Unless the presence infringes on right of others or is medically or therapeutically contraindicated. Slide 17 of 53

18 Patient Provider Communication Standards Addresses: Non-discrimination in patient care (RI EP 29) Prohibited based on age, race, ethnicity, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Slide 18 of 53

19 Patient Provider Communication Standards Addresses: (PC EP 1, RI EP 2) Providing language services provides information in a manner tailored to the patient s age, language, and ability to understand. Slide 19 of 53

20 Patient Provider Communication Standards Resources: Advancing Effective Communication, Cultural Competence, and Patient-Centered Care: A Roadmap for Hospitals is now available to download at: mapforhospitalsfinalversion727.pdf Joint Commission requirements Laws and Regulations Sample policies and documents Resource guide with reference and links issue 1 Slide 20 of 53

21 Top Standards Compliance Issues at Joint Commission accredited Critical Access Hospitals between January 1 - June 30, 2011 Slide 21 of 53

22 Medical Staff FPPE AND OPPE John Herringer, R.N., M.S., Associate Director Standards Interpretation Group The Joint Commission

23 John Herringer, R.N., M.S., Biography John Herringer is an associate director in the Standards Interpretation Group for The Joint Commission. In this capacity, Mr. Herringer is lead associate director responsible for the development, communication and application of interpretive information for standards and other performance measures related to medical staff, and credentialing and privileging for the hospital, ambulatory care, long term care, and behavioral health care manuals. Mr. Herringer is a certified surveyor for The Joint Commission Hospital Accreditation Program. Prior to his role as associate director, Mr. Herringer also served as a surveyor in the home care accreditation program. Before joining The Joint Commission, Mr. Herringer held the position of Vice President and Senior Consultant for Healthcare Concepts, Inc., a national health care management consulting firm based in Memphis, Tennessee. In addition to his consulting background, Mr. Herringer has held a variety of clinical and administrative positions in the home health care field in New York, Connecticut and Tennessee during the last thirty-five years, and is the author of numerous clinical and administrative manuals and documentation systems. Mr. Herringer earned his master's degree in nursing jointly from New York Medical College and Pace University, Pleasantville, New York. Slide 23 of 53

24 MS Focused Professional Practice Evaluation Defines circumstances requiring monitoring and evaluation Termed Peer Review until 2004 when renamed Focused Review of Practitioner s Performance. Renamed Focused Professional Practice Evaluation in 2007 Slide 24 of 53

25 MS EPs 2 9 are nothing more than historical peer review. Existing peer review processes may be compliant and simply renamed Slide 25 of 53

26 MS Focused Professional Practice Evaluation EP 1 Effective January 1, Focused professional practice evaluation is done for all new privileges All new privileges meaning all privileges for new applicants and all new privileges for existing practitioners. All applicants for new privileges must have a period of focused evaluations No exemption for board certification, documented experience, or reputation. Slide 26 of 53

27 MS Focused Professional Practice Evaluation Option: Multi-tiered approach Different for different levels of documented training and experience Different for practitioners coming directly from an outside residency program vs. the organization s residency program Different for practitioners coming with a documented record of performance of the privilege and its associated outcomes vs. practitioners coming with no record of performance of the privilege and its associated outcomes Slide 27 of 53

28 MS Focused Professional Practice Evaluation Option group very similar activities together evaluate a set number of any mix of the privileges, e.g., any five or ten from the group will be evaluated to determine competence for the whole group, cannot just look at one privilege from the group. Slide 28 of 53

29 MS Focused Professional Practice Evaluation EP 2--Criteria are developed for evaluating performance when issues affecting care are identified, e.g., small number of admissions/procedures over an extended period of time that raise the concern of continued competence increasing lengths of stay compared to other practitioners Increasing number of returns to surgery Slide 29 of 53

30 EP 2 Criteria Frequent/repeat readmission for the same issue possible suggesting inadequate/ineffective initial management/treatment patterns of unnecessary diagnostic testing/treatments failure to follow approved clinical practice guidelines--may or may not indicate care problems but the variance needs explanation Slide 30 of 53

31 MS Focused Professional Practice Evaluation EP 3 Clearly defined Process method for establishing the monitoring plan specific to the requested privilege Predefined for new privileges Determined at time of review Review committee Department chair MEC Slide 31 of 53

32 MS Focused Professional Practice Evaluation EP 3 Clearly defined process method to determine the duration of performance monitoring Activities vs. time period Volume may be excessive or insufficient when using time periods -12 month provisional period could be burdensome for high volume activity Slide 32 of 53

33 MS Focused Professional Practice Evaluation Activity numbers allow flexibility method to determine the duration of performance monitoring defined number of admissions e.g., 5 or 10 defined number of procedures, such as 5 or 10 short time period of time such as 1, 2 or 3 months for infrequently performed privilege, numbers might work better than a time period especially if the privilege isn't performed in that time period. Slide 33 of 53

34 MS Focused Professional Practice Evaluation EP 3 Defined Process Single process vs. Multi-tiered approach Different for different levels of documented training and experience, Different for practitioners coming directly from an outside residency program vs. the organization s residency program Different for practitioners coming with a documented record of performance of the privilege and its associated outcomes vs. practitioners coming with no record of performance of the privilege and its associated outcomes Slide 34 of 53

35 MS Focused Professional Practice Evaluation Circumstances under which monitoring by an external source is required No other qualified practitioner Those available would be biased Slide 35 of 53

36 EP 4 FPPE is consistently implemented in accordance with criteria and requirements defined by the OMS. Slide 36 of 53

37 MS Focused Professional Practice Evaluation EP 5--Triggers indicating need for performance monitoring are defined The very obvious, e.g., infection rates sentinel events complaints other events that are not sentinel Slide 37 of 53

38 EP 6 Decision to assign further period of review based on evaluation of practitioners: Current clinical competence Practice behavior Ability to perform the requested privilege Other privileges in good standing should remain unaffected. Slide 38 of 53

39 MS Focused Professional Practice Evaluation EP 7 Criteria to determine type of monitoring Review type can vary, e.g. direct observation for certain privileges vs. chart audits for other privileges periodic chart review direct observation monitoring of diagnostic and treatment techniques discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel. EP 8 Defined measure to resolve performance issues EP 9 Resolution measures consistently implemented Slide 39 of 53

40 MS Focused Professional Practice Evaluation An historical peer review process triggered by practice indicators or performance issues or untoward outcomes could meet EP's 2 9 But, would not meet EP 1 for a review for all privileges Slide 40 of 53

41 MS Ongoing Professional Practice Evaluation Traditional credentialing and privileging process: Cyclical: every two years Procedure activities Revised process Ongoing continuous evaluation Identify performance problems early and resolve them Results in evidence-based privileging at time of renewal Ability to extrapolate good performance practices into clinical practice guidelines Slide 41 of 53

42 MS Ongoing Professional Practice Evaluation Information for decisions to maintain privileges Process includes Evaluation of each practitioner s professional practice not just negative/outlier/trending data but also data on good performance Use of information from ongoing evaluation to determine status of privileges Slide 42 of 53

43 MS Ongoing Professional Practice Evaluation EP 1. Clearly defined process, e.g., Who will be responsible for reviewing performance data. department chair, department as a whole, the credentials committee, the MEC, or a special committee of the organized medical staff. how often the data will be reviewed. frequency defined by the organized medical staff three months, six months, eight months, etc. ** twelve months would be periodic rather than ongoing. the process to use the data to make decision whether to continue, limit or revoke privileges. the department chair, credentials committee, MEC, governing body How the decision and/or data will be incorporated into the credentials files Slide 43 of 53

44 MS Ongoing Professional Practice Evaluation EP 2. The type of data to be collected defined by individual medical staff departments and approved by the organized medical staff Departments will know best what type of data will reflect both good and problem performance for the various practitioners in their departments Standard requires evaluation for all practitioners not just those with performance issues.. Slide 44 of 53

45 MS Ongoing Professional Practice Evaluation The standard's rationale outlines suggested data that the organization may choose to collect along with the following suggestions for methodologies for collecting information: period chart review direct observation monitoring of diagnostic and treatment techniques discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel. Slide 45 of 53

46 MS Ongoing Professional Practice Evaluation Most practitioners perform well Data on their actual good performance As well as those practitioners with performance issues Failure to fall out on pre-defined screening criteria is not sufficient to comply with performance data on every practitioner. Slide 46 of 53

47 MS Ongoing Professional Practice Evaluation Zero data is in fact data. Can be evidence of good performance, e.g., no returns to the OR, no complications, no complaints, no infections, etc. It is also important to know when someone is not performing certain privileges over a given period of time Would not be acceptable to find at the two year reappointment that someone has not performed a privilege for two years. Slide 47 of 53

48 MS Ongoing Professional Practice Evaluation Zero performance of a privilege should be evaluated to determine possible reasons is the practitioner no longer performing the privilege, e.g., no open cholecystectomies because they are now done laproscopically? is the practitioner taking patients needing the privilege to other organizations or settings such as ambulatory surgery? is the privilege typically a low volume procedure that has yet to be done? Slide 48 of 53

49 MS Ongoing Professional Practice Evaluation EP 3. Information resulting from the evaluation needs to be used to determine whether to continue, limit, or revoke any existing privilege (s) at the time the information is analyzed. Based on analysis, several possible actions might occur, including but not limited to: continuing the privilege as no performance issues exist. revoking the privilege because it is no longer required by the practitioner. determining that the collected data or evidence of zero performance or low volume should trigger a focused review (MS EP 5). suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it they must request a reactivation. determining that the privilege should be continued because the organization's mission is to be able to provide the privilege to its patients. Slide 49 of 53

50 MS EP 2 Upon renewal of privileges when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations. Cannot serve as justification to not collect OPPE data Slide 50 of 53

51 Resources Joint Commission Standards Questions Call SIG at Standards online question submission form Go to Select Standards from subject box Select Online Question Form Standards FAQs Go to Select Standards from subject box Select Standards FAQs Search FAQs by key word or topic Slide 51 of 53

52 Contact Us Critical access hospitals that are interested in Joint Commission accreditation can We will walk you through the entire accreditation process, from submission of the electronic application to your final accreditation decision report. Slide 52 of 53

53 Thank you for your participation! Questions? Slide 53 of 53