Patrick T. Driscoll, Jr. and Pat Merryweather (non-director Members)

Transcription

1 Minutes of the meeting of the Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System held Friday, April 20, 2018 at the hour of 10:00 A.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois. I. Attendance/Call to Order Chairman Gugenheim called the meeting to order. Present: Chairman Ada Mary Gugenheim and Directors Mary Driscoll, RN, MPH and Layla P. Suleiman Gonzalez, PhD, JD (3) Board Chairman M. Hill Hammock (ex officio) and Directors Emilie N. Junge and Mary B. Richardson-Lowry Absent: None (0) Patrick T. Driscoll, Jr. and Pat Merryweather (non-director Members) Additional attendees and/or presenters were: Trevor Lewis, MD John H. Stroger, Jr. Hospital of Cook County Jeff McCutchan General Counsel John O Brien, MD Chairman, Department of Professional Education Deborah Santana Secretary to the Board John Jay Shannon, MD Chief Executive Officer II. Public Speakers Chairman Gugenheim asked the Secretary to call upon the registered public speakers. The Secretary responded that there were none present. III. Report on Quality and Patient Safety Matters A. Regulatory and Accreditation Updates Dr. John Jay Shannon, Chief Executive Officer, provided an update on regulatory and accreditation matters. He stated that Stroger Hospital is in the window for a visit from representatives from The Joint Commission (TJC); that visit will include Stroger Hospital and the Stroger Hospital-affiliated clinics, and will happen sometime between now and October. The administration is also planning for what is expected to be the final visit from the monitors at Cermak Health Services on April 30 th and May 1 st. B. Metrics (Attachment #1) The metrics were presented for the Committee s information.

2 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, April 20, 2018 Page 2 IV. Action Items A. Approve appointments and reappointments of Stroger Hospital Department Chair(s) and Division Chair(s) (Attachment #2) Dr. Shannon presented the following reappointment of a Division Chair for the Committee s consideration: Reappointment One (1) Division Chair: Heather Stanley-Christian, MD Dept. of Obstetrics/Gynecology Division Chair of 4/20/2018 4/19/2020 Maternal Fetal Medicine Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the proposed Stroger Hospital Division Chair reappointment. THE MOTION CARRIED UNANIMOUSLY. B. Department of Professional Education i. Receive overview of strategic initiatives (Attachment #3) ii. Approve proposed clinical training affiliation agreements (Attachment #4) Dr. John O Brien, Chairman of the Department of Professional Education, provided an overview of his presentation and presented proposed clinical training affiliations agreements for the Committee s consideration. The presentation included information on the following subjects: Strategic Planning Department of Professional Education Leveraging Medical Education to Improve the Care for Our Patients Generally Accepted Benefits of Residencies/Fellowships Metrics Clinical Learning Environment (CLER) Visit 2017 Areas of Focus 2017 CLER Report Findings Metrics Quality and Safety Maintaining Accreditation Board Passage Three (3) Year Rolling Average (since 2014) Residents and Fellows Train and Retain: Attracting More Local Students for Residency 2018 Resident Match Train and Retain: 2018 Intern Match - % American School Graduates, CCHHS vs. U.S. International V American Medical Graduates Contributions of Local Schools Improving Recruiting Metrics Train and Retain: Since 2011 How Successful Are We? Rotator Programs Proposed Clinical Training Affiliation Agreements Summary

3 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, April 20, 2018 Page 3 IV. Action Items B. Department of Professional Education (continued) Following the presentation and discussion of the information, Director Driscoll suggested that more emphasis should be placed on integrating educational opportunities in the curriculum for residents and fellows regarding social determinants and population health. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the proposed clinical training affiliation agreements. THE MOTION CARRIED UNANIMOUSLY. C. Executive Medical Staff (EMS) Committees of Provident Hospital of Cook County and John H. Stroger, Jr. Hospital of Cook County i. Receive reports from EMS Presidents ii. Approve Medical Staff Appointments/Re-appointments/Changes (Attachment #5) Dr. Valerie Hansbrough, President of the EMS of Provident Hospital of Cook County, was unable to attend the meeting. Dr. Trevor Lewis, President of the EMS of John H. Stroger, Jr. Hospital of Cook County, presented his report. At this month s EMS meeting, presentations from the Trauma Committee, Cancer Committee and internal Quality and Patient Safety Committee were reviewed. He noted that staff continue to work on TJC readiness. Additionally, he stated that he expects that the Medical Staff Bylaws will go out for approval within the next month. The Committee considered the proposed medical staff appointments/reappointments/changes for Stroger and Provident Hospitals. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the Medical Staff Appointments/Re-appointments/Changes for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. Director Suleiman Gonzalez, seconded by Director Driscoll, moved to approve the Medical Staff Appointments/Re-appointments/Changes for Provident Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. D. Minutes of the Quality and Patient Safety Committee Meeting, March 23, 2018, as amended An amendment was necessary to correct one of the items at this meeting, to reflect that, of the five (5) Stroger Hospital Division Chair matters presented for approval, only one (1) was a reappointment, and the other four (4) were initial appointments. Director Suleiman Gonzalez, seconded by Director Driscoll, moved to approve the Minutes of the Quality and Patient Safety Committee Meeting of March 23, 2018, as amended. THE MOTION CARRIED UNANIMOUSLY. E. Any items listed under Sections IV and VI

4 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, April 20, 2018 Page 4 V. Recommendations, Discussion/Information Items A. Regulatory Primer (Attachment #6) Dr. Shannon provided an overview of the presentation, which included information on the following subjects: History and Meaning of Accreditation Accrediting Organization Scope Accrediting Organizations for Hospitals Hospital Standards Antedated Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) The Joint Commission (TJC) Changes Over Time The Vernacular CMS Survey Overview CMS vs. TJC Decision Making and Analysis of Findings Condition Level Findings Plan of Correction Impact of Significant Citations Recent Trends in CMS Condition-Level Deficiencies Environment of Care Patient Rights Quality Assessment and Performance Improvement Infection Prevention Medication Management Emergency Medical Treatment and Labor Act (EMTALA) CMS Validation of Accrediting Organizations Next Stroger and Ambulatory Survey New Survey Processes Survey Analysis For Evaluating Risk (SAFER) Matrix Top Standards Cited by TJC: Hospital Standards Trends in Findings of 763 Hospitals for Q1& Top Standards Cited by JTC: Ambulatory Standards Trends in Findings of 352 Applicable Surveys for Q1& Director Junge noted that, based on the organization s own surveys, cleanliness has been an issue. Dr. Shannon responded that additional attention and additional resources will be focused upon that subject, to address performance issues. VI. Closed Meeting Items A. Medical Staff Appointments/Re-appointments/Changes B. Litigation Matter(s) The Committee did not recess into a closed meeting.

5 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, April 20, 2018 Page 5 VII. Adjourn As the agenda was exhausted, Chairman Gugenheim declared the meeting ADJOURNED. Respectfully submitted, Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXX Ada Mary Gugenheim, Chairman Attest: XXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary Requests/follow-up: There were no requests for follow up at this meeting.

6 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #1

7 COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Dashboard Overview 20 April 2018 Claudia Fegan, MD, Chief Medical Officer 1 CCHHS Board QPS Committee

8 Quality Stroger 2 CCHHS Board QPS Committee

9 Quality Provident 3 CCHHS Board QPS Committee

10 Safety Stroger 4 CCHHS Board QPS Committee

11 Patient Experience Stroger 5 CCHHS Board QPS Committee

12 Patient Experience Provident 6 CCHHS Board QPS Committee

13 ACHN LEGEND * Data is being reported from HEDIS Data 7 CCHHS Board QPS Committee

14 Board Quality Dashboard 8 CCHHS Board QPS Committee

15 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #2

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17 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #3

18 Cook County Health and Hospitals System PROFESSIONAL EDUCATION John M. O Brien, M.D. April 20, 2018

19 Strategic Planning Department of Professional Education (PE) Building a high quality, safe, reliable, patientcentered, integrated health system that maximizes resources to ensure the greatest benefit for the patients and communities we serve Improve Health Equity Provide high quality, safe and reliable care Demonstrate value, adopt performance benchmarking Develop human capital HOW??? Lead in Medical Education relevant to vulnerable populations METRICS? Professional Education 4/20/2018 2

20 How Do We Leverage Medical Education to Improve the Care for Our Patients? Create Programs that are fixated on Patient Quality and Safety Successfully Recruit High Quality Medical Students Increase Curriculum in Quality and Safety in the Educational Environment Retain Well- Trained Residents and Fellows to LEAD the System as medical staff members High quality, safe, reliable, patientcentered, integrated health system Professional Education 4/20/2018 3

21 Generally Accepted Benefits of Residencies/Fellowships Facilitate a Cost Effective Model of 24/7 Care of Acutely Ill Patients Help to Attract Attending Physicians Provide Valuable Feedback That Can Improve Hospital Performance Improved Hiring Decisions When Familiar With Graduate s Work Product Can Be Used to Drive Information Upward Professional Education 4/20/2018 4

22 Metrics Quality and Safety Clinical Learning Environment Culture of Safety Survey emers Data Program Quality Accreditation Board Passage Train and Retain Med Student Match % of Grads Hired by Dept Professional Education 4/20/2018 5

23 Clinical Learning Environment (C.L.E.R.) Visit 2017 Emphasis is on the QUALITY and SAFETY of the Environment for learning and patient care Learning Environment has durable effect on long-term practice habits Visits are every 18 months (our 3 rd visit) Two Day Visit Must start and end with a meeting that includes the CEO and the DIO Interview Residents, PD s and Faculty using Audience Response System Walk rounds include: Observations of handoffs 1:1 Interviews of Nurses Required to maintain accreditation 6 Professional Education 4/20/2018

24 CLER Visit - Six Areas of Focus: Safety and Reporting Residents - no uniform understanding of what to report Care Transitions Only 31% of residents participated in INTERPROFESSIONAL care transitions Health Care Quality Only 45% of residents receive aggregated, benchmarked QI data on their patients Supervision Residents increasingly recognizing situations requiring supervision Professionalism Cutting and Pasting - Some residents document a piece of history or part of physical that they did not personally elicit. This is a national Electronic Medical Record (EMR) issue. Wellness 80% of residents would power through fatigue while 70% of Program Directors and faculty thought they would ask for help Professional Education 4/20/2018 7

25 2017 CLER Report Findings Item Reported a safety concern Program Director 72% 84% Reported a safety concern-faculty 32% 85% Encountered and reported a safety concern - Resident 65% 70% Root Cause Analyses (RCAs) conducted w/in the past year 9 43 RCA with Resident participation w/in the past year 4 19 Timeouts: Do nurses see residents routinely conduct them? No Yes Res Participated in INTERPROFESSIONAL educational activity 15% 31% Handoffs follow a standardized process 58% 84% Professional Education 4/20/2018 8

26 Metrics Quality and Safety Culture of Safety Survey Goal: Increase Institutional Response Rate from <10% to >30% Institutional Response rate = 29.6% Resident Response Rate = 44% EMERs Data In 2017, 736 emers reports were submitted by residents ~ 2 reports for each resident ~ 7.9% of total Professional Education 4/20/2018 9

27 Maintaining Accreditation ( ) = Full Time Equivalent Trainees/program Accredited Anesthesiology (36) Cardiovascular Disease (9) Child Abuse Pediatrics (3) Colon/Rectal Surgery (3) Dermatology (12) Emergency Medicine (68) Family Medicine (36) Gastroenterology (9) Hematology-Oncology (7) Internal Medicine (120) Neonatal Perinatal Medicine (6) Neurosurgery (AOA) (2) Ophthalmology (12) Oral Surgery (CODA) (8) Pain Medicine (4) Palliative Care/Hospice (3) Pharmacy (3) Primary Care (Integrated) (12) Pediatrics (13 6) Preventive Medicine (4) Pulmonary /Critical Care Medicine (9) Radiology- Diagnostic (16) Surgical Critical Care (3) Toxicology (Integrated) (2) Urology (8) Non-Accredited Burn (2) Corneal Disease (1) Trauma (2) Retinal Disease (2) Simulation Laboratory (2) Professional Education 4/20/

28 Board Passage: Three Year Rolling Average (since 2014) Residents Residency Took Boards Passed Boards Anesthesiology 97% 88% Dermatology 100% 100% Emergency Medicine 100% 100% Family Medicine 97% 97% Internal Medicine 99% 91.5% Ophthalmology 100% 90% Pediatrics 96.7% 80% Radiology 100% 91% Urology 100% 100%

29 Board Passage: Three Year Rolling Average (since 2014) Fellows Fellowship Took Boards Passed Boards Cardiovascular Disease 100% 100% Colon and Rectal Surgery 100% 100% Gastroenterology 100% 100% Hematology/Oncology 66% 100% Neonatal-Perinatal Medicine 100% 100% Pain Medicine 50% 75% Palliative Medicine 89% 88% Pulmonary/Critical Care 100% 100% Surgical Critical Care 100% 100% Toxicology 100% 100%

30 Train and Retain: Attracting More Local Students For Residency 2018 Resident Match Program American Medical Graduate (AMG) U.S. International Medical Graduate (USIMG) Anesthesia Emergency Medicine Family Medicine Internal Medicine Primary Care Radiology TOTAL International Medical Graduate (IMG) Professional Education 4/20/

31 Train and Retain: 2018 Intern Match % American School Graduates, CCHHS vs. U.S Anesthesia Emergency Med Family Med IM Radiology Primary Care CCHHS Nationally Professional Education 4/20/

32 International V American Medical Graduates There are not enough American Medical Graduates (AMGs) to Fill All of the Residency Slots in the US (12,500 of 30,000 1 st Year slots filled by IMGs) ~25% of All Residents and ~30% of Fellows in the US are International Medical Graduates (IMGs) IMGs Pass Boards at Nearly the Same Rate as AMGs ~25% of All Practicing Physicians in the US are IMGs including 1 : 40% of Primary Care Physicians >50% of Those Practicing Geriatric Care 2/3 of all Physicians Practicing in Non-Urban Medically Underserved Areas 1 Association of American Medical Colleges; 2015 State Physician Workforce Data Book Professional Education 4/20/

33 Contribution of Local Schools Origin of Incoming Class RUSH, 2 UIC, 4 % of Students Rotating That Chose CCHHS 12.5% RFU, 3 NU, 1 7.5% MWU, 4 AT Still, 1 Other US, % Other US AT Still MWU NU RFU RUSH UIC AT Still MWU NU RFU Rush UIC -2.5% Professional Education 4/20/2018 Rotated/Matched 16

34 Improving Recruiting Metrics Attracting More of the Students That Rotate At CCHHS Post Match Survey Work/Life Balance Non Clinical Work Scholarly Activity Fitting In Professional Education 4/20/

35 Train and Retain: Since 2011 How Successful Are We? Dept CCHHS Trainees Hired Total Phys. Hired Percentage Anesthesiology % Cermak % Emergency % Family Medicine % Internal Medicine % OB/Gyne % Pediatrics % Radiology % Surgery % Trauma % Professional Education 4/20/

36 Rotator Programs ( ) = FTE Trainees/yr Integrated Adolescent Medicine (1) Allergy (1) Cardio Thoracic Surgery (2) General Surgery (23) Endocrinology (3) Infectious Disease (5) Neurology (2) OB/GYN (16) Rheumatology (2) Neurosurgery (2.5) Cost = $4,911,289 Claim these on Medicare Not Integrated Orthopedics (7.5) ENT (7) Pathology (5) Nephrology (2) Cost = $1,733,085 Professional Education 4/20/

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39 Summary Leveraging Medical Education Creating Programs that are fixated on Patient Quality and Safety Develop A Pipeline of Outstanding Doctors Successfully Recruit High Quality Medical Students Increase Curriculum in Quality and Safety in the Educational Environment Retain Well- Trained Residents and Fellows as medical staff High quality, safe, reliable, patientcentered, integrated health system 22 Professional Education 4/20/2018

40 Questions? Professional Education 4/20/

41 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #4

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44 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #5

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53 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes April 20, 2018 ATTACHMENT #6

54 COOK COUNTY HEALTH & HOSPITALS SYSTEM Accreditation and Deemed Status Quality and Patient Safety Committee John Jay Shannon, MD April 20,

55 Brief History of Accreditation Since the inception of Medicare via the Social Security Act in 1965, there has been a requirement for participating organizations to undergo periodic review to assure standards are met. Minimum requirements were developed: the Conditions of Participation (CoPs) and promulgated in 1986 Meeting those requirements is assured by review by either state agencies or an approved Accrediting Organization (AO) 2

56 What Does Accreditation Mean? The system or site has met or exceeded the Centers for Medicare and Medicaid Services (CMS) CoPs The Accrediting Organization then recommends to CMS to allow the facility to participate via deemed status (instead of a state survey agency certification) 3

57 Accrediting Organization Scope Accrediting Organizations have been granted deeming status by CMS for ambulatory surgical centers critical access hospitals home health agencies hospices hospitals outpatient physical therapy providers psychiatric hospitals rural health clinics 4

58 Accrediting Organizations for Hospitals American Osteopathic Association/Healthcare Facilities Accreditation Program (4%) Center for Improvement on Healthcare Quality (<1%) Det Norske Veritas (DNV GL-Healthcare, integrates compliance with CoPs and ISO 9001 standards, 7%) The Joint Commission (88%) 5

59 Hospital Standards Antedated CMS CoPs 1910: Ernest Codman, MD (Massachusetts General Hospital), proposed that hospitals develop procedures for tracking patients long enough to determine whether treatment was effective. 1918: American College of Surgeons (ACS) developed Codman s ideas into the Minimum Standards for Hospitals, used in its first inspection of hospitals. 1951: ACS joined with the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association (CMA) to create The Joint Commission on Accreditation of Hospitals (JCAH). 1953: The JCAH begins voluntary accreditation to hospitals 1988: JCAHO-name change to reflect spectrum of certification activities 6

60 TJC Changes Over Time Pre-1999 Scheduled survey, retrospective chart review, croissants Post To Err is Human (IOM, 1999) Unannounced survey 25% documentation review and 75% staff interaction Modern era 10% documentation review and 90% staff interaction at the point of care or at each patient care unit. Random chart selection for tracing, or visiting, the same departments or services where the patients received treatment Periodic performance review (PPR) mid-term 2008: Mark Chassin, MD named president Competition (DNV approved as an AO) 7

61 The Vernacular Centers for Medicaid and Medicare Services (CMS) - Conditions of Participation (CoPs) - Specific dimensions called Standards - Deficiencies cited are tags - Participation = Reimbursement The Joint Commission (TJC) Standards Specific dimensions called Elements of Performance (EPs) Today, any deficiencies observed are placed into a SAFER matrix report 8

62 CMS Survey Overview CMS vs. Joint Commission CMS has: Conditions of Participation (COP) Overarching minimum health & safety requirements that Medicare has fleshed out with targeted and more specific Standards. Joint Commission has: Standards Overarching minimum health & safety requirements that are fleshed out with targeted and more specific Elements of Performance (EP). 9

63 Determining Deficiency Severity Decision Making & Analysis of Findings CONDITION Level deficiency: Noncompliance with requirements in a single standard or several standards within a condition that represents a SEVERE and CRITICAL health or safety breach. Even a seemingly small breach in critical actions or at critical times can kill/seriously injure a patient, and represents a critical/severe health or safety threat. STANDARD Level deficiency: Noncompliance with any single requirement or several requirements within a particular standard that: Does NOT substantially limit capacity to furnish adequate care, or Would NOT jeopardize or adversely affect the health or safety of patients if the deficient practice occurred. 10

64 Determining Deficiency Severity IMMEDIATE JEOPARDY Decision Making & Analysis of Findings A situation in which the provider s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. 11 (

65 Condition Level Findings Always drive a return site visit (within 45 days) Always trigger a Leadership citation Governing body failure to ensure regulations were met 12

66 Plan of Correction (POC) Corrective action to be taken, including any system changes, typically includes Review of policies and procedures Education of staff Title of the person who will monitor the corrective action Frequency of monitoring Definition of metrics Data source Sampling method and frequency Goal Completion date 13

67 Impact of Significant Citations CMS CoPs: to qualify for Medicaid/Medicare reimbursement. State agency regulations: to maintain state licensure. License is needed to operate a hospital. Significant citations: always bring negative public attention. Negative public attention around safety and quality damages reputation and takes years to rebuild. 14

68 Recent Trends in CMS Condition-level Deficiencies Physical environment ( Environment of Care ) Patient Rights, including Patient Safety Quality Assurance and Performance Improvement (QAPI) Infection Prevention Medication Management Specials: EMTALA Governing body 15

69 Environment of Care The hospital shall maintain adequate facilities for its services Designed and maintained in accordance with federal, state, and local laws, regulations and guidelines (facility layout, toilets, sinks, drinking water supply, fire suppression systems, etc.). Designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice (sufficient space to provide care, treatment and services; proper sterilization & disinfection areas). 16

70 Environment of Care The hospital s Hospital Maintenance and hospital departments or services are responsible for the hospital s buildings and equipment (both hospital equipment and patient care equipment) must be incorporated into the hospital s QAPI program and be in compliance with QAPI requirements. Environmental findings may include: Missing documentation for patient or other equipment biomedical checks Off site locations are not included Environmental tours not conducted Issues reported or observed are not resolved Environmental issues not reported to the QAPI committee or other leadership 17

71 Patient Rights Information and engagement in decision making (including informed consent) Safety (including protection from abuse, self-harm, fire) Privacy Freedom from restraints Access to records 18

72 Quality Assessment and Performance Improvement The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital s governing body must ensure that the program reflects the complexity of the hospital s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. 19

73 Infection Prevention The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. 20

74 Infection Prevention Focus Sterilization and disinfection procedures Focus outside main Operating Room Attention to pressure differentials for clean and dirty rooms Scopes, probes, instruments Acceptable operating room attire: masks, shoes, hair and fingernails Ice machines kept clean Air handling 21

75 Medication Management Drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice consistent with federal and state law. Strategy re high-risk medicines: Labeling Sound-alike, look alike drugs Drugs with abuse potential Therapeutic duplication Limits on titrated drugs 22

76 EMTALA The Emergency Medical Treatment and Labor Act (EMTALA, 1986) requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination. Key elements include: Medical Screening Examination by a Qualifying Medical Provider to ascertain if an Emergency Medical Condition is present (requires stabilization) Memorandum of Transfer if moved to another facility 23

77 CMS Validation of Accrediting Organizations Validation surveys (usually by state agency) Complaint surveys Representative sample within 60 days of AO around 100/year (of ~1200 surveyed by AOs) More likely for prominent institutions, or interval complaint surveys 2016 report to Congress Sensitivity of TJC to state agency survey as gold standard for condition level findings was low 42% disparity rate in FFY

78 Next Stroger and Ambulatory Survey The previous triennial accreditation survey was October 13-16, The duration of the 2018 survey is 4 days. The Survey Team has expanded to accommodate the ACHN clinics and PCMH certification. The Joint Commission Survey Team Nurse, Physician, Generalist, Administrator, Life Safety Engineer, Ambulatory, Primary Care Medical Home and a Social Rehab Specialist 25

79 New Survey Processes New survey report format using SAFER (Survey Analysis For Evaluating Risk) methodology Identifies risk level for each finding, which determines follow up requirements All findings require an Evidence of Standards Compliance (ESC) at 60 days High risk findings will be monitored at future surveys Lower risk findings are monitored by the hospital Every instance of non-compliance will be cited 26

80 27 SAFER Matrix Survey Analysis For Evaluating Risk

81 Top Standards Cited by TJC: Hospital Standards Almost identical in 2016 and /10 are focused on Environment of Care and Life Safety. (Also: High level disinfection and sign records) EOC/Life Safety issues: 18 inches open space below sprinkler heads and sprinkler heads are functional. Fire doors are maintained and tested. No penetrations in walls or floors Integrity of egress (clutter or blocking exit pathways) Equipment is functional Eyewash stations; appropriate labels on hazardous chemicals 28

82 29 Trends in Findings of 763 Hospitals for Q1&2 2017

83 Top Standards Cited by TJC: Ambulatory Standards Again, 2016 and 2017 very similar. High Level disinfection continues to be the #1 finding. Also o o o Cleaning medical equipment Medication management, including storage and security, managing high alert medications Human Resources: clinical privileging of staff Environment of Care: Inspecting medical equipment, managing sprinkler systems, fire drills, fire doors, labeling hazardous chemicals, addressing chemical spills and emergency power testing. 30

84 31 Trends in Findings of 352 Applicable Surveys for Q1&2 2017

85 We want to be always ready, always safe for the next patient System efforts led by operational leaders supported by Nursing Medical staff Regulatory expertise within Quality Department Chapter teams Internal tracers to assess readiness Manager rounding expectations Continual Readiness Oversight Committee 32

86 33 Discussion