Ins der November. Standards year in review

Transcription

1 Ins der November 2013 Vol. 6 New accrediting body Standards year in review contents This quarter s Meet-a- Member section introduces Rene Catalano, MS, RN, of Northwestern Memorial Hospital in Chicago. AHAP s latest benchmarking survey conducts a look back at restraint and seclusion challenges. Are you up to speed with the latest CMS changes? AHAP advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, reviews the most recent updates. A Canadian patient safety and advocacy organization is providing a blueprint for improving patient involvement worldwide. The Joint Commission focused on OPPE and FPPE challenges at its most recent Hospital Executive Briefings. Read more about these evergreen issues inside. Every fall, The Joint Commission announces the most-cited standards among its accredited hospitals in conjunction with the annual Hospital Executive Briefings events. As has become a theme in the most-cited standards list over the past several years, clinical-based findings have continued to take a backseat to facilities findings. Life Safety and Environment of Care standards make up the bulk of the top 10 and continue to plague hospitals with challenges to compliance. AHAP chairperson Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of accreditation, clinical compliance, and policy management for Northwestern Memorial Healthcare in Chicago, has reviewed the findings and offers commentary on each. In this issue, we will take a look at the top 10 challenges for hospitals in The top 10 kicks off for 2013 with a nonfacilities standard: RC EPs 19, 11, and 8, which tie directly into CMS Condition of Participation 482.2(c)(1), completion of the medical record. The most common finding still results from insufficient dating and timing of medical records. A point to make about this particular finding: Element of Performance 8 is the only direct impact and risk-stratified EP, says Eisenberg. On the CMS side it isn t a condition-level finding. It is an issue that organizations should keep working on. However, even though it is a top finding, it might not warrant extensive resources. The focus should be on building solutions into the electronic medical record to automate dating and timing of entries wherever and whenever possible. LS, IC, EC standards It doesn t take long in the top 10 list for the Life Safety standards to appear. The second on this year s list is LS and the everchallenging problem of hallway clutter. Why does this standard continue to provide hospitals with issues? There continues to be clutter in the corridor, says Eisenberg. Space is generally at a premium in hospital buildings. Anything that is in the corridor for more than 30 minutes that is to say, not in use is considered storage. Recent discussions between The Joint Commission and CMS have resulted in potential opportunities to request waivers relative to egress clearance. The terminology of means of egress has been enhanced to allow for the following: Patient lift and transport equipment can be stored outside the patient room as long as 5 feet of hallway remains clear, a fire plan is present that addresses the issue of storage, and the addition of this equipment accommodates equipment that is in use Fixed seating is now permitted as long as 6 feet of clear corridor remains, the space between groupings of fixed seating is sufficient (greater than or equal to 50 square feet with 10 feet between the groupings), and the groupings are on the same side of the egress corridor Additional exceptions allow for dead end corridors to be used for storage if those spaces are less than or equal to 50 square feet. Specific carts are not allowed to be stored in this way, however; crash carts, isolation carts, and chemo carts. The boundaries, dimensions, and exits must

2 be identified on your drawings, says Eisenberg. Use appropriate Life Safety legends. If the legends aren t present, potential issues and discrepancies could arise during your survey. Ensure that suites are defined to gain advantages of suites (sleeping areas, 5,000 square feet maximum and nonsleeping areas 10,000 square feet maximum). Indicate on your drawings any approved equivalencies or waivers. Infection Control (IC) makes its first appearance on this year s list with IC , which targets risks of infection through equipment, supplies, and devices, which is a focus on all surveys according to The Joint Commission, Eisenberg says. Surveyors are looking at two specific areas: high-level disinfection with a focus on scope cleaning, and lowlevel disinfection with a focus on cleaning of medical equipment used on multiple patients (i.e., medical equipment that travels from patient room to patient room). For the former, The Joint Commission has targeted decentralization as a reason behind many issues. This topic is consistent with the CMS Patient Safety Initiative, which focuses on infection control. Decentralization breeds inconsistency, says Eisenberg. Organizations need to make sure that manufacturer guidelines are followed consistently for disinfection of devices and that routine competency validation among staff takes place, not only at orientation and during training, but as a matter of periodic assessment. The severity and prevalence of issues identified during survey could escalate IC findings to Immediate Threat to Health and Life, says Eisenberg. To address low-level disinfection, hospitals should have a defined procedure indicating intervals for cleaning, and designate certain equipment per patient stay. Note: Eisenberg recommends the website www. DisinfectionAndSterlization.org created by William A. Rutala, PhD, MPH, for further reading on this subject. The Environment of Care chapter debuts in this year s top 10 with ventilation issues under EC This standard deals with pressure relationships, filtration, and air exchange values. Look for this issue to be reviewed early on in the survey as if identified, says Eisenberg. It could prompt a condition-level deficiency. However, if identified early in the survey, the organization will be allowed to resolve the issue and the Joint Commission central office will review to potentially move this finding from a condition-level finding to a standard-level finding. LS and EC continuing challenges Life Safety makes its second appearance on this year s list with fire wall penetrations (LS ). If you haven t implemented a control system (such as an above-ceiling work order permit) for above the ceiling work, make that one of your priorities for , says Eisenberg. Hospitals continue to struggle with EC , which contains requirements for documenting testing of fire protection features. As was indicated during last year s Executive Briefings, it is not so much a problem that the testing is being done at all, but rather a lack of documentation proving that the testing was performed. Your organization should be able to produce an inventory of devices and dates for testing, says Eisenberg. If the documentation isn t available during the survey, two findings will potentially be issued: one for EC and one for LD , EP4. If the organization clarifies the EC finding, the LD finding will remain. This puts the focus squarely on leadership. Ensure that your life safety program is organized and managed consistently. Yet another repeat from previous years is LS , addressing the amount of open space that must be maintained below the sprinkler deflector to the top of storage items. Remember, clearance rules depend upon the sprinkler type and storage conditions, says Eisenberg. As a general rule NFPA 13, Installation of Sprinkler Systems, requires 18 inches of clearance. However: In the case of standards pendent and upright spray sprinklers, the 18-inch dimension is not intended to limit the height of shelving or storage along a wall 2013 HCPro, Inc. November

3 The 18-inch rule does apply for sidewall and extended coverage and pendent sprinklers There must be 36 inches (minimum) clearance between early-suppression fast-response sprinkler deflectors and the top of storage Next up is a more generalized EC standard, EC , which requires that spaces meet not only the patient needs but are also safe and suitable for the care being provided. Findings under EP1 of this standard include any unsafe conditions, such as loose oxygen tanks, ripped carpet, broken cabinetry, or broken waiting room furniture, says Eisenberg. The field continues to see issues related to full and empty oxygen tanks unsecured, inappropriately stored, or too many tanks in one smoke compartment. Suitable ventilation, temperature, and humidity must be provided. Issues that are cited under this standard include humidity measurement over 60%, where the primary concern is mold growth, says Eisenberg. Other issues include inconsistent temperatures and ventilation issues. Medication Management Finally, we see a non-facilities related standard in the top 10: MM , which falls under CoP (a), (b), pharmaceutical services. Medication security requires ongoing vigilance, says Eisenberg. Hospitals need to ensure that those who need access to medication storage have access and those who have no need don t have access. Define secure in your policy and ensure that those who have access to medication storage areas understand the definition of secure. Monitor those areas and perform a risk assessment to identify any potential issues. This standard does not just address storage alone. Expired, damaged, and contaminated medications all fall under this element of performance, says Eisenberg. Put a process in place to monitor the integrity of these medications. Additionally, cleanliness in all medication storage areas is critical. Pay close attention to single dose vials versus multi-dose vials, notes Eisenberg. EP10 requires the use of the most ready to administer form of the medication, she says. If multi-dose vials are in place, ensure you have consistent procedures for using multi-dose vials, labeling multi-dose vials, and monitoring adherence to the procedure. Note: Vaccine storage should follow CDC guidelines. For the use of single-dose vials, Eisenberg recommends The One & Only Campaign, a public health campaign led by the CDC and the Safe Injection Practices Coalition to raise awareness among both providers and patients about safe injection practices. The campaign aims to eradicate outbreaks resulting from unsafe injection practices. With regard to storage, medications must be stored per manufacturer s guidelines, says Eisenberg. One area that has received focus over the past year relates to pharmacy bulk packaging specifically contrast. Pay attention to contrast storage and know your process to determine how long you can hang on to contrast and adhere to that requirement. An issue related to contrast administered via an auto injector has been a topic of interest over the past year due to a disconnect between the FDA, the ISMP, and manufacturer s guidelines. The primary issue revolves around the acceptability of using bulk contrast for multiple patients administered through a delivery system versus using a single dose for these same radiology patients. As we know, the implementation of multi-dose bulk IV contrast material delivery systems results in significant cost savings, says Eisenberg. Implementing single dose or some manner of laminar hood process in radiology isn t exactly ideal and likely would be cost prohibitive. One of the concerns that surfaced was the length of time the bulk contrast would hang. For organizations with high volumes of patients receiving contrast, the contrast rarely hangs more than one shift and never from one day to the next. FDA regulations state that hospitals must follow the manufacturer s guidelines and The Joint Commission would likely hold hospitals to that, says Eisenberg HCPro, Inc. November

4 However, the FDA also approved the contrast delivery systems. These delivery systems consist of an apparatus and process for injection of multiple numbers of patients with a sterile fluid; they also ensure sterility by providing devices that control the fluid flow in such a way that the injection devices are isolated from each other, as well as from the source of sterile fluid. Discussions are still under way between The Joint Commission, CMS, and the FDA to reconcile approval of bulk contrast and the use of this delivery system. In the meantime, organizations are encouraged to do a risk assessment, says Eisenberg. In light of the fact that this is considered under the Medication Management chapter, it would be beneficial to include pharmacy in the review as well. The review should determine whether any incidents have occurred, review the process to make sure the staff are following the proper procedures, limit the time that the bulk contrast hangs, label date and time prepared, and ensure cleanliness of the suites where the contrast is delivered. Protective equipment and hazardous materials Rounding out the top 10 most-cited standards is another Environment of Care standard, EC Eyewash stations continue to be problematic for areas to comply with, specifically confusing around the necessity and monitoring frequency of these stations. Eisenberg recommends conducting a risk assessment for each area where you have an eyewash station to validate if it is needed. Next, use a risk assessment to determine whether there should be eyewash stations installed in new areas or new construction. Finally, define frequency of checks. OSHA publishes recommendations for these checks, which are not requirements but an excellent starting point. Also falling under this standard is the transportation of hazardous materials. Organizations licensed to transport, store, and use radioactive material are required to: Secure radioactive material once it is at the designated storage location such as hot lab Maintain records of receipt, transfer, and disposal of any radioactive material Ensure that a trained person transports hazardous materials Some organizations require an escort but this is not required. Organizations can review their process and determine whether there is value in adding an escort and if so, define and adhere to organizational requirements. Organizations should conduct physical inventories at required frequencies to account for the continued security of radioactive material, says Eisenberg. Your organization policy should dictate specifically how this supervision takes place. n All good things Dear colleagues and friends of accreditation, You have in your hands the final issue of the AHAP Insider. Our organization is closing its doors at the end of the year after six years of service as a gathering place for accreditation professionals and survey coordinators. It has been a wonderful run. My colleagues and I have long considered the annual conference the highlight of our year, a time to see members face-to-face after months of talking by phone or , a chance to highlight the good work you do, and an opportunity to provide education and resources to help you develop your accreditation skills for the future. But the day-today interactions, publicly through the Talk Group and privately through phone calls and , have really made us feel like we had built a community here at AHAP, and we thank you for your dedication, your contributions, and your ever-present enthusiasm. When AHAP first began, we lived in a different accreditation world. There were fewer accrediting options available, and surveys were far more feared and far less collaborative than we see now. It could be said that accreditation has evolved more in the past half decade than it did in the previous half-century. You as survey coordinators and accreditation specialists have weathered those changes with innovation, intelligence, and good 2013 HCPro, Inc. November

5 humor. It has been our honor to be both a witness and a sounding board during these times of change. We want to ensure that AHAP members will continue to have a place to contact each other and discuss the accreditation issues of the day, and so we will keep the Talk Group open in perpetuity for you. If you are not currently signed up for the listserv, you can still join simply me directly at mphillion@hcpro.com and I will add your name to the roster. Please invite your accreditation colleagues if you would like. There is no fee to sign up, and we want the Talk Group to be a safe place for accreditation professionals to talk about survey suggestions and the latest changes to our field. Our sister newsletter, Briefings on The Joint Commission, will continue on as well, where several of our long-term AHAP advisors are writers, commentators, and contributors. If you have any questions about that publication, feel free to contact me at the address above as well. Please reach out to me with any suggestions for best practices or success stories you feel deserve to be highlighted in that newsletter I have always tried to give AHAP members priority as the editor there, and will continue to do so whenever a former AHAP connection suggests we follow up on an idea or topic. We hope that you ll take the time to stay in touch with your fellow AHAP alumni through the free listserv. It has been an honor to maintain this organization over the past few years. Thank you for the privilege of representing you. All the best, Matt Phillion AHAP Director, mphillion@hcpro.com Jackie Zagami Associate Director, jzagami@hcpro.com Meet a Member Staff education and accreditation For AHAP s final edition of Meet a Member, the organization wanted to do something special to highlight the continuity and shared experiences among accreditation professionals. When AHAP chairperson, Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, who has been a part of the organization since its inception, suggested that we highlight the background and achievements of a member of her accreditation team at Northwestern Memorial Hospital (NMH), we knew we had found the perfect person for this edition of Meet a Member. Rene Catalano, MS, RN, is an accreditation coordinator with the accreditation, clinical compliance, and policy management department at NMH. Like many accreditation professionals, she came to the role after an extensive career as a clinical nurse and nurse educator. I received my undergraduate and graduate degrees in nursing, says Catalano. My track was as a clinical nurse specialist with a teaching focus. She spent a number of years as a clinical nurse and moved into a staff educator role after receiving her masters, a position that turned into a rewarding 20-year journey. The majority of that time was spent in clinical nursing education. I taught a lot of nurses in the hospital setting. In that capacity, Catalano worked with Eisenberg and staff in quality and patient safety on numerous projects. A lot of our education focused on patient safety and The Joint Commission s standards and Elements of Performance, says Catalano. So I became familiar with how to create a curriculum with patient safety elements in mind. When she began to look for something new and different in her career, accreditation and clinical compliance was a very logical step. I had worked with Jodi and her team on several hospital initiatives, and I wanted to walk on the other side for a while. I wanted to understand the standards and 2013 HCPro, Inc. November

6 accreditation processes firsthand, she says. She immediately found her experience in nurse education applicable and useful. When developing programs, which I d had a lot of experience doing, the nurses must be educated as to why it is important to be compliant. Once the staff understands the importance of something, we get their buy-in, says Catalano. We always need to show how things relate to patient safety, she says, and with various rollouts of different programs, patient safety is always the first priority, above and beyond meeting a regulatory standard. When addressing a group of nurses, it is important to really know the underlying reasons why we do things in healthcare. Patient safety is front and center of everything we roll out, says Catalano. She also learned that it was necessary to make sure that frontline staff were involved in the development and rollout of these programs. Everything we do is in the name of patient safety, but it also has to become part of the frontline staff s workflow, she says. Everything ties into that workflow, says Catalano. We need senior leadership support to do educational rollouts, she says. "We need to ensurethat all staff have what they need to practice safely and in accordance with standards and requirements. Constant state of readiness The shared importance of accreditation across all areas of the organization can be unifying, says Catalano. I do feel that, working with all levels of leadership and staff, we were all connected in that way, she says. I always had this thought that [the accreditation team] was one of the most elite teams in the hospital in terms of what they did, how smart they were, and the knowledge they had. They have such an ability to work behind the frontline staff. They know the how s and why s and their primary responsibility is to support patient safety and quality of care. We always followed their lead. The biggest realization for her when she crossed over into this new department, though, was discovering how all of the regulatory bodies that impact a hospital are interconnected. I d never made the connection between CMS, The Joint Commission, our local health departments, and other agencies," says Catalano. I thought every agency did their own thing, but it s actually a hierarchy of deeming authorities. She calls understanding that hierarchy and The Joint Commission s role in it her aha moment as an accreditation professional. Learning the ropes AHAP always asks its members what the biggest challenge was in terms of coming to grips with the world of accreditation. I don t think I ll ever memorize all the standards and EPs, says Catalano. I will wait patiently for the day when that happens, but until then I m glad I have my book with me at all times. She anticipates her biggest challenge in the future will be writing evidence of standards compliance and developing action plans to help the organization be successful and meet its challenges. Being on the other side of a survey visit has been an enjoyable learning experience, she says. I always participated in these processes as an educator, a service line leader, and as a clinical nurse specialist, but this was my first time as an accreditation coordinator, Catalano says. In general, she says, the surveyors are all very appreciative of the work the organization and staff do for their patients, and she in turn appreciates the importance of their presence and their feedback. It s interesting to hear their focus and to see their interactions with staff, says Catalano. Overall, it was a really positive experience. The Northwestern staff welcomed the most recent surveyors, and Catalano appreciated the comments made about the organization s best practices HCPro, Inc. November

7 It s nice to hear their consultative recommendations. The information they share with us is very valuable, she says. It helps me realize that as an institution we re part of a large consortium of institutions that share best practices. We often hear about some best practices through our surveyors, says Catalano. Northwestern participates in a number of Joint Commission s disease-specific programs as well, which Catalano experienced as a clinical nurse specialist and nurse educator but is now experiencing from a different angle as an accreditation coordinator. I like those visits they re focused visits, and it helps me to orient to my role with a smaller focus, she says. They are looking at the same things as during a hospital visit but with a narrower focus. This helps me get through the process and helps me understand what will happen during a larger visit. Since joining the accreditation staff, Catalano has been part of two disease-specific surveys: carotid artery stenting and advanced primary stroke. The focused aspect of these disease-specific surveys made Catalano feel more prepared and confident for the larger hospital survey. I felt more ready not only have I done a couple, but I ve already done a hospital visit and I was a lot more familiar with the process, she says. What comes next Catalano says her next big challenge as an accreditation coordinator is preparing for the intracycle focusedstandard assessment period. "There was a huge bulk of work to be done after our hospital visit, and just as we re starting to take a breath, it s time to do a focused standards assessment, she says. The department is meeting with chapter leaders to see where the organization is in terms of compliance with the EPs. It s a misconception that upon receiving Joint Commission certification, Jodi and I can relax and take a long vacation. It s actually the exact opposite, says Catalano. After day five of the site visit, I was starting our working plan and creating a matrix of our findings, our primary contacts, our plan for corrective action, and our next steps. The work really started after the visit, she says. There never really is a reprieve, and that s what makes the work exciting. I m happy to be a part of it, says Catalano. Once a teacher Catalano does admit that she misses teaching, though she is still an educator of sorts in her accreditation coordinator role. I no longer teach cardiac nursing and disease processes, but I now teach about patient safety, quality, standards, and compliance," says Catalano. It s still teaching, but has a different focus. She feels like she has found a new home in the accreditation department. I not only like the work and the people I work with, but I feel like I ve planted new roots, says Catalano. She is looking for ways to continue using her teaching background in beneficial ways, including teaching a review course for certification for cardiac service line nurses. I typically teach three-to-six sessions of that review course, and [the accreditation department] is happy to have me do that, says Catalano. "It s hard to put away almost 25 years of your nursing education experience. As a quality strategy team, the department s partners are in infection control, patient safety, clinical quality, and risk management, so teaching is one way to keep a foot in the door for nursing education, teaming up service line skills with risk and quality initiatives. I m the point person for accreditation in the cardiac service line, and I can relate to that patient population because I ve had experience, says Catalano. I was able to take the lead on some of our findings with crash carts and other nursing/provision of care issues." Catalano feels her overall experience brings a uniqueness to her role as an accreditation coordinator. I bring my clinical experience to this role. I understand patient care, medical terminology, policies and procedures, safety and quality, she says. n 2013 HCPro, Inc. November

8 Restraint and seclusion: A look back and update For our final AHAP Benchmarking Report, we chose to take a look at our first year s surveys to reexamine some of our earlier topics and to survey our members on how far we ve come in that given topic. For this report, we selected our 2007 Restraint and Seclusion Benchmarking Survey, which is available for download at Using many of the same questions and addressing more upto-date concern with additional queries, the new report examines restraint and seclusion challenges for Demographics First, let s take a look at who participated in this year s survey. As always, the participants are made up of AHAP members from across the country and accounting for a wide range of accreditation professionals. Almost half of respondents (47%) came from urban hospital or healthcare facility settings. Rural facilities made up about a third (34%) while suburban the least (19%). The same percentage of respondents (42%) came from either a facility with fewer than 150 beds or more than 300 beds; only 16% of respondents came from midsized facilities with 150 to 300 beds. Death reporting AHAP asked respondents if their organization has updated its approach to death reporting since Roughly two-thirds (66%) said they had updated their approach, with the remaining 34% stating they had not. Respondents were then asked where the responsibility for the restraint death log rested. More than half (54%) stated that their risk management professionals or departments were in charge of the restraint death log. A fairly large number (31%) said responsibility for the log fell upon the patient care department, and 19% of respondents said that the log was the responsibility of their compliance department. A small group (4%) of respondents indicated that their medical records department handled the restraint death log. The question also allowed for write-in answers, which included many responses for the quality department, a single response for nursing supervisors, one response for the regulatory manager, and two which indicated that restraints were not used at their organization. Biggest challenge? The survey asked respondents to identify which aspects of restraint and seclusion their organizations found the most challenging. Clearly, documenting timely monitoring (48%) continues to be the single greatest challenge among AHAP members with regard to restraint and seclusion. Maintaining a current order also scored high (26%), while differentiating between the two types of restraint continued to plague 19% of respondents. A smaller percentage (7%) stated that getting an LIP to see the patient within one hour of application restraints is their biggest challenge. Again, write-in responses were allowed for this question. Specific answers listed included: Documenting removal of restraints Documenting discontinuing of activity Decreasing or eliminating the use of restraints Several respondents indicated that their facilities do not use restraints. Training and education Next, organizations were asked if they have implemented appropriate training for all staff caring for patients in restraints as a result of a violent or aggressive incident. Back in 2007, respondents had clearly made a strong effort to put this education in place, with 82% of respondents indicating they had provided proper training (18% indicating that they had not). According to the 2013 survey, however, it appears that this number has gone down, with 75% of respondents saying they had implemented appropriate training and 25% responding they had not. Respondents were then asked to indicate from a specific list of processes that they considered the most 2013 HCPro, Inc. November

9 troublesome under CMS Interpretive Guidelines. Medication restraints were voted overwhelmingly as the most challenging issue at 73%. This is an enormous jump from the numbers AHAP saw in its 2007 restraint and seclusion survey, where only 46% of respondents indicated medication restraints. This was the highest percentage in the 2007 list as well, but an almost 30% jump indicates that this issue has become even more challenging than it was half a decade ago. Only three other issues rated in the survey with any significance: Lower bed restraints: 12% Zipper comforter restraints: 8% Soft limb restraints: 8% Lower bed restraints and zipper comforter restraints saw just a slight uptick in the 2013 survey (up from 6% and 7%, respectively) while lower bed restraints saw its numbers cut in half down from 24%. Write-in answers included: Mittens Seclusion Education of staff Types of restraints Respondents were then asked what types of restraints are currently being used at their organizations. Soft limb restraints appeared to be nearly universal at 92%, while bed rails were used 39% of the time. Thirty-one percent of respondents worked in facilities where lower bed restraints were used, and only 4% of organizations responding to the survey use zippered comforters. Compare this to 2007 responses: Soft limb restraints: 79% Bed rails: 58% Lower bed restraints: 18% Zippered comforters: 3% It appears that soft limb and lower bed restraints have become more common since 2007, while bed rails have become less common. Zippered comforters remain almost unchanged. Medication restraints Respondents were asked how their organizations were using medication restraints. The vast majority (90%) used medication restraints to de-escalate aggressive or destructive behavior. Only 51% of respondents in 2007 said they used medication restraint in this manner. Nineteen percent stated they use medication restraint to manage behavior, a significant drop from the 37% indicated in Zero respondents indicated that medication restraints were used to restrict freedom of movement. A small percentage (7%) of the 2007 respondents said their organizations used medication restraints in this way. The survey did receive several write-in responses that organizations were not using medication restraints at all. Orders for restraints The final question on this year s survey asked who is allowed, under existing policies, to receive an order for restraints. All of respondents (100%) said that RNs are allowed to receive orders for restraints. This remains virtually unchanged from the 2007 survey (99%). APNs were the next-highest percentage at 32%, up slightly from 27% in LPN/LVNs were indicated by 18% of respondents, up slightly from 15% in Only 7% of respondents said that PAs could receive orders for restraints, a huge drop from 24% in Only 4% of respondents said that psychologists could receive orders for restraints in the 2013 survey, identical to the percentage indicated in the previous survey. Again, several write-in answers indicated that no restraints are used in the organization, while one stated that verbal orders are strongly discouraged and seldom used any longer. n 2013 HCPro, Inc. November

10 An overview of recent CMS changes Editor s note: The following report was authored by AHAP advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, Calif., and former Joint Commission surveyor. On August 27, 2013, CMS released significant changes impacting several areas of the Conditions of Participation (CoP). Interestingly, the information included in Transmittal 88 on August 27 rescinded and replaced a relatively recent update, Transmittal 86, on July 19, According to the official CMS documentation: Transmittal 86, dated July 19, 2013, is being rescinded and replaced by Transmittal 88, dated August 27, 2013 to reflect the deletion of sections through on the transmittal page as this information has been moved to new sections through Additionally, in the table of contents, sections through have been corrected to through All other information remains the same. Let s take a look at where the most extensive of changes occurred in the language of the August transmittal. Post-survey procedures Section 5110 Significant language was added under the header of postsurvey procedures, specifically under , Substantial Compliance. This language states that if condition-level deficiencies are not citied in a CMS survey, the provider is in substantial compliance with federal requirements. The new language also details the review process even if no deficiencies were cited, demonstrating that a survey was conducted to evaluate compliance with the listed requirements and that no deficiencies were identified in these areas. Condition-level, Immediate Jeopardy Section The changes also impacted , discussing conditionlevel and Immediate Jeopardy findings. If deficiencies pose an Immediate Jeopardy and that situation is removed while the surveyors are on-site, the deficiency citations are made at the condition-level. Condition-level deficiency procedures must then be followed. The CMS forms must indicate that an Immediate Jeopardy situation was cited even if it was removed with surveyors still on-site. The details of the Immediate Jeopardy and steps taken to remove it must be documented, and said documentation must include the date the surveyors verified the Immediate Jeopardy was removed prior to completion of the survey. However, if the Immediate Jeopardy is not removed while surveyors are on-site, the deemed provider is placed on a 23-calendar day termination track. The provider is notified of the termination date and a request is issued for an acceptable plan of correction within five calendar days of the notice. The provider is advised it will be surveyed after the receipt of the acceptable plan of correction and prior to the termination date. This notice also states that deemed status is removed. The new language does note that while deemed status is technically removed, because it is expected that deemed status will be restored once corrections are made and verified, no changes are made in the CMS ASPEN system to the provider s deemed status. The new information goes on to describe the followthrough process by CMS, including what occurs when: No acceptable plan of correction is submitted The Immediate Jeopardy is not removed at the first revisit The Immediate Jeopardy is removed and substantial compliance awarded after the first revisit The Immediate Jeopardy is removed and substantial noncompliance still remains after the first revisit And occurrences of substantial compliance or substantial noncompliance after the second revisit The transmittal goes into full detail about these visits and follow-up actions, which can be found under Condition-level, non-immediate Jeopardy Section This category, covered under , discusses the procedures followed when the regional office does not require a full survey after a complaint survey, as well as when the regional office requires the state agency to conduct a full survey. To decide between these two 2013 HCPro, Inc. November

11 options, the regional office may consider: The manner and degree of noncompliance identified as a result of the compliance investigation The provider s compliance history Recent changes in the provider s ownership or management Length of time since the provider s last accreditation survey Availability of state agency resources at the time required to conduct a full survey Advantages associated with conducting a more extensive survey compared to the advantages associated with the faster enforcement (and thus faster potential corrective action) that result when proceeding directly to enforcement action after the compliance survey CMS regional offices have the following options after a provider fails to demonstrate substantial compliance but do not pose an Immediate Jeopardy under the updated language in the August transmittal. These options are below: No full survey, proceed directly to termination track based on the complaint survey. As above, in this case deemed status is immediately removed but with the expectation it will be restored once corrective actions have been implemented and verified. The follow-up to this option depends upon the results of corrective action plans and revisits, including: If no timely, acceptable plan of correction is submitted, the regional office proceeds with termination of deemed status. Substantial compliance found on first revisit: termination is rescinded, provided substantial compliance is received and documented. Substantial noncompliance after first revisit: if surveyors find significant noncompliance on the first revisit, they will consult with the regional office to determine whether a second revisit will occur, or if they should proceed with termination. Full survey after the complaint survey. The regional office can order deemed status removed and a full survey conducted on an unannounced basis. The full survey must be conducted within 60 calendar days after removal of deemed status. Full survey after complaint survey Section Should the regional office authorize the stage agency to conduct a full survey after a complaint survey (as detailed under ) the following can occur: Substantial compliance: Should the follow-up survey find substantial compliance, notice of deemed status restoration is issued. Full survey findings: condition-level, Immediate Jeopardy. These findings run the gamut similar to those results we discussed under , for Immediate Jeopardy conditions removed while surveyors are still on-site, and Immediate Jeopardy situations not resolved with surveyors still on-site. Full survey findings: condition-level, non-immediate Jeopardy. Again, CMS options are similar to those already discussed for non-immediate Jeopardy, condition-level findings. Restraint and seclusion death reporting Section 5170 The other major changes seen in the August update involve hospital restraint/seclusion death reporting and investigation. This involves both deemed and nondeemed hospitals, critical access hospital distinct part psychiatric and rehabilitation units. Hospitals are required to report a death associated with the use of restraint/seclusion to their CMS regional office. The update details responsibilities of various agencies, stating that the regional office is responsible for communicating with hospitals in its region how it will accept these reports and how the data is entered in the system. The regional office should designate one person and a backup person as point of contact for reporting. State agencies conduct complaint investigations regarding patient deaths involving restraint or seclusion but only when authorized by the regional office. The state agencies respond to requests from protection and advocacy groups 2013 HCPro, Inc. November

12 and other parties. The regional office evaluates the information reported to determine whether the situation might involve a violation of CMS CoPs. It then authorizes an on-site investigation if there appears to be a possible violation. With the information provided, if the regional office determines that an investigation is needed, within two days of receiving the report the regional office enters the report into the restraint/seclusion model maintained by CMS and immediately notifies the state agency that it is authorized to conduct a complaint survey. The stage agency is expected to complete the investigation within five working days of receipt of authorization. Simultaneously, the regional office must also provide written notification to the appropriate protection and advocacy agency with the state where the hospital is located if that organization has a data use agreement with CMS. The names and addresses for each state s protection and advocacy agency can be found online at The regional office provides the following information to the protection and advocacy agency: Hospital name Hospital address Name of deceased Copy of restraint/seclusion death report submitted by hospital The August transmittal provides rules the protection and advocacy agency must comply with to receive this information as part of its CMS data use agreement. The agency may request information about an on-site survey by submitting the request to the state agency. If the agency identifies a particular patient, hospital, approximate date, or dates the patients was in that hospital, and makes a request for additional information related to the use of restraint or seclusion, that request is forward to the regional office. Other areas of note When examining this latest CMS update, we recommend looking at additional updates falling under the Interpretive Guidelines for ventilation, light, and temperature control, (c)(4). Proper ventilation rules have been added for anesthetizing locations in accordance to NFPA rules. Humidity levels for these areas have also been addressed under the same section, stating: Hospitals must maintain relative humidity (RH) levels at 35 percent or greater in each anesthetizing location; unless the hospital elects to use the CMS categorical waiver, which permits it to maintain a RH of at least 20 percent (see Appendix I, Section II for additional information). Hospitals must maintain records that demonstrate they have achieved the required levels. Although not required, CMS recommends that hospitals maintain the upper range of RH at 60 percent or less, as excessive humidity is conducive to microbial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be incorporated into hospital policy. Hospitals will be surveyed for humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels. n References: State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, (Rev. 84, ), Regulations-and-Guidance/Guidance/Manuals/ downloads/som107ap_a_hospitals.pdf CMS Manual System, DHHS, Centers for Medicare & Medicaid Services, Transmittal 88, Date: August 27, 2013, (Rev. 88, Issued: ), Revisions to Chapter 5 Guidance/Transmittals/Downloads/R88SOMA.pdf State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, (Rev. 89, ), Regulations-and-Guidance/Guidance/Manuals/ downloads/som107ap_a_hospitals.pdf 2013 HCPro, Inc. November

13 Bringing patients and providers together International organization improves communication by inviting patients to the table Communication whether among physicians, between physicians and nurses, or between physicians and patients remains central to the ongoing discussion of quality improvement in hospitals and how to build physician ownership and involvement. In searching for best practices to improve physician and patient communication, AHAP Insider explores an intriguing Canadian program, Patients for Patient Safety Canada (PFPSC), based in Saskatchewan. PFPSC is a patient-led program in conjunction with the Canadian Patient Safety Institute, which champions the patient s voice to advance safe healthcare. The organization s goal is to assist patients in helping providers improve overall care. When a patient safety incident occurs, patients and their families often see things that busy healthcare providers do not. By contributing the patient voice, experience, and perspective, the program tries to ensure that patient safety initiatives are truly patient-centered. PFPSC is made up of patients and families with safetyrelated experiences who volunteer to bring their perspectives to a forum in order to: Provide a collective, credible voice that reflects the diverse perspectives of patients across Canada Advocate for the inclusion of the patient s perspective in healthcare agendas Collaborate with patients, healthcare providers, health organizations, and other agencies to speed up efforts to improve patient safety AHAP had the chance to chat with two key figures in PFPSC, the organization s cochair Donna Davis and project manager Ioana Popescu. PFPSC was initially developed by the World Health Organization (WHO), which had identified a need to get groups of patients organized throughout the world to prevent patient harm. PFPSC was supported initially by and continues to be a part of the Canadian Patient Safety Institute. A few of our staff members had heard about the WHO program in 2005, says Popescu. We knew it involved sharing stories of patients who had experienced harm, but also it was about hope and about working together to make care safer. The institute realized that patients and family members provided perspective it did not yet have. We knew a lot about patient safety and theory, but the patients and families were able to tell us things we didn t know, says Popescu. The institute worked with PFPSC members and collaborated with the WHO program to develop the PFPSC concept and to incorporate the patient voice in developing disclosure guidelines and root-cause analysis frameworks. A changing world As the program s development was happening, the environment of healthcare was changing, notes Davis. She is a nurse by trade, but her immediate family has also experienced preventable patient harm firsthand, which inspired her involvement in the program. The industry realized that patients and their families need to be at the table and part of the discussion from the very beginning, says Davis. Patients and their families were made a part of the disclosure guideline development meetings. We sat at all the meetings, and brought the patient and family voices forward. Doctors were sitting at the table as well, says Davis. Though it was very respectful dialogue on both parts, there were a few blips. I was representing the patients and families at the table and I had my key points, and the physicians had their key points, and we developed a really good [disclosure] document. This was the first experience with patient involvement for some of the physicians, she says. It really opened up the physicians eyes, says Davis. Patients aren t there to say poor me or to rant and rave; they are there to bring their perspective forward. Every party at the table physicians, nurses, the risk 2013 HCPro, Inc. November