2016 Pharmacy Education Series

Transcription

1 2016 Pharmacy Education Series March 16, 2016 The Joint tcommission i Medication Management tstandards d Update 2016 Featured Speaker: Jeanne M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCP Principal Consultant, Medication Management and Safety Joint Commission Resources/Joint Commission International 1 Online Evaluation, Self-Assessment and CE Credit Submissionof of anonline evaluation is the only way to obtain CE credit for this webinar Go to Webinar attendees wi also receive an with a direct link to the web page Print your CE statement of completion online Credit for live or enduring only Deadline: April 15, 2016 CPE Monitor (applicable to pharmacists) CE information automaticay uploaded to NABP/CPE Monitor within 1 to 2 weeks of the completion of the self assessment and evaluation Event Code Code wi be provided at the end of today s activity 2 1

2 How to Ask a Question Locate menu bar on your computer desktop Click No! Click orange arrow button Menu box wi open Type question into question box Click Send Do not close menu box This wi disconnect you from the Webcast Please submit questions throughout presentation Enter question Click Send 3 Accessing PDF Handout Click the hyperlink that is located directly above the question box Do not close menu box This wi disconnect you from the Webcast Close other applications Click hyperlink No! 4 2

3 2016 Pharmacy Education Series March 16, 2016 The Joint Commission Medication Management Standards Update 2016 Featured Speaker: Jeanne M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCP Principal Consultant, Medication Management and Safety Joint Commission Resources/Joint Commission International It is the policy of to ensure balance, independence, objectivity and scientific rigor in a of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. A of today s presenters have no relevant commercial and/or financial relationships to disclose. Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature. 5 CE Activity Information & Accreditation (Pharmacist CE) 2.0 contact hours Funding: This activity is self fundedfunded through CHSPSC

4 2016 Joint Commission Medication Management Standards Update March 16, 2016 Jeanne Mansur, R.Ph., Pharm.D., FASHP, FSMSO, CJCP Principal Consultant, Medication Management & Safety Joint Commission Resources 7 Learning Objectives Identify at least one key issue found on survey relating to the top four chaenging medication management standards List recommendations to assess and address opportunities to improve safety with the use of electronic medical records and computerized prescribing applications List recommendations for evaluating a medication reconciliation program s effectiveness Identify at least 2 key areas where medication reconciliation performance improvement initiatives are often beneficial 8 4

5 MM EP24 Radiopharmaceuticals MM EP24 A 24. For hospitals that t use Joint Commission i accreditation for deemed status purposes: The hospital maintains records of the receipt and disposition of radiopharmaceuticals. (effective ) 9 Revision to Labeling Requirement NPSG EP3 In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the foowing: - Medication or solution name - Strength - Amount of medication or solution containing medication (if not apparent from the container) - Diluent name and volume (if not apparent from the container) - Expiration date/time (effective )

6 Medication Samples and New Language by TJC Announced December, 2013 Effective: July 1, 2014 Note: This element of performance is also applicable to sample medications Accreditation Programs which have Sample Medication requirements Hospital Cii Critical laccess Hospitals Ambulatory Home Care Behavioral Health Office Based Surgery 11 Applicable Standards for Sample Medications

7 Recommended Strategies if You Aow Samples Policy (see sample checklist tool provided with your handout) Who Dispenses? Labeling Playing the pharmacist. 13 SEA 54: Safe Use of Health Information Technology SEA 42: Safe implementation of Health Information and Converging Technologies SEA 54: Safe Use of Health Information Technology- March 31, sentinel events from Jan June 2013 health IT related

8 SEA 54: Safe Use of Health Information Technology 8 Dimensions relating to Health IT performance Human factors interfaces with computer Workflow and communication Clinical content including decision support Internal organization policies and safety culture Performance issues relating to training and failure to foow procedures Hardware/software Vendor and other external issues System measurements and monitoring 15 SEA 54: Safe Use of Health Information Technology Key areas for focus of activities to address Safety culture Reporting Evaluating each adverse event for potential IT link Shared accountability between vendor and HCO Performance improvement Downtime Standardized coded elements- aergies, problem lists, diagnostic tests Extensive testing before go-live Training Order sets Forcing functions to mitigate wrong patient errors

9 SEA 54: Safe Use of Health Information Technology Key areas for focus of activities to address Performance improvement continued Maximize use of EHR to order meds, tests, and procedures Clinical oversight over delegated clinical tasks Provide patients with access to their electronic records Leadership Chose vendors which interface easily and support cognitive work of clinicians Involve front line staff in planning Examine workflows for failures points Make changes in a controed fashion Use metrics to monitor performance 17 Recommendations for SEAs Published by the Joint Commission when significant safety events occur- to alert the field Prescriptive recommendations Your opportunity to look at your own processes Key role for medication safety leader SEAs that interface medication processes

10 Medication Management- Top Non-Compliant Standards/NPSGs for Hospitals (Jan-June, 2015) Standard/NPSG % Non compliant MM Storage and Security of Meds 32% MM Medication Orders 25% MM Medication Order Review 18% NPSG Labeling in OR/procedures 9.9% MM Preparing medications 5.4 % NPSG Reconciling Medications 4.3% MM High alert /Hazardous Meds 3.7% MM Emergency Medications 3.3% MM Look alike sound alike Med 3.1% 19 MM Medication Storage and Security Problematic EPs: EP 2: medications are stored according to manufacturer s recommendations EP 3: a medications and biologicals are stored in secure areas to prevent diversion and locked when necessary, in accordance with law and regulation Failure to address diversion EP 6: the hospital prevents unauthorized individuals from obtaining medications in accordance with law and regulation EP 7: a products are labeled with contents, expiration date (Bulk Packaging- Imaging) EP 8: removes expired, damaged, and/or contaminated meds/stores separately EP 10: most ready to administer form or repackaged by pharmacy (Bulk OTC) CoP Pharmaceutical Services

11 Medication Orders- MM Problematic EPs: EP 13: the hospital implements its policies for medication orders Failure to clarify unclear, iegible and incomplete orders Consistency in interpreting range orders Lack of indication on PRN orders Lack of special precautions for ordering LASA medications 21 Standing Orders/Protocols and Order Sets MM EP 15 Requirements clearly specified Medication orders initiated by RN prior to LIP order requires approval by MD, RPH and CNO Developed using nationay recognized and evidence based guidelines Regular review to determine continuing usefulness and safety Dating, timing and authentication according to law, bylaws or hospital policies i

12 Adjustment of Medications by non-lips Therapeutic substitution Protocols Non/off-protocol optimization CMS considerations Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf New Credentialing and Privileging Resource Center aling-and-privileging-resource-center 23 Pharmacist review of Medication Order MM A pharmacist reviews the appropriateness of a medication orders for medications to be dispensed in the hospital CoP Pharmaceutical Services (b) Problematic EPs: EP 1: pharmacist reviews a medication orders/prescriptions before dispensing/removing from floor stock or automated dispensing device (cont d)

13 Building a Better Override Assessment Process Override review process should assess Urgency of situation or presence of LIP at bedside Trends Medications Time of the day Users of override process Presence of a medication order Barcode scanning of medications removed Override rate 25 Multiple Choice Orders- Low Hanging Fruit Medication orders reviewed for: EP 7: therapeutic duplication»morphine 2 mg IV every 10 min PRN pain»tylenol #3 1 tablet every 4 hours PRN pain EP 11: after review, a concerns, issues, or questions are clarified with the individual prescriber before dispensing

14 Auto-Verification: What is TJC position? Auto-verification is a process that is part of the functionality of some EMR vendors that aows, depending on how it is set up by client, to aow access to medications without a pharmacist review Use of auto-verification in some settings where pharmacist review has been required In conflict with MM EP 1 and not an acceptable alternative to the required RPH review of order 27 MM Pharmacy Preparation of IV admixtures Intent: To move IV admixture preparation out of the nursing unit Consider where IV admixtures might be prepared outside the pharmacy Pharmacy should consider ways to make IV admixtures available when needed without admixture by nurses These are not exceptions: Non 24/7 pharmacies; ORs; off-site clinics

15 MM Emergency Medications Determination of contents Process for ensuring availability Replenishment Separate packaging of pediatric from adult medications in combined cart Ready to administer dosage forms 29 MM Safe dispensing of medications Medications are dispensed in the most ready-toadminister forms commerciay available and, if feasible, in unit doses that have been repackaged by the pharmacy or licensed repackager. (also MM EP10)

16 High Alert Medication Strategies MM How have you defined these? How have you defined strategies for reducing risk? How have you disseminated information about risks and new processes Recommendation: Address the specific risks of each high alert medication on your list 31 Hazardous Medications Requirements are included in MM ; EC , EC , EC , as we as LD, LS, and EM references Need a list! (MM ) Defined by NIOSH - revised 2014 Strategies to protect those who come in contact PPE Other Primary engineering g controls Processes Training

17 Look Alike Sound Alike Medication Strategies (MM ) Consider multiple concentrations of the same medication Have you defined policy on ordering LASAs? Recommendation: Address display of LASA via Taman lettering, use of brands or indications; address storage via restriction, separation, labeling Instruct on how TaMan lettering works 33 Hot Labs- Hot labs What is being done Procedures Non-radiopharmaceuticals Medication storage Storage and security of Radiopharmaceuticals, July 2012 Perspectives Inspection of medication storage Formulary what is being purchased and used?

18 Medication Reconciliation: Focus on Quality NPSG Reconciling Medication Information Components of the Revised Goal Coecting information on the home medications Good faith effort Reconciliation with medications ordered in the hospital Transfer of patient- and reconciliation of medications No longer specificay part of this NPSG Update medications in medical record part of RC and RC Discharge process Provide discharge medication information to patient Added responsibility of patient to maintain list and to communication to PCP No requirement for the hospital to provide list to next provider of care

19 NPSG Reconciling Medication Information Components of the Revised Goal continued Non-24 hour settings Must perform if changes in medications taken at home could occur; or if medications might be given during the encounter Organizations can define the medication information they require to be coected Aows tailoring gprocess for specific settings 37 Points of Error in Medication Reconciliation

20 Performance Improvement Focus The Quality of the Medication List Who should develop the list What can enhance the quality of the list Software Claims data from community pharmacies Interviewing skis Training 39 Performance Improvement Focus The Quality of the Reconciliation Process Clear delineation of accountability Auditing to confirm Involvement of a 2 nd set of eyes to assist in problem identification Clinical decision support/tools

21 Performance Improvement Focus The Development of the Home Medication List at Discharge Clear display of in-hospital and admission home medications for consideration Additional expertise to address home meds not prescribed in house and potential issues with continuing Resources to evaluate potential insurance issues with new medications prescribed 41 Performance Improvement Focus Making sure the patient understands the medications he/she wi take at home Discharge teaching doesn t start 15 minutes before discharge Assessment of patient needs, wiingness to learn Use of supplemental tools to support understanding Teach-back method Clear description of what medications are new, which are being changed or discontinued, and which are staying the same

22 Medication-related Contracted Services Outsourcing to compounding pharmacies TPNs, other compounded sterile admixtures Batch preparations Specialty custom products These services provide care, treatment and services to patients (direct patient care) 43 Contracted Services Expectations: LD Clinical leaders and medical staff have input as to source for outsourced services Written description of scope and nature of outsourced services in contract Expectations for performance provided by hospital according to defined measures provided to provider Performance is monitored Steps taken to correct identified performance problems

23 Joint Commission and Compounding Survey process State requirements Chemotherapy compounding EC EP 9,10 Preventing exposure to hazardous materials EC EP15 Appropriate pressures 45 Joint Commission and Compounding Changes in TJC processes Home Care- in place Hospital- anticipated

24 Antimicrobial Stewardship Presidential Ca to Action CDC recommendations: Joint Commission participation in White House Forum; pledged commitment to promote antimicrobial stewardship activities Field review for new standard on antimicrobial stewardship completed- expect to see in 2016, to be surveyed January, Disclaimer These slides are current as of February 28, The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbay by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent a the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or Joint Commission Resources

25 Questions MEDICATION MANAGEMENT UPDATE Tackling Our Problems To Resolve Them 25

26 Program Objectives Identify the most problematic Medication Management standards in 2015 for our associated facilities Outline areas of focus and issues to be addressed for each of those identified problematic standards Discuss actions to resolve the issues and enhance compliance to the identified problematic standards 51 Most Problematic MM Standards The majority of our MM RFIs were cited at: MM relates to safe storage of medications in compliance with law, regulation and manufacturer s guidelines (EPs 2-8 & 18) MM relates to clear, complete and accurate medication orders to enhance communication between a participants in the medication management process (EPs 1, 3, 6-9, 13 and 15) MM relates to the pharmacist s review of the appropriateness of medication orders for medications that are to be dispensed in the hospital (EPs 1, 8, 13)

27 Historical Perspective MM MM MM Over the past 3 year accreditation cycle, a three of these standards have been problematic for our facilities While there has been dramatic improvement in the outcomes for MM and MM ,but that is not true for MM MM Areas of Focus Special storage conditions Medications in warming cabinets Refrigerated medications Monitoring conditions 24/7 Temperature logs with temperatures out of acceptable range without recorded actions Securing medications from unauthorized access Locking storage areas v. continuous supervision Disposal of controed substances Securing prescription pads 27

28 55 MM Areas of Focus Expired medications Dating multidose containers upon opening Expired medications that remain accessible for administration IV bags removed from overwraps or stored in warmers without revised expiration dates 56 Improving MM Outcomes Ensure your written policy on medication storage addresses a elements of storage Locking v. constant supervision Who may access the locked areas The circumstances under which they may have access Educate staff to revise expiration dates of medications stored in a warming cabinet- foow the manufacturer s guidelines! Review refrigerator temperature logs and provide refresher training when out of range temperatures are recorded without appropriate actions being documented Ensure that Crash Carts are visible at a times, especiay if stored in occupied ED rooms 28

29 MM Areas of Focus Incomplete medication orders Order lacks any of the parameters required by policy (i.e. route of administration, frequency of dosing, etc.) Order includes prohibited abbreviations Weight-based dosing required but not done Not clarified with prescriber prior to medication being dispensed Blanket Resume Orders Medication orders not found in the patient record Undocumented verbal orders Missing protocols MM Areas of Focus Unresolved therapeutic duplication Orders lack selection criteria to guide administration Involves preprinted order sets as we as orders generated by an individual provider Not clarified with prescriber prior to medication being dispensed Titration and Sedation orders Lack specific criteria i for titration (initial iti and/or incremental doses, clinical parameters) Lack sedation goal and/or dosing parameters Not clarified with prescriber prior to medication being dispensed 29

30 Improving MM Outcomes Educate and re-educate a clinical staff involved in the medication management process on a requirements of a complete order Review preprinted order sets to ensure only complete, accurate orders are included Monitor the clarification process to ensure incomplete, inaccurate orders are clarified with the prescriber prior to dispensing the medication Monitor troublesome types of orders (titration, sedation) to ensure criteria for use are included and foowed Provide feedback to prescribers (OPPE?) and those who administer medications on the monitoring results you obtain 59 MM Areas of Focus Pharmacist s review of orders Orders faxed from physician s office and implemented without t pharmacist s review PACU orders not transmitted for pharmacist s review Preprinted order sets and protocols Clarifying orders Incomplete, inaccurate orders not clarified before dispensing A issues not clarified with prescriber before dispensing Confusion over nursing v. pharmacy role in clarification process

31 61 Improving MM Outcomes Educate and re-educate a clinical staff involved in the medication management process on the need for pharmacist s review of orders Review preprinted order sets and protocols with a critical eye to determine any potential unresolved therapeutic duplication issues Work with clinicians who administer medications to promote understanding of the clarification process Orders should be written correctly from the beginning Ideay, nursing can clarify at the time of issuance But, remember the final responsibility for clarification rests with the dispensing pharmacist Resolve these issues To ensure a successful survey outcome!

32 63 Update on Current tph Pharmacy Initiatives and Strategies Jerry H. Reed, MS, RPh, FASCP, FASHP Corporate Director, Pharmacy Operations Community Health Systems

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34 A Checklist for Safe Use of Medication Samples Proactively identify your organization s approach to medication samples. If you decide to aow the use of medication samples, determine the foowing: For which types of patients? On a trial basis or for chronic use? Which medications? Wi you accept controed substance medication samples? Define control over medication samples. Identify a secure location, with authorized access only. Determine who wi receive samples. Determine who wi log in samples. Determine who wi maintain the sample location, remove and properly dispose of expired medications, and oversee recaed medications. Review state laws to determine who is authorized to dispense sample medications to the patient. Review the list of aowed medication samples for compliance with the foowing: Look-alike, sound-alike medication process, if appropriate High-alert or hazardous medication process, if appropriate Applicability for weight-based dosing in pediatric patients Include the foowing in the decision to provide a patient with a sample medication: Document in the patient s medical record. Properly label the sample. Take steps to ensure no contraindications, interactions, duplications, or patient-specific variables that might affect prescribing (check with the pharmacist). Log dispensing in sample medication log book. Provide information to the patient about the medication and its proper use. Consider providing the patient with a prescription for subsequent refis, with instructions. Consider formalizing medication sample decisions for your practice site with a policy. Educate staff and pharmaceutical representatives on these policy decisions