Review for Required Monitors

Transcription

1 Review for Required Monitors The Joint Commission Hospital Accreditation Manual, 2009 Medicare Conditions of Participation, Hospitals Update: February 2009 Indicator / Monitor Restraint, Medical (non-specific requirement. For example, prevalence, use of various methods, etc., however, specific requirements about data collection, measurement, data display, evaluation and actions) [PC EPs.1-11] Restraint, Behavioral, in behavioral health care environment only (specific data elements: data collection, measurement, data display, evaluation and actions required) [PC EP.2, 6, 7, 8, 9,10] Seclusion. Must be measured in all areas (specific data elements: data collection, measurement, data display, evaluation and actions) required for behavioral health care setting [PC EP.2, 6, 7, 8, 9,10] Behavior management and treatment [PI EP.12] Critical value / result reporting, from availability to practitioner [PSG EP.5] Critical test processing, from order to result [PSG EP5] Clinical practice guidelines, practitioner variation (if guidelines are used) [LD EP.5] A A A A 2009 The Greeley Company, A Division of HCPro, Inc. 1

2 Appropriateness of clinical practice patterns and significant departures from established patterns of practice [MS EP.7 and EP.8] Anticoagulation program data [PSG EP.9 / MM EP.1-9] Prevention of Multi-Drug Resistant Organism data [PSG EP 9]*effective 2010 Prevention of Central Line Associated Blood Stream Infection data [PSG EP 9]*effective 2010 Prevention of Surgical Site Infection data [PSG EP 9 & 10]*effective 2010 Utility and effectiveness of the Rapid Response program [PSG EP.7] Cardiopulmonary arrest rate [PSG EP 6/PI EP 11] Respiratory arrest rate [PSG EP 6/PI EP 11] Resuscitation outcomes [PI EP.11, LD , EP. 2] Mortality rate [PSG EP 6] Patient satisfaction [PI EP.16] Culture of safety [LD EPs.1 & 2] A 2009 The Greeley Company, A Division of HCPro, Inc. 2

3 Patient safety data with annual reporting to the governing body [MS EP.11, LD EP.13] Sentinel event data [MS EP.10, PI EPs 1-4] Blood and blood product use [PI EP.7, MS EP.5] Operative and other invasive procedures [PI EP.4 MS EP 6, LD EP. 2] Medication management, non-specific, usually includes medication errors, adverse drug reactions and other risk points based on an evaluation of the medication management system. [PI EP.15 &15/MM EP. 1-9] Medication use [PI EP.1-4/MS EP.4] Serious adverse drug events [PI EP.15] Significant medication errors [PI EP 14] Confirmed transfusion reactions [PI EP 8] Infection control surveillance and reporting [IC EP.3] Quality control [WT EP 1-5] Use of developed criteria for Autopsies [MS EP.9] 2009 The Greeley Company, A Division of HCPro, Inc. 3

4 Organ procurement effectiveness [PI EP.7] ORX indicators [APR EP.11] Grievance data (for example, frequency, type, individual issues) [42CFR (a)(2) (Interpretive Guideline)] [RI EP.4 & 17] Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use [PI EP.6] Major discrepancies between preoperative and postoperative diagnosis [PI EP.5] Information received from / reported to the hospital s Quality Improvement Organization [42CFR (b)(1)] LD EP.6 Performance Improvement Projects 42CFR (d) LD EP. 5-7 Environmental occurrences, [EC EP 1] and related EPs: injuries to pts or others, EP.3, occupational illnesses EP.4, property damage EP.5, security incidents EP.6, hazardous materials / waste spills / exposures EP.8, fire-safety management problems EP.9, equipmentmanagement problems EP.10, utilities systems management problems EP.11 Opportunities to improve the environment of care [EC EP.1] 2009 The Greeley Company, A Division of HCPro, Inc. 4

5 Monitors for each environment of care plan: safety, security, hazardous materials and waste, emergency management, fire safety, medical equipment, and utilities [EC EP.1] Human resource indicators (e.g. hours per patient day, overtime, agency use) [PI EP.4] Quality of history and physical examinations [MS EP.7] Medical Assessment and Treatment of patients [MS EP 2, PI EP 1-4] Concurrent medical records indicators, including readability / legibility and other factors [RC EP 1, MS EP.3] Medical records delinquency rate [RC EP 3 & 4, MS EP.3 ] Available supply of patient bed space [LD EP.5] Service Efficiency [LD EP 5] Falls incidence, severity and fall-related injuries (implied) [PSG EP.6] Sentinel Events [LD EP.11, PI , EP1] Monitors for the risk reduction strategies employed as a result of a sentinel event root cause analysis. [LD EP.13] Monitors for the effectiveness of redesigned processes as a result of failure mode effects analyses (FMEA). [LD EP.10] A 2009 The Greeley Company, A Division of HCPro, Inc. 5

6 Performance of contract services. (Indicators are not necessarily required, but some form of evaluation against established expectations must be documented). [LD EP. 4-6] Staffing Effectiveness Indicators [PI EP.1-10] 2009 The Greeley Company, A Division of HCPro, Inc. 6