2018 Pharmacy Education Series

Transcription

1 2018 Pharmacy Education Series February 21, Joint Commission Update Featured Speakers: Patricia C. Kienle, RPh, MPA, FASHP Director, Accreditation & Medication Safety Cardinal Health Innovative Delivery Solutions Jacqueline E. Moran, RN, CPHQ Senior Director of Survey Management Community Health Systems Lisa Stefanov, RN, MSN, CPHQ Director of Survey Management Community Health Systems Online Evaluation, Self-Assessment and CE Credit Submission of an online post test and evaluation is the only way to obtain CE credit for this webinar Go to Print your CE statement of completion online Credit for live or enduring (not both) Deadline: March 23, 2018 Pharmacists and Pharmacy Technicians: CE credit uploaded to CPE Monitor User must complete the claim credit step Attendance Code Code will 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 orange arrow button to open menu box Type question into question box Click Send Do not close menu box This will disconnect you from the Webcast Please submit questions throughout presentation Enter question Click No! Click 3 Accessing PDF Handout No! Click the hyperlink that is located directly above the question box Do not close menu box This will disconnect you from the Webcast Click hyperlink 4 2

3 February 21, Pharmacy 2018 Joint Commission Education Update Series Featured Speakers: Patricia C. Kienle, RPh, MPA, FASHP Director, Accreditation & Medication Safety Cardinal Health Innovative Delivery Solutions Jacqueline E. Moran, RN, CPHQ Senior Director of Survey Management Community Health Systems Lisa Stefanov, RN, MSN, CPHQ Director of Survey Management Community Health Systems It is the policy of to ensure balance, independence, objectivity and scientific rigor in all 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. Ms. Kienle is an employee and stockholder of Cardinal Health, has served as an author for ASHP, is a committee member for USP, and is a speaker for Critical Point. Ms. Moran has no relevant commercial or financial relationships to disclose. Ms. Stefanov has no relevant commercial 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 and Pharmacy Technician CE) This CE activity is jointly provided by and CHSPSC, LLC. ProCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number L03 P/T has been assigned to this knowledge based live CE activity (initial release date ). This CE activity is approved for 2.0 contact hours (0.2 CEU) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Successful completion of the online post test and evaluation at is required to receive CE credit. CE credit will be uploaded to NABP/CPE Monitor. No partial credit will be given. Funding: This activity is self funded through CHSPSC

4 2018 Joint Commission Update PATRICIA C. KIENLE, RPH, MPA, FASHP 7 Disclosure Patricia Kienle is an employee of Cardinal Health She is a member of the USP Compounding Expert Committee, but this presentation is not affiliated with or endorsed by USP 8 4

5 Learning Objectives - Pharmacists State the top four types of non-compliant medication issues Identify the medication-related contracted services that require leadership approval Explain the difference among protocols, order sets, and standing orders State the top five citations identified during compounding certifications Cite the pharmacy-related issues in the Antibiotic Stewardship standards 9 Learning Objectives - Technicians State the three criteria for storage of medications State the type of expectations a hospital should have when using outsourced compounders Explain the difference among protocols, order sets, and standing orders State the top five citations identified during compounding certifications

6 CMS Conditions of Participation Regulatory requirements are based on the Centers for Medicare and Medicaid Services Hospital Conditions of Participation Available at and- Guidance/Guidance/Manuals/downloads/som107 ap_a_hospitals.pdf Pharmaceutical Services Joint Commission and AOA/HFAP are deemed by CMS for hospital certification 11 Most Challenging HFAP Standards Standard Topic TJC Standards Contractor Quality Contracted Clinical Services Monitoring Medical Staff Bylaws Medication Management Infection Control Sterile Compounding Medical Errors and Adverse Events Preparation and Administration of Drugs Medication Errors, ADRs, and Incompatibilities Medication Management 2017 HFAP Quality Report

7 Most Challenging MM Standards Standard Topic % Non-Compliant MM Med Orders 49% MM Med Storage 48% MM Review of Orders 15% MM Safe Med Preparation 14% NPSG Med Labeling 9% MM Med Labeling 3% MM Emergency Meds 8% NPSG Med Reconciliation 7% The Source, November Environment of Care Emergency power Backup Essential medication equipment Refrigeration

8 Medication Orders Big issue: clarity Differentiate Order Sets Protocols Standing Orders 15 What s the Difference? Type of Document Order Set Protocol Standing Order Description List from which a practitioner can choose Treatment plan for patient who meets the criteria Order(s) that may be initiated prior to LIP assessment if the patient meets certain criteria

9 The Big Problem: EP 13 One element of performance causes the most citations MM , EP 13: The hospital implements its policies for medication orders Problems: Unclear and incomplete Range orders Titration orders 17 Approval CMS Conditions of Participation Approval by medical staff committee, pharmacy, and nursing Review and update and defined frequency Must be consistent with national guidelines

10 It s Not Just Critical Care Imaging Including Nuclear Medicine Dialysis Obstetrics Any area where these type of orders are used 19 Be Sure to Include Orders must be part of the patient s medical record Avoid opportunities for therapeutic duplication Be sure titrate orders are clear

11 Storage of Medications Secure Safe Integrity Protected 21 Controlled Substances Security and control of containers as they move through the organization Patient care areas Procedural areas Storage of full containers Waste disposal systems that deactivate drug substances

12 Control Between Dispensing and Administration Updated EP 4 in MM Control including safe storage, handling, wasting, security, disposition, and return to storage Define specifics in policy All controlled substances must have wastage documented 23 Anti-Diversion Strategies ASHP Guidelines on Preventing Diversion of Controlled Substances Published in AJHP

13 Common Storage Issues Insulin and other multiple dose vials Follow CDC Safe Practices rs/provider_faqs_multivials.html Refrigerators, freezers, and warmers Temperature monitoring Action when out of range 25 Review of Orders ADC overrides: NEW MM , EP 16 Effective January 1, 2018 When automatic dispensing cabinets (ADCs) are used, the hospital has a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews 100% review of overrides is not required Review all overrides for valid order

14 Compounding CMS Conditions of Participation USP Chapters State Board inspections 27 CMS Survey Letter Pharmaceutical Services: Revisions made to CoP to bring them into alignment with current accepted standards of practice including: accepted professional pharmacy principles, including United States Pharmacopeia (USP) standards; compounding of medications, particularly compounded sterile preparations (CSPs); determining beyond-use dates (BUDs) Preparing CSPs Outside of the Pharmacy: clarify that hospitals must ensure staff adherence to accepted standards of practice in those limited instances when CSPs may be prepared outside of the pharmacy

15 Contracted Services CMS (e) LD Care, treatment and services provided through contractual agreement are provided safely and effectively Leadership Approves all contractual agreements Monitors contractual services Establishes and communicates expectations Takes action to improve services that don t meet expectations 29 Contracted Clinical Services Nuclear pharmacy Remote order entry Medication Therapy Management (MTM) services Compounding pharmacy services Pharmacy management Any other clinical service outsourced to outside vendor

16 Immediate Use For urgent use Not convenience Not scheduled cases Distance from compounding site doesn t matter Clean, uncluttered, functionally separate area for preparation 31 Mixing on Patient Care Units What do your areas look like?

17 TJC Compounding Certification Hospital accreditation MM Home Care accreditation Medication Compounding standard as of January 1, 2018 Certification differs from accreditation Compounding certification Michigan Organizations approved by Board of Pharmacy 33 Top Non-Compliant Compounding Standards Standard % Non-Compliant MDCS.01 Work practices and environment consistent 60% with low-medium-, and high-risk levels MDCS.08 Written policies and procedures for 47% environmental quality control MDCS.12 Hand hygiene 47% MDCS.13 Staff follow cleaning and disinfecting 47% practices MDCS.10 Integrity of the compounding area, handling 41% CSPs, and use of protective equipment The Joint Commission Perspectives, September

18 Top Non-Compliant Compounding Standards Standard MDCED.05 % Non-Compliant Education and training in aseptic technique 33% includes demonstration of competency MDCGR.02 Definition of compounding staff responsibilities 30% MDCSN.03 MDCGR.01 MDCED.04 Policies and procedures for hazardous compounding Leaders responsible for safety and quality of care Education and training includes equipment competency 22% 15% 15% MDCS.03 Manipulation, workflow, and storage of singleand multiple-dose vials 15% 35 Labeling

19 Emergency Medication Containers Code carts Malignant hyperthermia carts/kits Reaction kits Anything you define as an emergency supply Anything marked emergency or similar 37 Consistency of Policy and Procedures Seal Log List of contents Overseen by pharmacy

20 NEW Broselow Tape 39 Antimicrobial Stewardship Required members of oversight committee Infectious disease physician Infection preventionist Pharmacist Practitioner

21 Pain Management Not MM standards Leadership individual or team Medical Staff participation Provision of Care define criteria and provide patient education Performance Improvement data, analysis, and monitoring 41 Tracers List the key elements Develop a form Use it to trace processes Compare Standards Policies What actually happens

22 2018 MEDICATION MANAGEMENT UPDATE Tackling Our Problems To Resolve Them 43 Program Objectives By the end of this presentation, attendees will be able to: Identify our most common TJC citations related to medications and their management Articulate successful strategies to address citations

23 Historical Perspective In January 2017, TJC dramatically changed the survey process rendering numerical comparisons with prior years meaningless Each single observation is cited and may be cited at multiple chapters/standards Historically, our most frequently cited medication-related standards are: MM , MM and MM For 2017, our most frequently cited medication-related standards are MM , MM and PC MM Outlines the requirements for safe storage of medications in compliance with law, regulation and manufacturer s guidelines (EPs 2-9 & 18)

24 MM Areas of Focus Preventing unauthorized access to meds Locking cabinets Mobile carts not being observed Special storage conditions Medications/contrast media in warming cabinets Refrigerated medications Monitoring conditions 24/7 Temperatures out of acceptable range without recorded actions 47 MM Areas of Focus Expired medications Dating multidose containers upon opening Expired medications that remain accessible for administration IV bags removed from plastic stored in warmers without revised expiration dates overwraps or

25 Improving MM Outcomes Educate staff to revise expiration dates of medications stored in a warming cabinet Follow the manufacturer s guidelines! Post manufacturer s guidelines at the storage location Review refrigerator temperature logs routinely Provide refresher training when out of range temperatures are recorded without appropriate actions being documented 49 MM Outlines requirements to have clear, complete and accurate medication orders in order to enhance communication between all participants in the medication management process (EPs 1-14 and 21)

26 MM Areas of Focus Incomplete medication orders Incomplete titration orders Order lacks any of the parameters required by policy (i.e. route of administration, frequency of dosing, etc.) Not clarified with prescriber prior to medication being dispensed Medication orders not found in the patient record Undocumented verbal orders Missing full protocols 51 MM Areas of Focus Unresolved therapeutic duplication Orders lack selection criteria to guide administration Involves preprinted order sets as well as orders generated by an individual provider Not clarified with prescriber prior to medication being dispensed Titration and Sedation orders Lack specific criteria for titration (initial and/or incremental doses, clinical parameters) Lack sedation goal and/or dosing parameters Not clarified with prescriber prior to medication being dispensed

27 Improving MM Outcomes Establish process for clarification is it nursing or pharmacy? Educate and re-educate all clinical staff on all requirements of a complete order & clarification process Review preprinted order sets to ensure only complete, accurate orders are included Monitor problematic orders (titration, sedation) to ensure completeness and provide feedback to prescribers (OPPE?) and those who administer medications on the monitoring results you obtain 53 PC Outlines the requirement to provide care, including medication administration, in compliance with the most current orders from a licensed independent practitioner; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. (EPs 1, 7 and 20)

28 PC Areas of Focus Titration orders not followed as written Sedation orders Pitocin orders Pain Meds not given as ordered Medication given without an order Pharmacy changed order without completing clarification Med ordered for one indication but given for another Referenced protocol not on medical record Order set with all pre-checked orders, no evidence physician deleted inappropriate orders 55 Improving PC Outcomes Educate all providers and staff of the need to have current, appropriate medication orders for any medication administered Re-educate staff on the potential impact of administering medications without an LIP order Review records to ensure any order to follow a protocol results in a copy of the full protocol being added to the record Monitor, then close the feedback loop to ensure all staff are aware of needs to improve

29 Resolve these issues To ensure a successful survey outcome!