2017 Pharmacy Education Series

Transcription

1 Providing Continuing Education For Healthcare Professionals 2017 Pharmacy Education Series Featured Speaker: Kurt A. Patton, MS, RPh President Emeritus Patton Healthcare Consulting, LLC April 27, 2017 Joint Commission Update 2017 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 Webinar attendees will also receive an with a direct link to the web page Print your CE statement of completion online Credit for live or enduring (not both) Deadline: May 26, 2017 CPE Monitor (applicable to pharmacists) CE credit automatically uploaded to NABP/CPE Monitor upon completion of post test and evaluation (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 Update on Current Pharmacy Initiatives and Strategies Robert Fink, Pharm.D., MBA, FACHE, FASHP, BCNSP, BCPS VP Ancillary Services & Chief Pharmacy Executive QUORUM Health 5 Providing Continuing Education For Healthcare Professionals Featured Speaker: Kurt A. Patton, MS, RPh President Emeritus Patton Healthcare Consulting, LLC April 27, 2017 Joint Commission Update 2017 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. Mr. Patton has served as a consultant for Patton Healthcare Consulting. 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

4 CE Activity Information & Accreditation (Pharmacist) 2.0 contact hours Funding: This activity is self funded through Quorum Health. 7 Joint Commission Update 2017 Kurt A Patton Patton Healthcare Consulting, Inc

5 New TJC Scoring System All surveys beginning 1/1/17 now use a new risk assessment methodology to score standards. No A or C elements, no direct or indirect Two variables will be considered. How wide spread is the defect? How critical, how important is the defect? Examples: 1 paper medical record entry missing a time. All endoscopes improperly processed 9 Project Refresh Onsite SAFER Matrix Survey Analysis for Evaluating Risk (SAFER) Matrix Help you prioritize Visual on report Can sort & filter Scope

6 How Will Surveyors Assign Risk Surveyor experience and expertise based on scope and likelihood to harm Talking amongst the team Impact of risk assignment: Guldens mustard color and red will require coaching session with TJC leadership and additional content on leadership involvement and sustainability in ESC. As of 3/20/17 26% of findings are red or dark mustard color. 11 What Might Be Red in Medication Management? The most difficult and complex medication issue on surveys today - improper medication titration in the ICU setting. Nurses practicing outside the scope of licensure Protocols not in the chart or not referenced Incremental dose missing from the order Assessment criteria missing from the order Failure to assess How and where this gets scored is very diverse so this does not show in stats published by TJC

7 Why Do Surveyors Like to Score the MM Chapter? It s objective: you did it or you did not. TJC shares lots of medication safety information with surveyors including the ISMP newsletter. Compare with the more subjective PC standards regarding the quality of a history and physical or the accuracy of a pre-sedation assessment. TJC does not perform peer review. 13 The Most Problematic MM Standard Today

8 MM Seems Easy, But it is Not and it may be Red The most problematic standard today. The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use. This includes, PRN, standing orders, titration orders, taper orders, range orders, etc. Hospitals did not specify enough order details so TJC has posted an FAQ with the minimum requirements. 15 Titration Order Minimum Elements Medication name Medication route Initial or starting rate of infusion Incremental rate the infusion can be increased or decreased Frequency of rate adjustments Maximum rate of infusion Objective clinical endpoint, RASS, BP, etc

9 Sedation Titration Example Propofol 5-50 mcg/kg/min, start at 5 mcg and increase by 5 mcg every 5 minutes to a maximum dose of 50 mcg/kg/min to achieve a RASS of -3. If this is in a structured order set in an EMR or a paper order form, practitioners don t need to remember all the required order details. If you allow ad hoc EMR or paper orders you are likely to have many gaps requiring clarification. 17 Sedation Titration Pitfalls The order is written well, but the hospital policy is to document a RASS every 2 or 4 hours. You will not have documentation that an adjustment was needed. You will not have documentation that the adjustment reached the therapeutic endpoint. You need an assessment of RASS to adjust the dose, and you need a reassessment of RASS after that adjustment

10 More Sedation Titration Pitfalls If the order is written well, and the nurses are diligent about documenting RASS But the patient has a head injury creating a level of sedation greater than the RASS goal The patient has pain and nursing staff want to adjust propofol. The patient is on a paralytic The patient has a second drip, e.g., fentanyl or Versed The staff are having difficulty maintaining a systolic BP The patient is having ventilator asynchrony 19 Sedation Titration Solutions Use a structured order set, not a secondary document as a reference with the order details. Modify the RASS target or therapeutic endpoint for head injury patients. Discuss patient management with the ICU nurses and physicians to document how to manage SBP, ventilator asynchrony, pain, use of paralytics

11 Sedation Titration Survey Follow up Simple RFI, document in ESC how you fixed it and sound convincing, easy. If survey outcome is AFS, PDA or MM Medicare condition out, document in ESC how you fixed it and sound convincing, but TJC surveyors are coming back to validate and you must be 100% compliant, all titrations all charts - and this is hugely different. MM Condition out less than 45 days PDA you have about 60 days AFS you have about 4 months to make it perfect. 21 Sedation Titration, Real Example of Survey Disaster Full survey, hospital cited for improperly written and documented sedation titrations. Survey outcome AFS ESC submitted said a titration protocol was prepared for nursing staff with instructions on how to titrate sedating agents. AFS follow up survey conducted, nursing staff interviewed and replied: we just use our clinical judgment. Accreditation status changed to PDA, hospital now decides to develop detailed order sets in EMR

12 Other Frequently Scored MM Standards 23 MM High Alert EP 1: The hospital identifies in writing its high alert and hazardous medications. The hazardous list is often missing. TJC does not mean dangerous, they mean hazardous just like NIOSH. This was moved from EC to MM a decade ago and still often missing

13 MM LASA EP 3: The hospital annually reviews its list of LASA medications. Date the list? You incentivize the surveyor to drill down if your list is undated. Need to find reauthorization in minutes. You get no credit if its 2 years old. Staff on the units need to be able to find the list. Write your enhanced safety strategies describing what you do and where you do it. If hospital practices vary, mention it, e.g. these strategies occur in the pharmacy itself, while these are required for nursing, etc. 25 Frequently Scored, but Much Easier to Manage MM Medication storage temperatures Paper logs gaps and failure to act on out of range conditions is the problem Automated data loggers failure to document actions taken is the problem Failure to document what happened over the weekend in a 5 day/week clinic Failure to document vaccine storage per CDC Data loggers required, no dorm refrigerators. Failure to track or document fluid and contrast warmer storage conditions and shortened expiration dating

14 MM Medication Security Non controlled drugs can be secured by supervision or locking Your hospital sets the standard for noncontrolled drug security. You identify those authorized. If you say licensed professionals only, TJC holds you to that. No materials management or central sterile supply delivery of IV fluids No unlocked storage in a clean utility room on the floor 27 MM Medication Security If you say the area is secure, but the surveyor walks in and there are no staff around If you say the OR is secure, but the surveyor walks in and only the housekeeper is present cleaning up after a case and there are medications present. Crash carts in areas not open 24/7 and supervised must be placed in locked storage when closed

15 MM Medication Security New Spin 2017 Pharmaceutical waste and sharps bins in nonsecure locations like a dirty utility room, or in a pick up cart in the hallway, or on the back loading dock, and even in the OR with the housekeeper. 29 MM Medication Expiration EP 7: All meds are labeled with contents and an expiration date. MDV not a date opened, an expiration date Short stability meds like propofol need a time of expiration even from anesthesia Warmers not a date placed, an expiration date Remember the One and Only campaign: If a MDV has been brought into a procedure room is becomes an SDV and any residual is discarded after the procedure

16 MM Emergency Medications EP 3: Whenever possible, emergency medications are available in unit-dose, age specific, and ready to administer form. Magnesium sulfate is often stocked 1G/2 ml Broselow tape for 3-4 Kg infants calls for doses 150mg, 225 mg Can staff in a crisis situation easily calculate the volume of magnesium sulfate to administer? Test your own ED staff, but consider a volume table as an aide. 31 MM Medication Orders EP 13: The hospital implements its policies for medication orders. A PRN without indication An unclear order not clarified A range order not adherent to your policy TJC does not prohibit range orders, but it would be easier if they did. Consistency in application is the problem. Go and interview 10 nurses and check the documentation in the record

17 MM Minutiae and Gotcha s EP 7: The hospital reviews and updates preprinted order sheets EP 15: Processes for the use of preprinted and electronic standing orders, order sets and protocols include: 4 bullet points that only reference standing orders and protocols. Regular review by medical, nursing, pharmacy leadership. CMS tag A-0457 is clearer that basic order sets do not require this 3 department approval. However EP 7 above does call for the hospital to be involved in approval. 33 Ambiguous Definitions Suggestion: Order sets basic preprinted or electronic orders that a physician will make selections from individually or in its entirety. Standing order an order that authorizes a nurse to administer a medication prior to a physician actually writing that order. Protocol details about medication dosing or administration not included in the body of the order

18 MM Pharmacist Review of Orders EP 1: Pharmacist reviews the new order prior to administration, unless LIP control. Exemptions: ED, radiology if radiologist is present to intervene and urgent situations anywhere in the hospital. What do you do in PACU and outpatient clinics? EP 8: Pharmacist reviews for therapeutic duplication. *** Duplicative PRN analgesics, antiemetic's Advice: stratify your order sets Analyze your interventions; ID root cause and fix 35 MM EP 8 Complication The order is written well with all the details such as Tylenol for mild pain, Percocet for moderate pain and Dilaudid for severe pain. The patient with a pain of 9 requests Percocet instead of Dilaudid because they don t want. New FAQ, you can do it if approved in policy The patient with a pain of 3 requests Dilaudid because they just saw the physical therapist walk down the hallway and they know their pain will spike during therapy. You can t do it

19 MM IV Preparation TJC hospital surveyors are not expert in all things relative to USP 797. Over time they may gain knowledge from their colleagues performing the new Medication Compounding certification or these standards. They are very familiar with specialized air pressures and may carry a vaneometer. If you have wall meters, be ready and able to discuss what those meters are measuring. 37 MM IV Preparation EP 2: Staff use clean or sterile techniques and maintain clean, uncluttered, and functionally separate areas for product preparation to avoid contamination. Surveyors readily ID filth, clutter and too close a proximity to sinks in medication rooms. Sometimes pill crushers and tablet splitters are the problem. Make these patient specific with patient labels

20 MM Self Administration Seldom scored, except in the sleep lab. Policies are often well written for the inpatient units describing pharmacist verification of the patients own medication and a specific physician order to self administer or use own medication. Sleep labs routinely advise patients to bring their medications and to self administer before going to bed. Suggestion: Define your policy for inpatients only. 39 MM Errors and ADR s Often a topic of discussion at the MM System Tracer. Bring your data Describe your actions in response Describe your actions to increase ADR reporting Only scored if there is failure to act, failure to analyze, failure to try and enhance ADR reporting

21 MM PI FOR MM 7 Elements of performance stating you collect information, you analyze it, you compare over time, you review best practices in the literature and you take action. Consider an annual report addressing each of these elements. You may be able to scramble and piece it together, but prepared is always better. 41 MM Antibiotic Stewardship Nicely written new set of requirements, 1 standard, 8 elements of performance. Consistent with CDC and NQF guidance Survey process design is about the best seen for any new requirements. ASP designed to be explored in 6 different survey sessions. Patient tracers, competence assessment session, medical staff, data management system tracer, MM system tracer, leadership

22 ASP EP 1 Leadership has identified ASP as an organizational priority. Accountability documents Budget plans IC plans PI plans Strategic plans EMR used to collect ASP data 43 ASP EP 2 The hospital educates staff, and LIP s involved in ordering, dispensing, administration and monitoring about antimicrobial resistance and ASP practices. Upon hire and periodically. You are going to want some evidence this was done, even though this is not a D element

23 ASP EP 3 The hospital educates patients and their families as needed, regarding appropriate use of antimicrobials. TJC suggests CDC document: Suggest using EMR patient teaching logs even though there is no D. Surveyors may interview patients or families of patients being discharged on antibiotics. 45 ASP EP 4 The hospital has an ASP team that includes: ID physician ICP Pharmacist Practitioner Part time, consultants and telehealth are all acceptable

24 ASP EP 5 The ASP includes core elements:(same as CDC) Leadership commitment Accountability (single leader) Drug expertise Action Tracking Reporting Education What are you going to show to TJC to convince them you have all these elements? D for documentation This document is requirement #49 in Day one document list. 47 ASP EP 6 The hospitals ASP uses organization approved multidisciplinary protocols. Examples: Formulary restrictions Community acquired pneumonia Skin and soft tissue infections UTI infections C. diff care Appropriate use in pediatrics Parenteral to oral conversion Preauthorization Use of prophylaxis D for documentation be ready to discuss and show at MM system tracer session

25 ASP EP 7 The hospital collects, analyzes and reports data on its ASP. D for documentation Be prepared to discuss and show at the data use system tracer and potentially MM system tracer. 49 ASP EP 8 The hospital takes action on improvement opportunities identified in its ASP. Be careful how you word minutes of meetings, don t point fingers. Get it done, don t whine Be ready to discuss accomplishments in MM system tracer. Provide leadership some bullet points in the event this is asked at the leadership session

26 ASP Conclusion Meticulously written requirements, consistent with other expert groups. Superb survey process written for surveyors for these new standards. So far in 2017, not seeing scoring on this issue. May be due to surveyor training, may be due to newness Be prepared to pro-actively discuss if you have accomplishments at MM, Data. 51 NPSG.03 Label medications in procedural settings. The OR usually does this well Surveyors look in outpatient procedural settings, bedside procedures and ED procedures. No one can be compliant if you don t give them the tools to be compliant sterile labels in procedure kits. Try to convince anesthesia that even propofol needs a label. Try to convince radiology that contrast and saline in a power injector needs a label. PS the saline is single dose, the contrast if manufactured, labeled and used appropriately may be MDV. This safety goals is scored way too often and it will be red

27 NPSG.03 Anticoagulation safety goal, seldom scored today. Sometimes EP 2: Use approved protocols for the initiation and maintenance of anticoagulants. You want to be able to say: yes we have protocols and here they are If the protocol is used by an LIP to aide in decision making the protocol does not need to be in the chart. PC Top 10, 46% of hospitals getting hit for failure to include the protocol used by a dependent practitioner in the EMR. If the protocol is used by a dependent practitioner, a copy of the protocol must be in the chart. Not easy to do with most EMR s 53 NPSG.03 Medication reconciliation: Seldom scored today. Sometimes EP 3: Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies. Many times staff during a tracer are unable to display the end result of med rec drug by drug. I reconciled button is a problem Errors of omission are a problem User security and viewing is a problem

28 D for Documentation The MM chapter has 24 elements of performance identified as D. Do you really have 24 policy statements addressing all these EP s? Remember a written policy is different from our practice, or usually we.. If you think you do, congratulations, you will be the first I have encountered. 55 Obscure D MM : The hospital has a written policy addressing the control of medication between receipt by the individual healthcare provider and administration of the medication, including safe storage, handling, security, disposition and return to storage. Can a nurse or respiratory therapist take multiple patient doses out of an ADC at one time? If they do, where may it be stored until administered? If it is not administered, how can they return it to stock and cancel the transaction? Can an anesthesiologist carry sedating agents from the OR, down to MRI to help sedate a patient? How do they carry it? If they inadvertently carry it out of the hospital, can it be returned to stock? What if it was in their car trunk? What if it is a controlled drug?

29 D with an Invisible Component MM , EP 2: The hospital has a written policy that defines the required elements of a complete medication order. You probably have this one, but Day one document list #46 says you must make this policy available and include your definition of therapeutic duplication. 57 Preparing for the MM System Tracer Plan for a conference room, but the surveyor may surprise you and want to go trace a patient with you. Come prepared and bring that which is good about your practices and be prepared to discuss. Take the initiative. Come prepared to discuss, defend, prevent potential findings you have heard about from the morning briefings. Everyone invited should come prepared, knowing what they are invited to talk about

30 Examples for the MM System Tracer If ASP is significant, do show and tell If you did an annual report for MM.08 Bring your medication error data and be sure to include good catches that never reach the patient. Bring your ADR data Bring your interventions data Coach and rehearse what to say with your planned attendees TJC looks to you for MM leadership throughout the hospital, not just within the 4 walls of the pharmacy. 59 Questions? Kurt@Pattonhc.com To review past monthly newsletters, or to subscribe go to: