Joint Commission Resources Quality & Safety Network (JCRQSN)

Quality & Safety Network (JCRQSN) Resource Guide The CMS Patient Safety Initiative: Discharge Planning, Infection Control, and Quality Assessment & Performance Improvement (QAPI) September 25, 2014

About Joint Commission Resources Joint Commission Resources (JCR) is a client-focused, expert resource for healthcare organizations. It partners with these organizations, providing consulting services, educational services and publications to assist in improving the quality, safety, and efficiency of healthcare services, and to assist in meeting the accreditation standards of The Joint Commission. JCR is a subsidiary of The Joint Commission, but provides services independently and confidentially, disclosing no information about its clients to The Joint Commission or others. Visit our web site at: www.jcrinc.com. Disclaimers Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The information in this Resource Guide has been compiled for educational purposes only and does not constitute any product, service, or process endorsement by The Joint Commission or organizations collaborating with The Joint Commission in the content of these programs. NOTE: Interactivation Health Networks is the distributor of the Joint Commission Resources Quality & Safety Network series and has no influence on the content of the series. 2014 Joint Commission Resources. The purchaser of this educational package is granted limited rights to photocopy this Resource Guide for internal educational use only. All other rights reserved. Requests for permission to make copies of this publication for any use not covered by these limited rights should be made in writing to: Department of Education Programs, Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. 2014 Joint Commission Resources 2 of 46

TABLE OF CONTENTS Program Summary...4 Program Outline...5 Continuing Education (CE) Credit...6 Faculty Slides: The CMS Patient Safety Initiative (PSI) Pilot Worksheets...7 Excerpts from the PSI Discharge Planning Worksheet...17 Excerpts from the PSI Infection Control Worksheet...28 Excerpts from the PSI Quality Assessment & Performance Improvement (QAPI) Worksheet...30 Appendix A: Additional Resources...40 Appendix B: Faculty Biography...41 Appendix C: Continuing Education (CE) Accrediting Bodies...42 Appendix D: Discipline Codes Instructions...43 Appendix E: Post-Test...44 Appendix F: JCRQSN Contact Information...46 2014 Joint Commission Resources 3 of 46

Program Summary This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents and Program Outline for a detailed list of the topics covered. The information included in this Resource Guide is intended to support but not duplicate the video presentation content. There may be additional information available online for this topic. Program Description The Centers for Medicare & Medicaid Services (CMS) continues to test three revised surveyor worksheets for assessing compliance with three hospital Conditions of Participation (CoPs): Infection Control, Discharge Planning, and Quality Assessment & Performance Improvement (QAPI). This new Patient Safety Initiative (PSI) is meant to focus on compliance with these CoPs as a means to reduce hospital-acquired conditions (HACs), including healthcare-associated infections (HAIs) and preventable readmissions. Through expert panel discussion and mock survey examples, this live, 60-minute program provides information that can help hospitals better understand these worksheets and the PSI as a whole. Program Objectives After completing this activity, the participant should be able to: 1. Describe the PSI pilot. 2. Describe the goals of the PSI pilot. 3. Describe CMS's survey process specific to the PSI pilot. Target Audience This activity is relevant to all healthcare leaders, the entire hospital and medical staff, risk management professionals, performance improvement (PI) directors/joint Commission coordinators, and nurse managers/directors. 2014 Joint Commission Resources 4 of 46

Program Outline The CMS Patient Safety Initiative: Discharge Planning, Infection Control, and Quality Assessment & Performance Improvement (QAPI) September 25, 2014 I. Introduction A. Program Content B. Objectives C. Faculty II. An Overview of CMS's Patient Safety Initiative (PSI) III. The Discharge Planning Worksheet IV. The Infection Control Worksheet V. The Quality Assessment & Performance Improvement (QAPI) Worksheet VI. Conclusion VII. Post-Program Live Question and Answer Session A. Audio only telephone seminar with program faculty for 30 minutes following the program. B. Call 1-888-206-0090; enter conference code: 7925428. Or e-mail your questions or comments to: Questions@jcrqsn.com Program Broadcast Time Eastern: Central: Mountain: Pacific: 2:00 p.m. to 3:00 p.m. 1:00 p.m. to 2:00 p.m. 12:00 p.m. to 1:00 p.m. 11:00 a.m. to 12:00 p.m. Program Question and Answer Session During the live airing of this program on September 25, 2014, you may be able to talk directly with the faculty when prompted by the program s host. After this date, your message will be forwarded to the appropriate personnel. Immediately following the program, we invite you to join in a live discussion with the program presenters. Call 1-888-206-0090 and enter Conference Code: 7925428 to be included in the teleconference. To submit your question ahead of time or for additional details, please send an e-mail to questions@jcrqsn.com. If you submit your questions after this date, your message will be forwarded to the appropriate personnel. You can also receive answers to your questions by calling The Joint Commission s Standards Interpretation Hotline at 630-792-5900, option 6. 2014 Joint Commission Resources 5 of 46

Continuing Education (CE) Credit After viewing the JCR Quality & Safety Network presentation and reading this Resource Guide, please complete the required online CE/CME credit activities (test and feedback form). The test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The feedback form provides us with valuable information regarding your thoughts on the activity s quality and effectiveness. NOTE: Effective April 1, 2012, the Learning Management System web site URL changed as noted below. Prior to the Program Presentation Day 1. Login to the JCRQSN Learning Management System web site at http://twnlms.com/ 2. Enroll yourself into the program Note: Your administrator may have already enrolled you in the program Select All Courses from the courses menu. Select the course category for the current year, 2014 Programs. Select the course for this program, The CMS Patient Safety Initiative: Discharge Planning, Infection Control, and Quality Assessment & Performance Improvement (QAPI) When prompted, choose Yes to confirm that you would like to enroll yourself. 3. Display and print the desire documents (Resource Guide, etc.). Online Process for CE/CME Credit 1. Read the course materials and view the entire presentation. 2. Login to the JCRQSN Learning Management System web site at http://twnlms.com/ 3. Select The CMS Patient Safety Initiative: Discharge Planning, Infection Control, and Quality Assessment & Performance Improvement (QAPI) from the courses menu block. Note: This assumes you have already been enrolled in the program as described above. 4. If you didn t view the broadcast video presentation, view it online. 5. Complete the online post test (see Appendix E). You have up to three attempts to successfully complete the test with a minimum passing score of 80%. Physicians must take the post test to obtain credit. 6. Complete the program feedback form. 7. On the top right corner of the main course page, you will see your completion status in the Status block. 8. Select Print Certificate from within the Status block to print your completion certificate. 2014 Joint Commission Resources 6 of 46

Faculty Slides: The CMS Patient Safety Initiative (PSI) Pilot Worksheets Course Objectives Describe the PSI pilot. Describe the goals of the PSI pilot. Describe CMS s survey process specific to the PSI pilot. Background Pre-Test Phase S&C-12-01 released 10/14/11. Pilot Testing S&C-12-32 released 05/18/12. Patient Safety Initiative FY 2013 Pilot Phase S&C-13-03 released 11/09/12. Worksheets The Tools Address three CoP areas: Quality Assessment and Performance Improvement (42 CFR 482.21). Infection Control (42 CFR 482.42). Discharge Planning (42 CFR 482.43). Pre-Test Phase CMS supports Partnership for Safety (PfP). Assumes full compliance with QAPI, infection control, and discharge planning will reduce HACs. Promote more in-depth, consistent approach to onsite hospital surveys related to the three target areas. Provides refinement of worksheets during pre-test phase. Pilot Testing All State Survey Agencies (SAs) testing each of the three worksheets. Selected based on risk-adjusted all-cause readmission data. Patient Safety Initiative FY 2013 Pilot Phase Test all three surveyor worksheets together. Multi-campus hospitals surveyed at one inpatient hospital. SAs to perform one to nine integrated PSI surveys. Hospitals selected based on combination of risk-adjusted all-cause Medicare readmissions data. 2014 Joint Commission Resources 7 of 46

Goals Promote consistency. Improve effectiveness. Modify Interpretive Guidelines (IGs). 40% reduction in preventable HAC. 20% reduction in 30-day readmission. 3-years save $35 billion. Current State Worksheets revised. No citations will be issued at standard or condition level. Immediate Jeopardies (IJs) will be called if identified. Form 2567-Statement of Deficiencies and Plan of Correction No citations at standard or condition level no plan of correction required. Provide feedback at end of survey to hospital staff detailing areas at risk. Document only the completion of the survey on the 2567. No 2567 will be issued. Copy of each completed worksheet will be provided. Feedback on PSI Surveyor Worksheets Publicly distributed November 9, 2012. Encourages hospitals to voluntarily utilize the worksheets for self assessment. CMS welcomes feedback from hospitals after utilizing the worksheets. Patient Safety Initiative (PSI) Survey Process Entrance Conference Worksheet Completion Citation-Enforcement 2014 Joint Commission Resources 8 of 46

QAPI Worksheet Part 1 Hospital Characteristics. Part 3: Data Collection and Analysis Quality Indicator Tracers. Part 4 Applying Quality Indicator Information Activities and Projects. Part 5 Patient Safety Adverse Events and Medical Errors. Part 5: Casual Analysis Tracers. Part 6 Broad QAPI Requirements and Leadership Responsibilities. Part 3 of QAPI Worksheet Part 3 is Quality Indicator Tracers. Assesses evidence regarding aspects of Tags A-273 and A-283 that have to do with collecting, analyzing and making sure that data being collected are used for improvement. Note distinctions Part 3 does not focus on: Data collection related to medical errors or adverse events (those are Part 5); or Requirements related to prioritization and Performance Improvement Projects Standard (those are Part 4). Selecting Quality Indicators for Part 3 Tracer Questions Identify through interviews with QAPI program leadership, other hospital leadership staff, front-line staff as applicable. Pertinent documentation includes: QAPI program policies and procedures. QAPI tracking data and data analyses. Governing Body minutes. Minutes of QAPI program committee(s), if applicable. Some Sources of Quality Indicators CMS Hospital Compare. National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC). Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse. Registries maintained by national accreditation organizations, specialty societies or healthcare professional associations. National Quality Forum (NQF). Quality Improvement Organization (QIO) initiatives. 2014 Joint Commission Resources 9 of 46

Organization of Part 3 Quality Indicator Tracers Is the hospital using indicators related to improved health outcomes? (3.1.a) Is the scope of data collection appropriate for these indicators? (3.1.b) Is the method for data collection specified? (3.1.c) Are data collection and aggregation being done as specified/correctly? (3.1.d, e & f) Are the data being analyzed? (3.1.g, h & i) Are the results of the analysis being used for improvement, and evaluated? (3.1.j, k, l & m) Part 4 of QAPI Worksheet Part 4 covers Applying Quality Indicator Information - Activities and Projects. Assesses evidence regarding: Aspect of QAPI Tag A-283 that relates to prioritization of improvement activities. QAPI Tag A-297. Survey Procedures - Prioritizing Will ask the hospital to describe current or recent improvement activities. On what basis did the hospital select these areas for attention? Can the hospital demonstrate that its improvement activities are focused on high risk, high volume or problem prone areas? Does it have data (either derived from its own QAPI data collection or from public data) on incidence, prevalence or severity to support its choices? Prioritizing Improvement Activities High risk areas opportunity for error is higher than in other areas, e.g., complex processes, and/or where the consequences of poor quality or medical errors are more likely to have a serious, adverse impact on patients. High volume areas where the number of potential patients who could be adversely affected is high due to common elements in their care. Problem-prone areas where internal QAPI data shows a history of problems, or where nationally available research or expert consensus has identified areas especially prone to problems. Performance Improvement Projects Per regulation, number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital s services and operations. Hospital must always have some performance improvement project(s) underway. But they don t all have to be completed in < one year May undertake complex projects that last more > one year. 2014 Joint Commission Resources 10 of 46

Part 5 of QAPI Worksheet Part 5 covers Patient Safety, subdivided into: General policies/procedures; and Tracers. Assesses evidence regarding: QAPI Tag A-286. QAPI issues that also implicate Tags A-410, 508, and 756 (transfusion, medication administration and infection control). Expectations for Patient Safety Q s 5.1 designed to produce evidence whether leadership communicates expectations for patient safety throughout the hospital. Focuses on: Evidence of training on what staff should do when they observe a medical error, adverse event, or potentially dangerous situation; Adoption of non-punitive approach to staff reporting of errors, adverse events, unsafe situations; Whether unit staff can explain their role in patient safety. Identifying Events and Near Misses/Close Calls: Incident Reporting When asked by the Office of Inspector General (OIG) why internal reporting systems missed many incidents, hospital administrators frequently cited a lack of perception on the part of staff that harm was both preventable and reportable. Hospitals expected to provide staff with detailed, unambiguous guidance on what types of events they should report. Hospitals should advise staff to report all serious preventable adverse events as defined by NQF and should also define a broader range to report. Identifying Events and Near Misses/Close Calls: Other Methods Must have policies and procedures for identifying patient adverse events. Regulation does not mandate a specific method for identifying adverse events. However, evidence about the insufficiency of internal staff reports means that hospitals must use additional methods. Must be able to explain how their methods are effective. Serious Preventable Adverse Events Serious Preventable Adverse Events in Questions 5.7 and 5.8 means an event on the National Quality Forum s (NQF) list of Serious Reportable Events in Healthcare. Hospitals expected to identify occurrence of the events on the NQF list as part of medical error/adverse event tracking system and to analyze each one that occurs. 2014 Joint Commission Resources 11 of 46

Part 6 of QAPI Worksheet Part 6 is Broad QAPI Requirements and Leadership Responsibilities.. Assesses evidence regarding: QAPI Tags A-308, A-309, and A-315. Aspect of Tag A-273 that has to do with Governing Body approval of QAPI program indicators and frequency of data collection. Issues that also implicate Governing Body Tags A-083 and A-057. Executive Responsibilities Governing body, medical staff, and administrative officials jointly responsible and accountable for QAPI program. Administrative officials includes CEO, at a minimum. Medical staff may delegate to the medical staff executive committee. Services Under Contract Governing body CoP at 42 CFR 482.12(e) requires hospital to ensure that contracted services comply with CoPs and accepted standards. QAPI CoP requires inclusion of contracted services. Must be able to demonstrate how such services are included in QAPI by: Providing evidence of assessment; When appropriate, conducting performance improvement activities or projects related to services under arrangement or contract. Tag A-315: QAPI Resources Must allocate sufficient and qualified staff (may include consultants), staff time, information systems and training to support all elements of QAPI program. Resources must be commensurate with overall scope and complexity. CEO and QAPI program manager must be able to identify in detail the resources dedicated to QAPI program. Infection Control Tool for Hospitals: Vision Ultimate goal develop a tool to promote HAI prevention and patient safety in hospitals. Hospital surveyors to assess the minimum health and safety standards to meet the Medicare CoP for Infection Control. Effective and easy to use. Consistency. Data collection to understand current state of compliance. The tool will be accessible for hospitals. Best practices self-assessment. Self-assessment for infection control compliance. 2014 Joint Commission Resources 12 of 46

Patient Focused Tool will help surveyors focus on direct patient care and high risk locations for HAIs. Alignment with the HHS HAI Action Plan and the specific HAIs that are being measured. www.hhs.gov/ash/initiatives/hai/actionplan/index.html Infection Control Worksheet Structure 5 Modules: Module 1: Infection Control/Prevention Program Module 2: General Infection Control Elements to be applied to all locations Module 3: Equipment Reprocessing Module 4: Patient Tracers Module 5: Special Care Environments Module 1: Infection Control/Prevention Program Section 1. A. Infection control/prevention program and resources Section 1. B. Hospital QAPI systems related to Infection Prevention and Control Section 1. C. Systems to prevent transmission of multi-drug resistant organisms (MDROs) and promote antibiotic stewardship, Surveillance Section 1. D Personnel Education System/Infection Control Training Module 2: General Infection Control Elements Section 2. A Hand Hygiene Section 2. B Injection Practices and Sharps Safety (Medications, Saline, Other Infusates) Section 2. C Personal Protective Equipment/Standard Precautions Section 2. D Environmental Services 2014 Joint Commission Resources 13 of 46

The My 5 Moments for Hand Hygiene Approach Module 3: Equipment Reprocessing Section 3.A. Reprocessing of Semi-Critical Equipment Section 3. B Reprocessing of Critical Equipment, Sterilization of Reusable Instruments and Devices Section 3. C Single-Use Devices (SUDs) Manual Cleaning Soak until ready to clean. Worker safety: Wear heavy-duty utility gloves. Mask. Eyewear. Protective clothing. Work carefully and slowly. Use long handled brushes. Avoid spray and spatter. Cleaning Supplies Using the right products? Spot check expiration dates and labeling, especially if in secondary container. High-level disinfectants: Tested for concentration? Right test strips? Log book of results? Staff competency tested? 2014 Joint Commission Resources 14 of 46

Module 4: Patient Tracers Section 4. A Urinary Catheter Tracer Section 4. B Central Venous Catheter Tracer Section 4. C Ventilator/Respiratory Therapy Tracer Section 4. D Spinal Injection Procedures Section 4. E Point of Care Devices (e.g., blood glucose meter, international normalized ratio [INR]) monitor) Section 4. F Isolation: Contact Precautions Section 4. G Isolation: Droplet Precautions Section 4. H Isolation: Airborne Precautions Section 4. I Surgical Procedure Tracer Surveying the Patient! The most important infection control takes place at the patient bedside. Always visit within several patient rooms if appropriate and not intrusive for the patient, family, or staff. Take a few minutes to just look around, there is often a lot to see! Isolation Precautions Surveyors will make sure they check for any patients on isolation precautions. Right isolation sign outside door? Check room pressure, if suppose to be + or. Do staff check negative pressure rooms daily and document results? Supplies readily available outside door? Hand hygiene agent near door? Module 5: Special Care Environments Section 5. A Protective Environment (e.g., bone marrow patients) Strategy Move away from significant surveyor time spent on document review. Assess basic infection control in all areas of hospital. Observe patients and procedures where there is high risk of infection transmission. Focus on prevention efforts for HAIs in HHS HAI Action Plan and P4P (reported to National Healthcare Safety Network [NHSN]). 2014 Joint Commission Resources 15 of 46

Discharge Planning Worksheet Section 1 Hospital Characteristics Section 2 Discharge Planning Policies and Procedures Section 3 Discharge Planning Reassessment and QAPI Section 4 Discharge Planning Tracers Section 1: Discharge Planning Hospital Characteristics Survey details: Survey dates. Number of surveyors and time onsite. Accreditation status. Recent surveys. Section 2: Discharge Planning Policies and Procedures Policies and Procedures Will ask to see written policies. Do you follow your policies? Do you do what you say you will be/are supposed to be doing? Are discharge planning policies followed consistently throughout all inpatient settings? Section 3: Discharge Planning Reassessment and QAPI Need to have ongoing assessment of hospital-wide discharge planning practices. Plan-Do-Study-Act. Readmissions are reportable and displayed on Hospital Compare. Potential for penalties reduced reimbursement for high readmission rates. Section 4: Discharge Planning Tracers Select 1-2 current inpatients. Preferably at least one that was recently readmitted. Select 2-3 closed records. With discharge evaluation and plan, readmissions preferred. Skilled nursing facility/nursing facility (SNF/NF) and home discharges. Some questions throughout the tool ask for information on best practices. There are no citations currently associated with these questions. Will allow for assessment of best practices. If present, reinforces best practice. If not, gives examples of ways to improve. 2014 Joint Commission Resources 16 of 46

Excerpts from the PSI Discharge Planning Worksheet Section 2 Discharge Planning Policies and Procedures Elements to Be Assessed Manner of Assessment Code (list all that apply) & Surveyor Notes 2.1 Are discharge planning policies and procedures in effect for all inpatients? Specifically: 2.1a For every inpatient unit surveyed is there evidence of applicable discharge planning activities? 2.1b Are staff members responsible for discharge planning activities correctly following the hospital s discharge planning policies and procedures? NOTE: If no for either 2.1a or 2.1b the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to identification of patients needing discharge planning, 42 CFR 482.43(a) (Tag A-0800); discharge planning evaluation, 42 CFR 482.43(b) (Tag A-0806); and/or developing and implementing the discharge plan, 42 CFR 482.43(c) (Tag A-0817) 2.2 Does the discharge planning process apply to certain categories of outpatients? If yes, check all that apply: Same day surgery patients Observation patients who are not subsequently admitted ED patients who are not subsequently admitted Other 2.3 Is a discharge plan prepared for each inpatient?, skip to question 2.8, go to question 2.4 NOTE: No citation risk related to responses to questions 2.2 and 2.3; for information only. 2.4 For patients not initially identified as in need of a discharge plan, is there a process for updating this determination based on changes in the patient s condition or circumstances? Specifically: 2.4a Does the discharge planning policy address changes in patient condition that would call for the development of a discharge plan in patients not previously identified as in need of one? Key: Interview = 1 Observation = 2 Discharge Planning Policy Review = 3 Medical Record Review = 4 Other Document Review = 5 2014 Joint Commission Resources 17 of 46

Elements to Be Assessed 2.4b Are inpatient unit staff aware of how, when, and whom to notify of such changes in patient condition? Manner of Assessment Code (list all that apply) & Surveyor Notes NOTE: If no to either 2.4a or 2.4b, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(a) (Tag A-0800) 2.5 Is there a process for patients, or their representatives, and physicians to request a discharge planning evaluation? Specifically: 2.5a Does the hospital have a standard process for notifying patients (or their representative if applicable) that they may request a discharge planning evaluation and that the hospital will conduct an evaluation upon request? 2.5b Does the hospital have a standard process for notifying physicians that they may request a discharge planning evaluation and that the hospital will conduct an evaluation upon request? 2.5c Can both discharge planning and unit nursing staff personnel describe the process for a patient or the patient s representative to request a discharge planning evaluation? 2.5d Interview patients (or their representatives if applicable). If they say they were not aware they could request a discharge planning evaluation, can the hospital provide evidence the patient or representative received notice they could request an evaluation? 2.5e Interview attending physicians. If they are not aware they can request a discharge planning evaluation, can the hospital provide evidence of how it informs the medical staff about this? NOTE: If no to any part of question 2.5, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(1) (Tag A-0806) 2.6 Interview attending physicians. If they are not aware they can request a discharge plan regardless of the outcome of the completed evaluation, can the hospital provide evidence of how it informs the medical staff about this? NOTE: If no to 2.6, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(2) (Tag A-0819) 2014 Joint Commission Resources 18 of 46

Elements to Be Assessed 2.7 Can discharge planning personnel describe a process for physicians to order a discharge plan to be completed on a patient, regardless of the outcome of the patient s evaluation? Manner of Assessment Code (list all that apply) & Surveyor Notes NOTE: If no to 2.7, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(2) (Tag A-0819) 2.8 Does the hospital discharge planning policy include a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements? NOTE: If no to 2.8, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(4) (Tag A-0821) 3.1 Does the hospital review the discharge planning process in an ongoing manner, e.g. through QAPI activities? 3.2 Does the hospital track its readmissions as part of its review of the discharge planning process? 3.2a Does the assessment of readmissions include an evaluation of whether the readmissions were potentially preventable? 3.3 If the hospital identified preventable readmissions where problems in the discharge planning process were identified as a possible cause, did it make changes to its discharge planning process to address the problems? NOTE: If no to any one of 3.1 through 3.3, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(e) (Tag A-0843) and possibly QAPI 42 CFR 482.21(c) (Tag A-0283) 3.4 Does the hospital have a process for collecting and considering feedback from post-acute providers in the community about the effectiveness of the hospital s discharge planning process? NOTE: No citation risk related to responses to question 3.4; for information only. 2014 Joint Commission Resources 19 of 46

Section 2 Discharge Planning Policies and Procedures In this section, survey 1-2 current inpatients and review the closed medical records of 2-3 patients who were discharged to home or transferred to a post-acute care setting. When possible, include one inpatient who was readmitted within 30 days of a previous admission. For closed records, be sure to select a record that includes a discharge planning evaluation and a discharge plan, and do not choose N/A instead of a Yes or No response. Note key at bottom of page for Manner of Assessment code. DCP = Discharge Planning Patient/Record #1 Open Closed Patient/Record #2 Open Closed Patient/Record #3 Open Closed Patient/Record #4 Open Closed 4.1 When was the screening done to identify whether the inpatient needed a discharge planning evaluation? a. Before or at time of admission b. After admission but at least 48 hours prior to discharge c. N/A all admitted patients receive a discharge plan d. None of the above a. b. c. d. e. a. b. c. d. e. a. b. c. d. e. a. b. c. d. e. NOTE: If response 4.1d is selected, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(a) (Tag A-0800) 4.2 Can hospital staff demonstrate that the hospital s criteria and screening process for a discharge planning evaluation were correctly applied? NOTE: If no to 4.2, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(a) (Tag A-0800) Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.3 If the patient did not meet the hospital s criteria for an evaluation, were the patient (or patient s representative if applicable) and the patient s physician made aware they could still request a discharge planning evaluation? NOTE: If no to 4.3, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(1) (Tag A-0806) 2014 Joint Commission Resources 20 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.4 Was the discharge planning evaluation and, as applicable, the discharge plan developed by an RN, Social Worker, or other qualified personnel, as defined in the hospital discharge planning policies and procedures, or someone they supervise? NOTE: If no to 4.4, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(2) (Tag A-0807 - evaluation) and/or 42 CFR 482.43 (c)(1) (Tag A-0818 - plan) 4.5 Are the results of the discharge planning evaluation documented in the medical record? NOTE: If no to 4.5, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(6) (Tag A-0812) 4.6 Did the evaluation include an assessment of the patient s post-discharge care needs being met in the environment from which he/she entered the hospital? For patients admitted from home, answer questions 4.7 through 4.11a. For patients admitted from a nursing home, skilled nursing facility, or assisted living, skip to question 4.12 4.7 Did the evaluation include an assessment of the patient s ability to perform activities of daily living (e.g. personal hygiene and grooming, dressing and undressing, feeding, voluntary control over bowel and bladder, ambulation, etc.)? 4.8 Did the evaluation include an assessment of the patient s or family/support person s ability to provide self-care/care? 2014 Joint Commission Resources 21 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.9 Did the evaluation include an assessment of whether the patient will require specialized medical equipment or home and physical environment modifications? 4.10 If the assessment determined that the patient or family/support person is unable to meet care needs or there are additional care needs above their capabilities, did the evaluation include an assessment of available community-based services to meet post-hospital needs? 4.9a If the assessment determined the patient required specialized medical equipment or environment modifications, did the evaluation include an assessment of whether the equipment is available or if the modifications can be made to safely discharge the patient to that setting? 4.10 If the assessment determined that the patient or family/support person is unable to meet care needs or there are additional care needs above their capabilities, did the evaluation include an assessment of available community-based services to meet post-hospital needs? NOTE: If any no answer to questions 4.6 4.10, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(4) (Tag A-0806) 4.11 If the assessment determined the patient would need HHA or SNF care, did the hospital provide the patient with lists of Medicare-participating HHAs or SNFs that provide post-hospital services that could meet the patient s medical needs? 2014 Joint Commission Resources 22 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.11a If the hospital provided lists, were they geographically appropriate for the patient? NOTE: If no to 4.11 or 4.11a, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(6) (Tag A-0823) For patients admitted from a nursing home, skilled nursing facility, or assisted living, answer question 4.12. 4.12 Did the evaluation assess whether the prior facility has the capability to provide necessary post-hospital services to the patient (i.e. is the same, higher, or lower level of care required and can those needs be met in that facility?) 4.13 Did the evaluation include an assessment of the patient s insurance coverage (if applicable) and how that coverage might or might not provide for necessary services post-hospitalization? If no to 4.12 or 4.13 the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(4) (Tag A-0806) 4.14 Was the discharge planning evaluation completed in a timely basis to allow for appropriate arrangements to be made for post-hospital care and to avoid delays in discharge (including to a post-acute care setting)? NOTE: If no to 4.14, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(5) (Tag A-0810) 2014 Joint Commission Resources 23 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.15 Was the patient (or the patient s representative, if applicable) involved in a discussion of the evaluation results? NOTE: If no to 4.15, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(b)(6) (Tag A-0811) and possibly 42 CFR 482.13(b)(1) Patients Rights (Tag A-0130) 4.16 Did the discharge plan match the identified needs as determined by the evaluation? NOTE: If no to 4.16, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(1) (Tag A-0817) 4.17 If any significant changes in the patient s condition were noted in the medical record that changed post-discharge needs, was the discharge plan updated accordingly? NOTE: If no to 4.17, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(4) (Tag A-0821) For patients discharged to home or for whom discharge home is planned, answer all parts of questions 4.18 and SKIP question 4.19. For patients discharged/transferred to a post-acute care setting other than home, skip to question 4.19. Choose N/A for questions 4.18 through 4.20 only for open records of inpatients where it is premature for the question to apply. 4.18 For patients discharged to home, did the hospital arrange for the initial implementation of the discharge plan? Specifically, look for evidence of the following, if applicable, based on the discharge plan: 4.18a Providing in-hospital training to patient and family/support persons, using recognized methods. (Examples include teach-back or repeat-back, simulation laboratories, etc. but these specific methods are not required.) 2014 Joint Commission Resources 24 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.18b Written discharge instructions that are legible and use non-technical language. 4.18c A list of all medications the patient should be taking after discharge, with clear indication of changes from the patient s pre-admission medications 4.18d Evidence of education of patients and support persons on admission vs. discharge medications, highlighting changes. 4.18e Referrals to established/new primary care physician or health center. 4.18f Referrals, if applicable, to specialized ambulatory services, e.g., PT, OT, HHA, hospice, mental health, etc. 4.18g Referrals, if applicable, to communitybased resources other than health services, e.g., Depts. of Aging, elder services, transportation services, etc. 2014 Joint Commission Resources 25 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.18h Arranging essential durable medical equipment, e.g. oxygen, wheel chair, hospital bed, commode, etc., if applicable. 4.18i Sending necessary medical information to providers the patient was referred to prior to the first postdischarge appointment or within 7 days of discharge, whichever comes first. NOTE: If implementation of the discharge plan was not initiated, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(c)(3) (Tag A-0820) 4.19 For patients transferred, to a post-acute care setting other than home, was necessary medical information ready at time of transfer and sent to the receiving facility with the patient? NOTE: If no to 4.19, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(d) (Tag A-0837) 4.20 Were there portions of the plan the hospital failed to begin implementing, resulting in delays in discharge? 2014 Joint Commission Resources 26 of 46

Patient/Record #1 Patient/Record #2 Patient/Record #3 Patient/Record #4 4.21 For information only, were any of the following services initiated while the patient was hospitalized: a. Scheduling follow-up appointments b. Filling prescriptions c. Pharmacist meeting with patient and/or family/support persons to review medication regimen d. Pharmacist reviewing discharge medication orders prior to hospital departure e. Home setting visitation by hospital staff f. Transportation arranged for follow-up appointments g. Discharge planning checklists, e.g., CMS, AHRQ, CAPS checklists a. b. c. d. e. f. g. a. b. c. d. e. f. g. a. b. c. d. e. f. g. a. b. c. d. e. f. g. NOTE: No citation risk related to question 4.21; for information only. 4.22 Is there documentation in the medical record of providing the results of tests, pending at time of discharge, to the patient and/or post-hospital provider of care, if applicable? NOTE: If no to 4.22, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.43(d) (Tag A-0837) 4.23 Ask the hospital to check whether this inpatient admission is a readmission within 30 days of a prior admission to that hospital. Was there a prior admission? NOTE: No citation risk related to question 4.23, for information only. 2014 Joint Commission Resources 27 of 46

Excerpts from the PSI Infection Control Worksheet Section 3. B Reprocessing of Critical Equipment Sterilization of Reusable Instruments and Devices Elements to Be Assessed Manner of Assessment Code (list all that apply) & Surveyor Notes Sterilization of reusable instruments and devices is accomplished in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following: Note: Hospital policies should address what to do when there are discrepancies between manufacturer s instructions for a device and manufacturer s instructions for a device reprocessor. 3. B.1 Items are thoroughly pre-cleaned according to manufacturer's instructions and visually inspected for residual soil prior to sterilization. Note: for lumened instruments, pre-cleaning must include all device channels and lumens with cleaning brushes appropriate for size of instrument channel or port. 3. B.2 All reusable critical instruments and devices are sterilized on site. If no, no citation is issued and skip to 3.B.12. 3. B.3 Enzymatic cleaner or detergent is used and discarded according to manufacturer s instructions (typically after each use). 3. B.4 Cleaning brushes are disposable or cleaned and high-level disinfected or sterilized (per manufacturer s instructions) after each use. 3. B.5 After pre-cleaning, instruments are appropriately wrapped/packaged for sterilization (e.g., package system selected is compatible with the sterilization process being performed, hinged instruments are open, and instruments are disassembled if indicated by the manufacturer). 3. B.6 A chemical indicator (process indicator) is placed correctly in the instrument packs in every load. 3. B.7 A biological indicator is used at least weekly for each sterilizer and with every load containing implantable items. Key: Interview = 1 Observation = 2 Discharge Planning Policy Review = 3 Medical Record Review = 4 Other Document Review = 5 2014 Joint Commission Resources 28 of 46

Elements to Be Assessed 3. B.8 For dynamic air removal-type sterilizers, a Bowie-Dick test is performed each day the sterilizer is used to verify efficacy of air removal. 3. B.9 Sterile packs are labeled with the sterilizer used, the cycle or load number, and the date of sterilization. 3. B.10 Logs for each sterilizer cycle are current and include results from each load. 3. B.11 Routine maintenance for sterilization equipment is performed according to manufacturer s instructions (confirm maintenance records are available). 3. B.12 After sterilization, medical devices and instruments are stored so that sterility is not compromised. 3. B.13 Sterile packages are inspected for integrity and compromised packages are reprocessed prior to use. 3.B.14 If immediate-use steam sterilization is performed, the following criteria are met: The item being sterilized is thoroughly cleaned prior to placing it in the sterilizer container (that is FDA cleared for use with the cycle) or tray The sterilizer cycle being used is one that is approved by both the instrument and sterilizer manufacturer The sterilizer function is monitored with monitors (e.g., mechanical, chemical and biologic) that are approved for the cycle being used The facility maintains a sufficient volume of instruments to meet the surgical volume and permit time to complete all steps of reprocessing 3. B.15 Instruments that are subject to immediate use sterilization procedures are used immediately and handled in a manner to prevent contamination during transport from the sterilizer to the patient. 3. B.16 HCP respond (i.e., recall of device and risk assessment) according to facility policies and procedures in the event of a reprocessing error/failure that could result in the transmission of infectious disease. Manner of Assessment Code (list all that apply) & Surveyor Notes If no to any of 3.B.1 and/or 3.B.3 through 3.B.16, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.42(a)(1) (Tag A-0749) 2014 Joint Commission Resources 29 of 46

Excerpts from the PSI Quality Assessment & Performance Improvement (QAPI) Worksheet PART 3: DATA COLLECTION AND ANALYSIS - QUALITY INDICATOR TRACERS Instructions for Part #3 Questions: Select 3 quality indicators (not patient safety analyses) and trace them answering the following multi-part question. Focus on indicators with related QAPI activities or projects. At least one of the indicators must have been in place long enough for most questions to be applicable. Elements to Be Assessed Indicator #1 Indicator #2 Indicator #3 3.1 Write in indicator selected. Indicator selection identified through: 3.1.a Can the hospital provide evidence that each quality indicator selected is related to improved health outcomes? (e.g. based on QIO, guidelines from a nationally recognized organization, hospital specific evidence, peer-reviewed research, etc.) 3.1.b Is the scope of data collection appropriate to the indicator, e.g., an indicator related to labor and delivery might be appropriate to all areas of that unit and the ED, but indicators related to hand hygiene would require data from multiple parts of the hospital. 3.1.c Is the method (e.g., chart reviews, monthly observations, etc.) and frequency of data collection specified? 3.1.d Is there evidence that the data are actually collected in the manner and frequency specified for this indicator? E.g., Is there evidence of late, incomplete, or wrong data collection? Manner of Assessment Code: 1-Interview 2-Observation 3- QAPI Documentation 4- Medical Record Review 5- Other 2014 Joint Commission Resources 30 of 46

Elements to Be Assessed Indicator #1 Indicator #2 Indicator #3 3.1.e If unit staff play a role in data collection, is collection consistent with the specifications for how the data are to be collected? 3.1.f Are data that have been collected aggregated in accordance with the hospital methodology specified for this indicator? 3.1.g Are the collected data analyzed? 3.1.h If the indicator is the type that measures a rate, are rates calculated for points in time and over time, and are comparisons made to performance benchmarks when available (e.g. established by nationally recognized organizations)? 3.1.i When feasible, are aggregated data broken down into subsets that allow comparison of performance among hospital units covered by the indicator? For example, a hand hygiene indicator should allow comparison among different inpatient units. If no to any of 3.1.a through 3.1.i, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.21(a)(1), (a)(2), (b)(1), & (b)(3) (Tag A-273) 2014 Joint Commission Resources 31 of 46

Elements to Be Assessed Indicator #1 Indicator #2 Indicator #3 3.1.j If the data analysis identified areas needing improvement, is there evidence that the hospital instituted interventions (activities and/or projects) to address them? Check N/A if analysis did not lead to interventions, but the hospital could demonstrate that other areas were of higher priority. Check NO if analysis did not lead to interventions and the hospital could not demonstrate that other improvement activities were of higher priority. 3.1.k Are interventions evaluated for success? 3.1.l If interventions taken were not successful, were new interventions developed? 3.1.m If interventions were successful, did evaluation continue longer to assess if success was sustained? If no to any of 3.1.j through 3.1.m, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.21(b)(2)(ii), (c)(1), & (c)(3) (Tag A-283) 2014 Joint Commission Resources 32 of 46

PART 4 APPLYING QUALITY INDICATOR INFORMATION - ACTIVITIES AND PROJECTS Elements to Be Assessed 4.1 Can the hospital provide evidence that its improvement activities focus on areas that are high risk (severity), high volume (incidence or prevalence), or problem-prone? Manner of Assessment Code (Enter all that apply) & Surveyor Notes If no to 4.1, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.21(c)(1)(i) & (ii) (Tag A-283) 4.2 Can the hospital provide evidence that it conducts distinct performance improvement projects? 4.3 Is the number of projects proportional to the scope and complexity of the hospital s services and operations? No fixed ratio is required, but smaller hospitals with a smaller number of distinct services would be expected to have fewer projects than a large hospital with many different services. 4.4 Does the scope of projects reflect the scope and complexity of the hospital s services and operations? For example, if the hospital offers more complex services, such as neonatal intensive care, or open heart surgery, have there been QAPI project(s) related to any of those services? If no to any of 4.2 through 4.4, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.21(d)(1) (Tag A-297) 4.5 Can the hospital provide evidence showing why each project was selected? (NOTE: If the project is a QIO cooperative project or an IT project, such as computer ordered physician entry for medications or an electronic medical record, no rationale is required. Check N/A in these cases) If no to 4.5, the hospital would be at risk on a non-psi, non-pilot survey for a deficiency citation related to 42 CFR 482.21(d)(3) (Tag A-297) 2014 Joint Commission Resources 33 of 46