CAMH February 2005 Update HIGHLIGHTS

CAMH February 2005 Update HIGHLIGHTS STANDARD UP 1. How to Use Manual Multiple changes to scoring, category changes and Measure of Success (MOS) designation removed 2. Accreditation Policies & Procedures 3. Management of Information (IM) 4. Management of Information (IM) 5. Management of Information (IM) IM.6.10 EP 9 IM.6.30 EP 2 IM.6.30 EP 10 New Participation Requirement addressing employees reporting concerns to JCAHO. The hospital defines a complete record and the time frame within which the record must be completed after discharge, not to exceed 30 days after discharge. Operative or other high risk procedure reports dictated or written immediately after an operative or other high risk procedure record the name of the surgeon and assistants, procedure(s) performed and description of each procedure, findings, estimated blood loss, specimens removed, disposition of each specimen, and postoperative diagnosis. The history and physical examination and the results of any indicated diagnostic tests are recorded before the operative or other high-risk procedures. 6. Medical Staff (MS) Overview The governing body and the medical staff define medical staff membership criteria, which, as deemed necessary by the governing body and the medical staff, may include licensed independent practitioners and other practitioners. 7. Medical Staff (MS) MS.1.20 A description of the medical staff executive committee s function, EP 9 size, and composition, and of the methods for selecting and removing its members and the July 1, 2005

8. Medical Staff (MS) MS.1.20 8. Medical Staff (MS) EP 19 STANDARD UP MS.1.20 EP 19 organized medical staff officers. When administrative procedures, associated with processes described in the medical staff bylaws for corrective actions, fair hearing and appeal, credentialing, privileging, and appointment (elements of performance 12-18), are described in medical staff governance documents that supplement the bylaws (such as rules and regulations, and policies) the following must occur: The mechanism for the approval of the administrative procedures, which may be different from that for adoption and amendment of the medical staff bylaws, is described in the medical staff bylaws. Criteria to identify those administrative procedures that can be in the supplementary documents are described in the bylaws. The administrative procedures are approved by both the medical staff and the governing body through the bylaws-described mechanism. 9. Nursing (NR) NR.3.10 The nurse executive established nursing policies and procedures, nursing standards of patient care, treatment, and services, standards of nursing practice, and a nurse staffing plan(s). 1. New JCAHO Accreditation Process STANDARD UP Addition of conditional accreditation twice in a 6- year period to conditions for

preliminary denial of accreditation recommendation. Sentinel Events Reviewable sentinel events expanded to include: Suicide of any patient receiving care, treatment and services in a staffed aroundthe-clock setting or within 72- hours of discharge. 2. Accreditation Policies & Procedures 3. Accreditation Policies & Procedures 4. Provision of Care, Treatment and Services 5. Provision of Care, Treatment and Services 6. Medication Management (MM) PC.13.20 PC.17.10 PC.17.20 PC.17.30 MM.5.10 EP1 Abduction of any patient receiving care, treatment, and services. Unintended retention of a foreign object in a patient after surgery or other procedure (June 05 Perspectives). The hospital must adhere to the July 1, 2005 published guidelines for describing information in its Quality Report. PPR (Periodic Performance January 1, 2005 Review) must be completed annually (rather than once midpoint of accreditation cycle) EP 1: Sufficient numbers of July 1, 2005 qualified staff (in addition to the individual performing the procedure) are present to evaluate the patient, help with the procedure, provide the sedation and/or anesthesia, monitor, and recover the patient. Three new standards relating to July 1, 2005 transplant and implant tissue storage and issuance. Health care staff who may administer medications, with or without supervision, consistent with law and regulation and hospital policy. (The hospital s policy may address an

7. Improving Organization Performance (PI) PI.1.10 EP1 individual s qualification to administer by medication, medication class, or route of administration.) Relevant information developed from the following activities is integrated into performance improvement initiatives. Now includes: 29. Organ procurement effectiveness is monitored by the conversion rate data, which are collected and analyzed, and when possible, steps are taken to improve the rate. NOTE: Conversion rate is defined as the number of actual organ donors over the number of eligible donors as defined by the organ procurement organization (OPO), expressed as a percentage. 8. Management of Environment of Care (EOC) 9. Management of Environment of Care (EOC) STANDARD UP EC.5.20 When evaluating LSC July 1, 2005 compliance within the Statement of Conditions (SOC) assessment process, it is important that hospitals establish the qualifications of the person(s) they select for performing the assessment. While there are no prescriptive requirements for the education and experience of this person (s), these qualifications should be based upon the scope of the required LSC assessment activities, and the building complexity and occupancy type(s) being assessed. EC.5.20 The hospital assigns July 1, 2005 responsibility for completing EP 6 the SOC to one or more

10. Management of Environment of Care (EOC) 11. Management of Human Resources (HR) 12. Management of Human Resources (HR) EC.8.10 HR. 1.20 HR. 1.30 individuals whose experience and/or education is commensurate with the scope of the required LSC assessment activities and the building complexity and company occupancy rate. Emergency access provision is provided to all locked, occupied spaces. Verification of current licensure, certification, or registration from primary source at time of hire and documented. Revision of Staffing Effectiveness Standards: -Minimum of two hospital units -Minimum of four indicators (2 clinical; July 1, 2005 July 1, 2005 July 1, 2005 2 human resource) -Nursing staff includes RN, LPN, nursing assistants or aides. -Acceptable trigger targets established -Annual report to leaders 1. New section in Comprehensive Accreditation Manual for Hospitals (CAMH) 2. Ethics, Rights and Responsibilities STANDARD UP RI.1.10 EP 2 Includes Elements of Performance for each national patient safety goal. Also includes their newly developed implementation expectations. The hospital develops a process to handle these ethical issues that are prone to

RI.1.30 EP 3 RI.1.40 RI.2.90 conflict and implements a process when these issues arise. Policies and procedures and information about the relationship between the use of care, treatment, and services, and financial incentives as they relate to either referring to or using services are available to all patients, staff, licensed independent practitioners, and contracted providers, when requested. When internal or external review results in the denial of care, treatment, services, or payment, the hospitals makes decisions regarding the ongoing provision of care, treatment, and services discharge or transfer based on the assessed needs of the patients. At a minimum, the patient and when appropriate, his or her family, is informed about the following: EP 1 The responsible licensed independent practitioner or his or her designee informs the patient (and when appropriate, his or her family) about those unanticipated outcomes of care, treatment, and services related to sentinel events, when the patient is not already aware of the occurrence, or further discussion is needed. Unanticipated outcomes of care, treatment and services that relate to sentinel events considered reviewable by the

EP 2 Joint Commission. RI.2.150 EP 2 All allegations, observations, or suspected cases of abuse, neglect, or exploitation that occur in the hospital are explored by the hospital and, based on the type of event, are referred to the appropriate authorities for investigation. 2. Provision of Care, Treatment, and Services (PC) STANDARD UP PC.2.20 The hospital defines in writing the data and information gathered during assessment and reassessment. Rationale Added: A full assessment involves obtaining relevant information from multiple sources. This may include obtaining information from the patient, a family member, or other sources including other providers. Sources might also include mediums that the patient has sought out to convey information to those who may provide care, treatment, or services. These include databases, medical jewelry, and paper or electronic documents. Whatever the source, information to complete a comprehensive assessment should be sought out from all available sources.

Care, treatment, and services are planned to ensure that they are individualized to the patient s needs. PC.4.10 EP 1 Food and nutrition products are prepared under proper conditions of sanitation, temperature, light, moisture, ventilation and security. Nutritional Care PC.7.10 3. Medication Management (MM) 4. Surveillance, Prevention, and Control of Infection (IC) EP 17 IC.1.10 EP 5 Entire section replaced, only word smiting seen. The hospital has systems for reporting infection surveillance, prevention, and control information to the following: The referring or receiving organization when a patient was transferred or referred and the presence of an HAI was not known at the time of transfer or referral. Note: When a referring hospital becomes aware that a patient they have transferred has an acute infection for which treatment should start or change, the referring hospital communicates this to the

receiving hospital. If a receiving hospital identifies an infection not identified by the referring hospital (that is an infection wound), the receiving hospital should communicate the omission to the referring hospital. This action will aid the referring hospital s improvement efforts. 4. Surveillance, Prevention, and Control of Infection (IC) STANDARD UP IC.7.10 The infection control program is managed effectively. Rationale statement includes: The individual gathering the data for the infection control program does not have to be the person analyzing the data and managing the program. IC.8.10 Relevant components/functions within the hospital collaborate to implement the infection control program. Rationale statement includes:..while in larger hospitals this may require representation by

multiple divisions. Whatever the number of components/functions represented, it is important that the components/functions that have a direct impact on infection control are represented. 5. Improving Organization Performance (PI) PI.1.10 The hospital collects data to monitor its performance. Rationale statement includes: Data may come from internal sources such as staff or external sources such as patients, referral sources, and so on. Undesirable patterns or trends in performance are analyzed. PI.2.20 EP 13 ORYX core measure data that, over three or more consecutive quarters for the same measure, identify the hospital as a negative outlier. 6. Leadership (LD) LD.3.15 The leaders develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital.

Rational statement includes: Managing the flow of patients through the hospital is essential to the prevention and mitigation of patient crowding, a problem that can lead to lapses in patient safety and quality of care. Overcrowding has been shown to be primarily a hospital-wide system problem and not just a problem for which a solution resides within the emergency department. Opportunities for improvement often exist outside the emergency department. 6. Leadership (LD) STANDARD UP LD.3.15 Twelve key elements of care have been identified to ensure adequate and appropriate care for admitted patients in temporary locations. LD.3.15 EP 2 Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations, for example, post anesthesia care unit and emergency department areas. EP 3 Leaders and medical staff share accountability to develop processes that support efficient patient flow.

EP 8 The hospital improves inefficient or unsafe processes identified by leadership as essential to the efficient movement of patients through the hospital. LD.3.20 Patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital. Rationale includes: For patients with the same needs, hospitals may be providing different services. Patient may receive more or fewer visits, or may receive equipment with or without enhanced features. Also, hospitals may choose to have branch offices that offer different services from one another. The leaders must make sure that factors such as different individuals providing care, treatment, and services; different payment sources, or different settings of care do not intentionally negatively influence the outcome. The leaders define the required qualifications and competence of those staff who provided care, treatment, and services, and recommend a sufficient number of qualified and competent staff to provide care, treatment, and services.

LD.3.70 Rationale includes: A single set of criteria must be used to judge the competency of all clinicians who provide care, treatment, and services within the hospital, regardless of whether they are an employee of the hospital or of a licensed independent practitioner. Leadership (LD) STANDARD UP LD.3.70 Note: The qualifications requirements pertaining to students and volunteers who work in the same capacity as staff when they provide care, treatment and services are addressed in Standard HR.1.20. LD.3.70 EP 3 Prior to the provision of care, treatment or services, the qualifications and competence of a non-employee individual, brought into the hospital by a licensed independent practitioner to provide care, treatment or service within scope of the hospital s services are assessed by the hospital and determined to be commensurate with the

qualifications and competence required if the individual were to be employed by the hospital to perform the same or similar services. Note: When the service to be provided by the individual is not currently performed by anyone employed by the hospital, it is leadership s responsibility to consult the appropriate professional practice guidelines with respect to expectations for credentials and competence. The hospital reviews the qualifications, performance, and competence of each nonemployee individual brought into the hospital by a licensed independent practitioner to provide care, treatment, or services at the same frequency as individuals employed by the hospital. EP 4 7. Management of EC.2.10 The hospital identifies and

Environment of Care (EOC) manages its security risks. Rationale includes: It is essential that a hospital manage the physical and personal security of patients, staff (including the potential for violence to patients and staff in the workplace), and individuals coming to the hospital s buildings. 8. Management of Human Resources STANDARD UP HR.1.20 EP 3 EP 4 Brief Summary When hospital policy requires current licensure, certification, or registration, but they are not required by law or regulation, the hospital verifies these credentials at time of hire and upon expiration of credentials. When credentials required by law or regulation, the hospital verified with primary source at time of hire and upon expiration of credentials. If a hospital uses a credentials verification organization the hospital must evaluate initially and periodically. All staff that provides patient care possesses a license, certification, or registration as required by law and regulation. (Could result in conditional accreditation if violation found.)

EP 18 9. Management of Information (IM) Entire section replaced, only word smithing seen. 10. Medical Staff (MS) MS.1.20 EP 19 Approval process for Medical Staff Rules & Regulations outlined delayed to 2007. January 1, 2007 MS.4.10 Rationale relating to credentialing criteria for current licensure added primary source verification at time of expiration. 1. JCAHO Accreditation Process 2. Accreditation Policies and Procedures STANDARD UP ACC-1 ACC-24 3. Sentinel Events SE-1-4. JCAHO Quality Report APP-1 APP- 38 SE-12 QR-1 QR-6 An overview of unannounced survey process and continuous systems compliance, new decision categories & decision rules. Updated chapter to include information on unannounced surveys. January 2006 Revised Sentinel event definition to include: Unintended retention of foreign object in a patient after surgery or other procedure. Expanded quality merit badges list (includes diseasespecific certification, Ernest Codman Award, John Eisenberg Patient Safety Award, Magnet Hospital, Franklin Award of Distinction, Hospital quality participant,

5. Accreditation Participation Requirements APR-1 APR 10 AHA Quest for Quality Prize, Cheers Award (ISMP), plus APR 8, Public interviews no longer with survey; public encouraged to contact JCAHO anytime if concerns not resolved. Due October each year. APR 14, Annual Periodic Performance Review required. 6. Leadership LD-11 7. Performance Measurement & ORYX Initiatives 8. Simplifying Compliance Activities LD-11A PM-1 PM-10 SCA-1 SCA-6 9. Glossary GL-1 APR 19, New survey process requires regular interactions with the Joint Commission, i.e., PPR. Timely submission of data and information is required. Leaders are required to implement budget and, as appropriate, the long-term capital expenditure plan is monitored. Control charts and comparison 2006 charts required to analyze performance measures. Three core measures required for 2006. Updated chapter providing 2006 resources (websites) for regulatory requirements in healthcare. New and revised 2006 Effective GL-24 2006 Critical Access Hospital and Hospital National Patient Safety Goals Note: New Goals and Requirements are indicated in bold.

Goal 1 Improve the accuracy of patient identification. 1A Use at least two patient identifiers (neither to be the patient s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. 1B Not applicable. Goal 2 Improve the effectiveness of communication among caregivers. 2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result readback the complete order or test result. 2B Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. 2C Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. 2D Not applicable. 2E Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. Goal 3 Improve the safety of using medications. 3A Retired in 2006. 3B Standardize and limit the number of drug concentrations available in the organization. 3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. 3D Label all medications, medication containers, i.e., syringes, medicine cups, basins, or other solutions on and off the sterile field in perioperative and other procedural settings. Goal 4 Not applicable. Goal 5 Retired in 2006. Goal 6 Not applicable. Goal 7 Reduce the risk of health care-associated infections. 7A Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene

guidelines. 7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. Goal 8 Accurately and completely reconcile medications across the continuum of care. 8A Implement a process for obtaining and documenting a complete list of the patient s current medications upon the patient s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 8B A complete list of the patient s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. Goal 9 Reduce the risk of patient harm resulting from falls. 9B Implement a fall reduction program and evaluate the effectiveness of the program. Note: Replacement for 9A. Goal 10 Not applicable. Goal 11 Not applicable. Goal 12 Not applicable. Goal 13 Not applicable. Goal 14 Not applicable.