HRSA/Bureau of Primary Health Care (BPHC) Presentation Educational Webinar September 14, 2017 Valerie Henriques, MA, M.Ed., RN Joint Commission Clinical Surveyor 1
Webinar Objectives: Discuss the theory behind the SAFER Matrix Describe the survey process Describe the most challenging compliance issues in 2016-2017 Provide sample checklists for tracers Identify examples and strategies to ensure compliance 2
The Joint Commission s Mission and Vision Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision: All people always experience the safest, highest quality, best-value health care across all settings. 3
Background on The Joint Commission Accredit/certify over 20,000 total organizations Accrediting over 2,100 ambulatory care organizations since 1975 HRSA/BPHC contract 1997 Primary Care Medical Home (PCMH) Certification 2011 4
Survey Analysis for Evaluating Risk (SAFER ) 5
SAFER Matrix The Question: How can we provide a more meaningful assessment of each organization s survey findings/results, and better enable the connection to risk and patient safety? 6
Survey Analysis for Evaluating Risk (SAFER ) A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys Helps organizations prioritize and focus corrective actions Provides one, comprehensive visual representation of survey findings Replaces current scoring methodology Implementation: January 2017 7
Applying SAFER to Findings 8
Operational Definitions Applied at the organization level Looks at the scope of patients impacted (or potentially impacted) by an issue of noncompliance Shift from historical approach of counting observations Now we want to assess the patient impact, or potential impact, of an issue(s) 9
A new SAFER concept Likelihood to Harm a Patient/Staff/Visitor Scope 10
A New SAFER Matrix Immediate Threat to Life (follows current ITL processes) HIGH Likelihood to Harm a Patient/Visitor/Staff MODERATE LOW LIMITED PATTERN Scope WIDESPREAD 11
Likelihood to Harm High: harm could happen at any time. Harm is likely Moderate: harm could happen occasionally. Harm is possible Low: harm could happen, but would be rare. Harm would be rare 12
Scope Widespread: has the potential to impact most/all patients, visitors, staff Process failure Pattern: has the potential to impact more than a limited number of patients, visitors, staff Process variation Limited: has the potential to impact only one or a very limited number of patients, visitors, staff Outlier 13
A Picture is Worth 1000 Words Immediate Threat to Life HIGH MM.03.01.01, EP8 MM.03.01.01, EP7 Likelihood to Harm a Patient/Visitor/Staff MODERATE LOW MS.01.01.01, EP5 PC.01.02.01, EP4 PC.01.02.03, EP6 PC.01.03.01, EP1 PC.01.03.01, EP5 RC.01.01.01, EP19 RC.02.03.07, EP4 IM.02.02.01, EP3 MS.08.01.01. EP1 MS.08.01.03, EP3 IC.02.01.01, EP2 IC.02.02.01, EP4 LIMITED PATTERN WIDESPREAD 14
Examples of the SAFER matrix Likelihood to Harm a Patient/Staff/Visitor High Moderate Low Immediate Threat to Life LIMITED PATTERN WIDESPREAD During tracer activity on a dental patient, the dental staff present did not suspend all their activities to focus on correct patient, procedure, and site. Also, noted in a second tracer activity in the dental suite, the dental team did not suspend all their activities to focus on correct patient, procedure, and site. 15
Examples of the SAFER matrix Likelihood to Harm a Patient/Staff/Visitor High Moderate Low Immediate Threat to Life LIMITED PATTERN WIDESPREAD During the Competency Session 10 personnel files were reviewed. The files of the Dental Hygienist and a Licensed Practical Nurse were missing documented evidence of job descriptions. The job descriptions were obtained and signed by both staff however signatures of the managers were pending. 16
Likelihood to Harm a Patient/Staff/Visitor Examples of the SAFER matrix High Moderate Low Immediate Threat to Life LIMITED PATTERN WIDESPREAD Emergency medication procedures were reviewed at ABC site. It was noted that a storage box designated for emergency medical supplies was being maintained. However, the emergency medications were not being stored with other supplies and the kit was not being securely stored. Observed at CDE site: The medications that could be used for emergencies, e.g. epinephrine, Benadryl, glucose were stored separately in a locked cabinet in the nurses' station, which could delay ready accessibility in case of an emergency. Also, there was no documentation of daily AED checks. Discussion with staff noted that this 17 was system wide.
Prioritized Follow-up Action 18
ONSITE SURVEY AGENDA AND ACTIVITIES
Typical Survey for Health Centers 2 surveyors (Administrator, Clinician) 2-3 days: Based on number of sites, volume, distance between sites Minimum of 50% of the sites visited 20
Patient Care/System Tracer Activities Comprises 50-60% of onsite survey time Approximately 90 minutes in length Starts in setting where patient is located 21
During the Survey Activity Name Surveyor Arrival and Planning Orientation to the Health Center Patient Tracers Duration Activity Topics Covered Organization check extranet site 30-60 minutesto validate survey, surveyors and retrieve copy of agenda. Surveyors will describe the survey process Health center will share its 30-60 minutes mission, structure and community involvement 60-120 minutes Patients are followed based on the care they received; medications, assessments, education, procedures 22
During the Survey Activity Name Leadership Process Tracer Infection Control Process Tracer Medication Management Duration Activity 60 minutes 30-60 minutes 30-60 minutes Topics Covered Discussion with senior leadership about culture and commitment to improve care Review of staff training and vaccinations, housekeeping procedures, cleaning and disinfection, and staff exposure Review of storage and documentation, hand-off process, patient education for medications 23
During the Survey Activity Name Competence Assessment and Credentialing & Privileging Environment of Care and Emergency Management Process Tracer Data Management Duration Activity 30-60 minutes 45-90 minutes 30-90 minutes Topics Covered Human resource files are reviewed for licensure, education, ongoing training Environmental safety risks and the health center s plan to manage risks are reviewed Health center s use of data is reviewed related to infection control, medications, and patient outcomes 24
During the Survey Activity Name Governance Discussion Clinical Leadership & Staff Discussion Duration Activity 45-60 minutes 60 minutes Topics Covered Review of structure and review of Board members including involvement and oversight for the health center Review of clinical staff s role in the health center, scope of care provided, and the coordination among staff 25
Last Survey Day Activities Survey report is shared Exit meeting and health center exit conference Additional opportunity to ask questions 26
Follow-up Survey Activities Corrective Action Plan is due 60 days after the survey High Risk Concerns: Follow-up onsite survey required Survey results are reviewed by the Joint Commission s Executive Clinical Leadership team for next steps Additional follow-up surveys to confirm high risks were completely removed 27
Follow-up Survey Activities 28
2017 Top Challenging Ambulatory Standards for Health Centers 29
2016-2017 BPHC Summary Immediate Threat to Health and Safety/Preliminary Denial of Accreditation Decisions 30
Infection Prevention & Control Evidence based guideline specific to HLD, instrument sterilization and intracavitary probes Policies and procedure that guide and support patient care, treatment, or services Sterilization breaches to include Immediate Use Steam Sterilization 31
Infection Prevention & Control cont. Lack of initial or on-going, documented frontline staff competency and training specific to sterilization No documentation of prioritized identified risks for acquiring and transmitting infections 32
Human Resources Credentialing/Privileging Lack evidence of education & training; i.e. Prescribing Suboxone Lack of job descriptions for staff Failure to define competencies for staff who provide patient care, treatment or services 33
Quality Assurance Performance Improvement (QAPI) Collecting quantifiable data on performance 34
Provision of Care, Treatment, and Services Accountable referral and disposition processes Self management goals Health literacy needs Management of medical emergencies/supplies 35
Medication Management Management of sample meds Look-alike sound alike High alert/hazardous meds Multi-dose vials Medication storage; i.e. temperature 36
Environment of Care & Emergency Management Safety Management Plan Lack of documented evidence for testing of utility systems Lack of documented evidence for fire safety training and emergency disaster drills Maintenance of sterilizer 37
Leadership Lack of oversight in planning, design and implementation of processes Policies and procedure that guide and support patient care, treatment, or services Accurate and proper testing of EOC systems 38
Sample Checklist and Grids 39
Example of Risk Assessment Grid 40
Example of Determining Prioritized Risks 41
Example Competency Assessment Checklist 42
Services to Support Customers Intracycle Monitoring Process Onsite evaluation from experienced surveyors Standards Interpretation Group Education Leading Practices Library Joint Commission Connect: e-portal Electronic Standards Manual Accredited and PCMH certified health centers Targeted Solutions Tools Senior Account Executive BoosterPaks SAFER Portal 43
Resources and Support For standards questions: 630-792-5900 Standards Interpretation Group Use our web site: www.jointcommission.org For BPHC-specific accreditation info: Brittnay Hull, Sr. Account Executive 630-792-5216 (bhull@jointcommission.org) Pam Komperda, CHCA Project Manager 630-792-5551 (pkomperda@jointcommission.org) Jeff Conway, Director, Government Programs 630-792-5717 (jconway@jointcommission.org) Joyce Webb, PCMH Initiative Project Lead 630-792-5277 (jwebb@jointcommission.org) 44
The Joint Commission Disclaimer These slides are current as of September 14, 2017. The Joint Commission and the original presenter reserve the right to change the content of the information, as appropriate. The Joint Commission reserves the right to review and retire content that is not current, has been made redundant, or has technical issues. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter and The Joint Commission. 45
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Questions 47