Joint Commission Intra Cycle Monitoring(ICM) Survey Results Joint Conference Committee February 28,2017
Agenda Overview Upcoming Surveys TJC Update Survey Methodology Changes Post Survey Response Changes 2
Upcoming Surveys Commission on Cancer, American College of Surgeons - May 25, 2017 California Department of Public Health(CDPH) Skilled Nursing Care Survey - Unannounced The Joint Commission Triennial Accreditation Survey - Expected survey window: 1/1/17 7/18/17 Joint Commission Lab Accreditation Survey - Scheduled Survey 3
NEW TJC Survey Process SAFER: Survey Analysis For Evaluating Risk New survey scoring methodology Based on estimated level of risk to patients, staff, and visitors Helps organizations prioritize and focus corrective actions Provides one comprehensive visual representation of survey findings Effective January 2017
Likelihood to Harm a Patient/Staff/Visitor SAFER MATRIX Immediate Threat to Life (a threat that represents immediate risk or may potentially have serious adverse effects on the health of the patient, resident, or individual served) HIGH (harm could happen at any time) MODERATE (harm could happen occasionally) LOW (harm could happen, but would be rare) LIMITED (unique occurrence that is not representative of routine/regular practice) PATTERN (multiple occurrences with potential to impact few/some patients, visitors, staff and/or settings) WIDESPREAD (multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings) Scope 5
Additional Changes No more Direct Impact and Indirect EP (Elements of Performance) designations Consolidated ESC into one 60 day timeframe Elements of performance will no longer be categorized as A or C Follow up will be customized and prioritized according to placement within SAFER Matrix All findings (including single instances of non -compliance) will be included in the survey report and will require a response This approach emanates from the CMS position: If you see it, you cite it. Findings rated at higher risk level on SAFER matrix will require plan describing how compliance will be achieved and sustained 6
Evidence of Standards Compliance Leadership Change For High/Moderate Matrix findings Leadership Involvement Success and sustainability are highly influenced by support from the executive level of leadership The measure of the success of change is in its sustainability within organizations Preventive Analysis 7
ZSFG Joint Commission ICM Findings: Infection control (high level disinfection and transportation of probes) (Corrected in real time) A three hour gap for a provider to complete a face-to-face evaluation of a restrained patient Missing ventilator order Looped endoscope (Corrected in real time) Blanket warmer temperatures out of range Incomplete documentation of use of interpreter services (Corrected in real time) Potential ligature points identified in Acute Psychiatry Storage of Dantrolene in the OR without an accompanying risk assessment Lack of privacy for triage in PES Range orders without specific parameters Education and orientation of outside law enforcement Dirty pill cutter ( Corrected in real time ) Bronchoscopy performed in a non-negative air pressure room Missing restraint documentation Missing elements from the Infection Control Annual Risk Analysis Incomplete dialysis consent form Open EKG electrodes (Corrected in real time) Lack of wayfinding cues for assisting SNF residents with dementia. Non-specific patient care planning 2/24/2017 Zuckerberg San Francisco General Hospital and Trauma Center 8
2017 ICM Survey: SAFER MATRIX ZSFG 2017 Hospital Survey Findings 2 P age
Thank you Zuckerberg San Francisco General Hospital and Trauma Center 10